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Abstract: This patient, an elderly female with chronic constipation in the past, recently presented to our hospital with abdominal pain with reduced bowel movements and other symptoms, and was initially considered to have incomplete intestinal obstruction, but during the subsequent search for the cause of the patient’s intestinal obstruction, the patient was found to have more severe hypothyroidism, and was therefore promptly treated for the cause. After a series of treatments, the patient’s condition was controlled and all indicators improved.
Basic information】Female, 70 years old
Disease Type】Hypothyroidism
Hospital】Beijing Hospital
Time of consultation】February 2018
Treatment plan】Fast + medication (Scopolamine tablets + injectable piperacillin sodium tazobactam sodium + levothyroxine sodium tablets)
Treatment period】8 days of hospitalization, 3 months of outpatient follow-up
Treatment effect] The disease is under control and all indicators are improving.
I. Initial consultation
The patient was a 70-year-old female who was admitted to the hospital one day ago with persistent distending pain in the whole abdomen without any cause, accompanied by anal discharge and reduced defecation, as well as generalized weakness, more obvious in both lower limbs, without nausea, vomiting, chest tightness, shortness of breath, etc. The patient reported a history of long-term constipation. There was full abdominal distention, soft abdomen, mild pressure pain throughout the abdomen, no rebound pain, no subcostal liver and spleen, no palpable mass, drum sound on percussion, weak bowel sounds, and mild edema in both lower extremities.
The results of CT scan of the whole abdomen and pelvis indicated that the patient had dilated ascending colon with edema of the intestinal wall and significant pneumatization, no fluid plane, and a small amount of fluid in the pelvic cavity, and then ultrasound examination of abdominal large vessels was performed, and no significant abnormality was seen. The results showed that aspartate aminotransferase was 81 U/L, creatine kinase was 1297 U/L, lactate dehydrogenase was 475 U/L, and troponin T was <0.01 µg/L. After combining the above tests, the patient was initially suspected of having incomplete intestinal obstruction and was admitted to the hospital.
II. Treatment history
After admission, the patient was given fasting treatment, and antispasmodic treatment with elimination scopolamine tablets and symptomatic treatment with injectable piperacillin sodium tazobactam for anti-infection. The results indicated that serum free triiodothyronine and free thyroxine were decreased, and thyroid stimulating hormone, anti-thyroglobulin antibody and thyroid peroxidase antibody were all elevated, which led to the suspicion of hypothyroidism. When asked about the patient’s medical history, the patient’s family complained that the patient was devastated by the death of a relative one year ago, and gradually developed chills, facial edema, indifference, unresponsiveness, sluggishness and swelling of the lower limbs, and weight gain of 10 pounds, but no attention was paid to them. The patient was found to have hypothyroidism and was treated with levothyroxine sodium tablets orally.
III. Treatment effect
After a series of treatments, the patient’s abdominal distension and pain gradually decreased after 3 days, and the anus resumed venting. Subsequently, ultrasound examination of the thyroid gland, gastroscopy, colonoscopy, and enhanced CT examination of the small intestine were performed, and no significant abnormalities were found. The patient was discharged after 8 days of hospitalization, and was advised to continue taking oral levothyroxine sodium tablets after discharge.
IV. Notes
We are glad that the patient’s abdominal pain symptoms were controlled and thyroid function was restored to normal after a series of treatments. However, because of the patient’s age, the patient’s family should provide more care in daily routine and pay attention to the following conditions.
1. Patients need to take levothyroxine sodium tablets for a long time after discharge from hospital to supplement thyroid hormones. The thyroid hormone level should be rechecked regularly during the medication period to prevent hyperthyroidism caused by insufficient or excessive medication. Early discharge from the hospital can be reviewed every 2 weeks, and after the condition is controlled and stabilized, it can be reviewed every 1-3 months, and the dosage of medication should be adjusted according to the results of the review.
2. Families should pay attention to the patient’s mental status, edema, bowel movement and physical strength, and go to the hospital immediately if there is any abnormality.
V. Personal insight
Hypothyroidism is a systemic disease caused by insufficient synthesis and secretion or physiological effects of thyroid hormones. The clinical presentation of hypothyroidism lacks specificity, and mild hypothyroidism is easily missed and misdiagnosed. In addition, older patients may have multiple co-morbidities, making it easy to overlook the insidious nature of hypothyroidism.
In this case, an elderly woman presented with incomplete intestinal obstruction as the first manifestation, probably because hypothyroidism caused a decrease in sympathetic excitability, which in turn inhibited the electrophysiological and mechanical activities of the digestive tract, resulting in the accumulation of mucopolysaccharides in the intestinal wall and mucus edema in the intestinal wall, which in turn affected the nerve conduction in the intestinal wall and caused neuropathy in the intestinal wall. However, many elderly people have long-term constipation, and it is easy to ignore the cause of the disease, and often simply use laxative treatment to solve the problem. Such treatment may be able to relieve the patient’s symptoms at the time, but the subsequent recurrence will still lead to hypothyroidism crisis. Therefore, in the face of unexplained paralytic intestinal obstruction in the elderly, the possibility of senile hypothyroidism should be considered, and routine thyroid function tests should be performed to facilitate early diagnosis and treatment.