Endocrine Abstracts

Introduction: Thyrotoxicosis classically presents with tremor, goitre, sweating and diarrhoea. It is increasingly appreciated, however, that presentations can be complex and non-specific. Gastrointestinal symptoms in thyrotoxicosis are thought to derive from increased motility. Thyroid overactivity may be a cause for unexplained repeated vomiting and abdominal pain.

Case: A case of 41-year-old man presented with a three-year history of intractable vomiting, intermittent abdominal pain, sweating, hiccups, and 20 kg weight loss. He previously had surgical laparotomy to correct malrotation that had been found on CT scan at his local hospital. The malrotation was thought to be the cause of his symptoms. However, surgery did not lead to symptomatic relief, and caused complications in the form of poor wound healing and infection. He was then commenced on Sertraline for anxiety that was attributed to multiple hospital admissions and invasive investigations over three years. He was referred over to our unit for further investigations. A repeat CT showed that the malrotation had not been fully corrected, but that there was no sign of obstruction. It was agreed that the malrotation was probably an incidental finding. A marked tachycardia and hypertension were noted at this point, but attributed, along with pyrexia, to infection with Clostridium difficile. Other differential diagnoses were considered and more tests ordered, including: a porphyria screen, C4 levels, serum lead, faecal calprotectin, C1 esterase and a specific test for Familial Mediterranean Fever. Moreover, imaging was scheduled: MRCP, a gastric emptying study, endoscopic ultrasound and, CT head. Towards the latter part of his admission, he noticed a swelling in his neck. One month later, thyroid function blood tests were ordered; these showed a TSH <0.03 mU/l (0.35–5.5) and T4 55.9 pmol (10–19.8). TRAB antibody was positive. He was diagnosed with Grave’s disease. The vomiting and epigastric pain remarkably improved following treatment with Carbimazole.

Discussion: Whilst uncommon, thyrotoxicosis should be considered in patients with persistent, unexplained vomiting. Thyroid function tests should be checked so as to avoid delays in diagnosis and potentially obviate the need for invasive and non invasive tests and procedures, allowing the initiation of treatment as early as possible.