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Kubiszewski K, Chapman RW, Piazza Y, Patel D, Neychev V. Hypothyroidism Presenting as Adynamic Ileus Mimicking a Mechanical Small Bowel Obstruction: A Diagnostic and Management Dilemma. Cureus 2023; 15:e50799. [PMID: 38239558 PMCID: PMC10796157 DOI: 10.7759/cureus.50799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2023] [Indexed: 01/22/2024] Open
Abstract
Patients who present with nausea, vomiting, constipation, and abdominal pain typically undergo workups for small bowel obstruction (SBO). SBO is commonly caused by mechanical obstruction due to adhesions, inflammatory conditions, or malignancies. Hypothyroidism is primarily associated with decreased basal metabolic rate and rarely, in severe cases, gastrointestinal motility dysfunction. We report a case of a 44-year-old man who presented to the emergency department with abdominal pain, nausea, and vomiting. The workup, including computed tomography, showed a small bowel feces sign, highly suspicious for a mechanical SBO. His past medical history was significant for a poorly controlled hypothyroidism due to Hashimoto's thyroiditis with a markedly elevated thyroid stimulating hormone (TSH) level. He had no prior surgical history, and his family history was significant for a suspected inflammatory bowel disease (IBD) in his son. The patient failed initial resuscitative nonoperative management and underwent exploratory laparoscopy that revealed diffusely dilated small bowel loops with no obvious cause of mechanical obstruction. Inflammatory markers for IBD were found to be negative, and the patient's gastrointestinal motility gradually improved with daily intravenous levothyroxine.
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Affiliation(s)
- Kacper Kubiszewski
- Medical School, University of Central Florida College of Medicine, Orlando, USA
| | - Rachel W Chapman
- Medical School, University of Central Florida College of Medicine, Orlando, USA
| | - Yelena Piazza
- Pathology, University of Central Florida College of Medicine, Orlando, USA
- Pathology, UCF-Lake Nona Hospital, Orlando, USA
| | - Dhruv Patel
- Radiology, University of Central Florida College of Medicine, Orlando, USA
- Radiology, UCF-Lake Nona Hospital, Orlando, USA
| | - Vladimir Neychev
- Surgery, University of Central Florida College of Medicine, Orlando, USA
- Surgery, UCF-Lake Nona Hospital, Orlando, USA
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Wrenn SM, Parsons CS, Yang M, Malhotra AK. Acute large bowel pseudo-obstruction due to atrophic visceral myopathy: A case report. Int J Surg Case Rep 2017; 33:79-83. [PMID: 28285209 PMCID: PMC5350498 DOI: 10.1016/j.ijscr.2017.02.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 02/22/2017] [Accepted: 02/22/2017] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Atrophic visceral myopathy is a pathological diagnosis characterized by atrophy of the smooth muscle layers of the viscera with intact ganglia. Rarely, it can present acutely as an intestinal pseudo-obstruction. We describe a rare case report and explore how this diagnosis can be distinguished from other forms of intestinal obstruction. CASE DESCRIPTION A 60-year-old male with a past medical history of hypothyroidism presented to the emergency department with a two-day history of worsening abdominal distention and pain associated with nausea and vomiting. Upon evaluation patient was found to have tachycardia, with abdominal distention and localized tenderness with peritonitis. Computed tomography demonstrated large bowel obstruction, likely caused by sigmoid volvulus. The patient underwent emergent laparotomy. Intra-operatively, the entire colon was found to be extremely dilated and redundant. With a working diagnosis of recurrent sigmoid volvulus causing intermittent large bowel obstruction, a sigmoid colectomy and primary anastomosis was performed. Pathology revealed atrophic visceral myopathy, with an extremely thin colonic wall and atrophic circumferential and longitudinal muscularis propria without inflammation or fibrosis. The ganglion cells and myenteric plexus were unaffected. Post-operatively, the patient developed prolonged ileus requiring nasogastric decompression and parenteral nutrition. The ileus resolved with pro-kinetic agents, and patient was discharged home on post-operative day fifteen. CONCLUSIONS Atrophic visceral neuropathy is a rare cause of intestinal pseudo-obstruction. While often presenting with chronic obstruction in younger populations, we present a rare late-onset acute presentation that may have been secondary to underlying hypothyroidism.
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Affiliation(s)
- Sean M Wrenn
- University of Vermont Medical Center, Department of Surgery, 111 Colchester Avenue, Burlington, VT, 05401, United States.
| | - Charles S Parsons
- University of Vermont Medical Center, Department of Surgery, 111 Colchester Avenue, Burlington, VT, 05401, United States; Beth Israel Deaconess Medical Center, Department of Surgery, 330 Brookline Avenue, Boston, MA, 02215, United States.
| | - Michelle Yang
- University of Vermont Medical Center, Department of Pathology, 111 Colchester Avenue, Burlington, VT, 05401, United States.
| | - Ajai K Malhotra
- University of Vermont Medical Center, Department of Surgery, 111 Colchester Avenue, Burlington, VT, 05401, United States.
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Shera IA, Vyas A, Bhat MS, Yousuf Q. Unusual case of Hashimoto's encephalopathy and pseudo-obstruction in a patient with undiagnosed hypothyroidism: a case report. J Med Case Rep 2014; 8:296. [PMID: 25194644 PMCID: PMC4168993 DOI: 10.1186/1752-1947-8-296] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 07/12/2014] [Indexed: 11/13/2022] Open
Abstract
Introduction Hashimoto’s encephalopathy is a relatively rare condition associated with an elevated concentration of circulating serum anti-thyroid antibodies, and is usually responsive to steroid therapy. However, hypothyroidism is a rare cause of pseudo-obstruction so here we present a case report of Hashimoto’s encephalopathy with gut pseudo-obstruction in an undiagnosed hypothyroid patient. Case presentation A diagnosis of unknown aetiology of encephalopathy with gut dysmotility in an undiagnosed profound hypothyroidism case associated with cognitive decline and behavioural disorder was made in a 60-year-old Indian man. The associated clinical and laboratory features led to the final diagnosis of overt hypothyroidism with Hashimoto’s encephalopathy with gut pseudo-obstruction. Conclusions Hashimoto’s encephalopathy is a rare disorder presenting with acute or sub acute encephalopathy of unknown aetiology so there are considerable chances of misdiagnosing it. The unusualness of this case is that since hypothyroidism is a rare cause of intestinal pseudo-obstruction, and presented concomitant with Hashimoto’s encephalopathy, that itself is a rare entity. Intestinal pseudo-obstruction is a potentially serious complication that must be recognized and treated promptly with adequate thyroid hormone therapy.
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Affiliation(s)
- Irfan A Shera
- Department of General Medicine Rama Medical College Hospital & Research Centre, Ghaziabad 245304, UP, India.
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Abstract
Ogilvie's syndrome [acute colonic pseudo-obstruction (ACPO)] presents as massive colonic dilatation without a mechanical cause, usually in critically ill patients due to imbalanced sympathetic and parasympathetic activity. The initial therapy remains conservative with supportive measures (correction of metabolic, infectious or pharmacologic factors) followed by neostigmine and decompressive colonoscopy. Surgery is reserved for patients with clinical deterioration or with evidence of colonic ischemia or perforation. A 60-year-old lady presented with fever, altered sensorium, obstipation, bradycardia and abdominal distension. Investigation revealed hyponatremia and acute colonic pseudo-obstruction. Supportive measures and decompressive colonoscopy were not of great benefit. Thyroid profile was suggestive of primary hypothyroidism. Colonic motility was restored only on starting thyroxin. The case is illustrative of the need to consider hypothyroidism, a common endocrine disorder, in the differential diagnosis of Ogilvie's.
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Affiliation(s)
- Uday Yanamandra
- Department of Internal Medicine, Armed Forces Medical College, Pune, India
| | - Narendra Kotwal
- Department of Endocrinology, Command Hospital, Pune, Maharashtra, India
| | - Anil Menon
- Department of Internal Medicine, Armed Forces Medical College, Pune, India
| | - Velu Nair
- Department of Internal Medicine, Armed Forces Medical College, Pune, India
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Connor FL, Di Lorenzo C. Chronic intestinal pseudo-obstruction: assessment and management. Gastroenterology 2006; 130:S29-36. [PMID: 16473068 DOI: 10.1053/j.gastro.2005.06.081] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2004] [Accepted: 06/06/2005] [Indexed: 12/21/2022]
Affiliation(s)
- Frances L Connor
- Division of Pediatric Gastroenterology, Royal Children's Hospital, Herston, Australia
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Abstract
The normal indigenous intestinal microflora consists of about 10(15) bacteria that under physiological conditions reside mainly in the lower gastrointestinal tract. Bacterial overgrowth implies abnormal bacterial colonization of the upper gut, resulting from failure of specific defense mechanisms restricting colonization under physiological conditions. At present two types of bacterial overgrowth with defined pathogenesis can be distinguished: (1) gastric overgrowth with upper respiratory tract microflora resulting from selective failure of the gastric acid barrier, and (2) gastrointestinal overgrowth with Gram-negative bacilli (enteric bacteria) resulting from failure of intestinal clearance. Helicobacter pylori-induced gastritis of the oxyntic mucosa is the main cause of acquired failure of the gastric acid barrier, which is common among the healthy elderly. Intestinal clearance may fail as the result of impaired intestinal peristalsis or anatomical abnormalities that alter luminal flow. Impaired peristalsis is associated with conditions interfering with intestinal neuromuscular function including myopathic, neuropathic, autoimmune, infectious, inflammatory, metabolic, endocrine, and neoplastic diseases. Anatomical abnormalities are mainly the result of gastrointestinal surgery, intestinal diverticula or fistula. Combined failure of intestinal clearance and the gastric acid barrier results in more severe colonization with Gram-negative bacilli. Gram-negative bacilli are uncommon in the upper gut of otherwise healthy individuals with gastric hypochlorhydria, being acquired (H. pylori) or drug-induced. Significant bacterial overgrowth with Gram-negative bacilli is a rational in the search for an explanation to optimize clinical management. The clinical significance of colonization with upper respiratory tract microflora remains unclear. Translocation of live bacteria, their metabolic products, or antigens from a small bowel colonized by Gram-negative bacilli play a role in the pathogenesis of spontaneous bacterial peritonitis in hepatic disease and in certain types of sepsis, indicating that further studies can point to new patient populations with potential benefit from medical treatment.
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Affiliation(s)
- Einar Husebye
- Clinic of Medicine, Hospital of Buskerud HF, Drammen, and Division of Medicine, Ullevaal University Hospital of Oslo, Oslo, Norway.
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Abstract
Hypothyroidism is a commonly diagnosed endocrine disorder. Typical signs and symptoms of hypothyroidism include lethargy, cold intolerance, hoarseness, dry skin, constipation, delayed relaxation phase of deep tendon reflexes, and bradycardia. Hypothyroidism, presenting with such classic manifestations, usually is readily recognized and, therefore, easy to diagnose. Occasionally patients have less commonly emphasized symptoms, making the diagnosis less apparent. Such atypical presentations may suggest other diseases as the primary problem and, therefore, the initial focus of attention is on a diagnosis other than hypothyroidism. We have observed patients with hypothyroidism with rare manifestations. The diagnosis of primary hypothyroidism was established in all patients by thyroid function tests, and initiation of thyroid hormone therapy resulted in significant improvement of the presenting symptom. We considered it instructive to report about these patients because it shows the need to be aware of the unusual presentations of hypothyroidism and to consider hypothyroidism when confronted with atypical clinical manifestations.
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Affiliation(s)
- S A Westphal
- Department of Medicine, Maricopa Medical Center, Phoenix, Arizona 85008, USA
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Leker RR, Peretz T, Hubert A, Lossos A. Vincristine-induced paralytic ileus in Parkinson's disease. Parkinsonism Relat Disord 1997; 3:109-10. [DOI: 10.1016/s1353-8020(97)00008-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/1997] [Indexed: 11/25/2022]
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Rudolph CD, Hyman PE, Altschuler SM, Christensen J, Colletti RB, Cucchiara S, Di Lorenzo C, Flores AF, Hillemeier AC, McCallum RW, Vanderhoof JA. Diagnosis and treatment of chronic intestinal pseudo-obstruction in children: report of consensus workshop. J Pediatr Gastroenterol Nutr 1997; 24:102-12. [PMID: 9093995 DOI: 10.1097/00005176-199701000-00021] [Citation(s) in RCA: 138] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- C D Rudolph
- Children's Center for Motility Disorders, University of Cincinnati, Ohio, USA
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