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BMJ Case Rep. 2010; 2010: bcr11.2009.2461.
Published online Mar 30, 2010. doi:  10.1136/bcr.11.2009.2461
PMCID: PMC3027514
Unusual presentation of more common disease/injury
Recurrent nausea, vomiting and abdominal pain due to hypothyroidism
Chris Sweet, Abhishek Sharma, and George Lipscomb
Royal Bolton Hospital, Gastroenterology, Minerva Road, Farnworth, Bolton BL4 0JR, UK
Correspondence to Abhishek Sharma, abisharma/at/hotmail.com
Abstract
A 45-year-old woman presented with recurrent episodes of diarrhoea, nausea, vomiting and abdominal pain. Investigations, including routine blood tests, gastroscopy with duodenal biopsy, colonoscopy and abdominal computed tomography (CT) scanning, failed to find a cause of these symptoms. Routine blood tests were repeated and included thyroid function tests. The latter confirmed a diagnosis of primary hypothyroidism. After initiating thyroid hormone replacement therapy, all of the patient’s symptoms resolved. She remains well and asymptomatic to date.
This case is important as it highlights an unusual presentation of hypothyroidism, a common and easily treated condition. Replacement with thyroxine resulted in the prompt resolution of intractable gastrointestinal symptoms. Nausea, vomiting, diarrhoea and abdominal pain are common symptoms that might indicate a number of underlying pathologies of the gastrointestinal tract, such as peptic ulcer disease, pancreatitis, cholecystitis and inflammatory bowel disease. As a result, invasive and expensive investigations are often requested. However, there is little in the literature of hypothyroidism causing such gastrointestinal symptoms, and no reports of these resolving completely with thyroid replacement therapy. Clinicians should remember to check thyroid function in patients with refractory abdominal pain and vomiting, especially when routine investigations do not find a cause.
A 45-year-old woman presented with a 6 month history of intermittent episodes of diarrhoea, vomiting and abdominal pain, each followed by persistent nausea. Before this she had been admitted to hospital for 5 days while on holiday in Mexico. She was diagnosed with gastroenteritis and a urinary tract infection, and her symptoms resolved completely. She later developed recurrent symptoms, and at the time of presentation reported approximately five episodes of diarrhoea, vomiting and abdominal pain, each lasting around 48 h; these were followed by persistent nausea. She also reported general malaise, and lost approximately 3 kg in weight. These symptoms were causing the patient considerable distress.
She had a previous medical history of menorrhagia but was otherwise fit and well, and was on no medications. There was no family history of any gastrointestinal disease, and she did not smoke or drink alcohol. The clinical examination was entirely unremarkable.
Routine blood tests including full blood count, urea and electrolytes, glucose, liver function and bone profile were normal. A gastroscopy and colonoscopy were arranged. However, the patient became more unwell with nausea and vomiting, so an urgent gastroscopy alone was performed, as the symptoms were felt more likely to be due to upper gastrointestinal pathology. Gastroscopy was normal, and gastric and duodenal biopsies were histologically normal. An abdominal computed tomography (CT) scan showed no intra-abdominal pathology.
Subsequently, repeat blood tests were performed. Thyroid function tests then revealed a raised thyroid stimulating hormone (TSH) >75 mU/ml (normal range (NR) 0.5–5.0 mU/ml), a low free T4 at 6.06 pmol/L (NR 10.0–25.0 pmol/l), and low T3 1.04 nmol/l (NR 1.1–2.8 pmol/L). A raised prolactin concentration of 1052 mU/l (NR 64–420 mU/l) was also noted. The plasma cortisol concentration was normal. The raised prolactin was thought to be due to the hypothyroidism.
Differential diagnosis
Initially a differential diagnosis of post infective irritable bowel syndrome was considered, but a diagnosis of primary hypothyroidism was made.
Treatment
The patient was commenced on thyroid hormone replacement therapy. Initially, she was given levothyroxine 25 μg daily for 2 weeks, increasing to 50 μg for a further 2 weeks and then to 75 μg as a maintenance dose.
Outcome and follow-up
At a 5 week review appointment the patient reported that all of her symptoms had gone. Pituitary, parathyroid and adrenal profiles were not carried out. In addition, the colonoscopy was cancelled. She continues on thyroxine replacement therapy and to date her symptoms have not returned.
Hypothyroidism is one of the most common endocrine conditions encountered in the UK, and is more common in females than males (ratio 6:1). In one study, the prevalence of overt hypothyroidism was reported to be 9.3% in women and 1.3% in men, with an annual incidence of 40/10 000 and 6/10 000, respectively.1 It is usually primary, as a result of disease of the thyroid gland itself. The most common cause is autoimmunity, but other causes include iatrogenic (damage from surgery, radiation, radioiodine or drug treatment—for example, amiodarone, lithium and thalidomide), and iodine deficiency. Hypothyroidism due to hypothalamic–pituitary disease, resulting in low thyroid stimulating hormone (TSH, “secondary”) or thyrotropin releasing hormone (TRH, “tertiary”), is rare.
Hypothyroidism may manifest with a multitude of symptoms in adults, including fatigue, excessive somnolence, increased cold sensitivity, pale and dry skin, face puffiness, hoarse voice, unexplained weight gain, myalgia, bradycardia, arthralgia, muscle weakness, menorrhagia, brittle fingernails and hair, and depression. Constipation is the classical gastrointestinal symptom associated with hypothyroidism.
The diagnosis of hypothyroidism can be confirmed by carrying out thyroid function tests (TFTs), which are widely available. In primary hypothyroidism, thyroid stimulating hormone (TSH) values are raised and the total T4 (thyroxine) and free T3 (tri-iodothyronine) and are classically low. Further investigations can be considered in the presence of goitres or nodules, such as ultrasonographc scanning with targeted fine needle aspiration for histology/cytology.
A literature review revealed no similar cases in adults. No reports were found of abdominal pain, vomiting and diarrhoea being associated with hypothyroidism. Theoretically, these symptoms might occur in the presence of hypothyroidism associated severe constipation; however, our patient did not have evidence of this. In the absence of severe constipation, the mechanism by which hypothyroidism might cause abdominal pain, vomiting and diarrhoea is unclear. In the paediatric literature there have been reports of congenital hypothyroidism presenting with recurrent vomiting due to severe intestinal hypomotility.2,3
Learning points
  • Persistent nausea, vomiting, diarrhoea and abdominal pain can be caused by hypothyroidism.
  • Hypothyroidism is a rare cause of these symptoms.
  • Thyroid function tests should be conducted in patients with refractory gastrointestinal symptoms, especially if routine investigations do not reveal a cause.
Footnotes
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.
REFERENCES
1. Laurberg P, Bülow Pedersen I, Pedersen KM, et al. Low incidence rate of overt hypothyroidism compared with hyperthyroidism in an area with moderately low iodine intake. Thyroid 1999; 9: 33–8. [PubMed]
2. Vidwans AS, Ratzan S, Sanders MR. An unusual presentation of congenital hypothyroidism: a report of two cases. J Pediatr Gastroenterol Nutr 2000; 31: 198–200. [PubMed]
3. Opitz JC. Congenital hypothyroidism presenting as functional bowel obstruction in the premature infant. Wis Med J 1979; 78: 23–5. [PubMed]
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