Endocrine Abstracts

Introduction: In cases of emergent surgical conditions, pre-medication of patients with thyrotoxicosis is required to reduce the patient’s risk of thyroid storm in the perioperative and postoperative state. Perforated viscus with concurrent thyrotoxicosis is rarely reported. We report 2 cases of thyrotoxicosis and acute abdomen with perforated viscus.

Case 1: A 27-year-old gentleman with underlying hyperthyroidism, presented with central epigastric pain for 3 days duration. He did not have any gastrointestinal losses. On assessment, blood pressure was stable, temperature was 38°C and patient was tachycardic at 144 beats/minute. He had fine tremors and a generalized tender abdomen with guarding. ECG showed sinus tachycardia while chest radiograph revealed air under the diaphragm. Bedside abdominal ultrasound showed free fluid in the Morrison’s pouch. His Free T4 was raised at 68.1 pmol/l (12-22) with suppressed TSH <0.005 mIU/l (0.27-4.2). He was started on rectal propylthiouracil and intravenous hydrocortisone. To optimize his condition prior to surgery, a peritoneal drain was inserted for temporary source control while plasmapheresis was done. Post plasmapheresis FT4 dropped to 1 pmol/l and he proceeded for exploratory laparotomy. Rectal PTU was continued until patient was allowed orally. He recovered well and was discharged with oral carbimazole.

Case 2: A 46-year-old construction worker with no prior medical illness, presented with 1 day history of epigastric pain. He had a history of chronic analgesia use. An initial chest radiograph done at primary care found air under the diaphragm and he was referred to hospital. On assessment he had a mild goiter and abdomen was tense and guarded. His temperature was 38°C, BP 137/89 and heart rate was 130 beats/minute. Bedside ultrasound showed free fluid in the abdominal cavity. His FT4 was elevated at 90.1 pmol/l with TSH <0.005 mIU/l. He developed fast atrial fibrillation requiring intravenous infusion amiodarone. Prompt treatment with intravenous hydrocortisone and rectal propylthiouracil was initiated. He was not able to proceed with surgery as patient was deemed unstable due to the atrial fibrillation with rapid ventricular response. Plasmapheresis was done and repeated FT4 post plasma exchange was 51 pmol/l. He subsequently underwent emergency exploratory laparotomy however post-surgery he had persistent fast AF requiring multiple synchronized cardioversions. His blood investigations showed worsening septic parameters and he eventually succumbed a day after surgery.

Conclusion: The presence of a compromised gastrointestinal tract requires alternative routes of administrating vital medications in thyrotoxicosis and utilization of other modalities of treatment such as plasmapheresis.