Hyperthyroidism with Peritoneal Serositis Leading to Small Bowel Obstruction: A Case Report.

Intestinal obstructions are rarely associated with endocrinopathy, and in emergency settings, the underlying endocrinopathy is often overlooked.2–4 Endocrinopathy causing mechanical bowel obstruction similar to our patient’s presentation is even rarer. Moreover, in the context of hyperthyroidism, especially in patients who develop thyroid storm, the diagnosis could be confused as patients can present with an acute abdomen, which can mimic SBO in some cases, for which the exact cause is unknown.5 Thyroid hormones are generally metabolic hormones that have a role in gut motility and other metabolic activities.6 Digestive symptoms, such as abdominal pain, intractable vomiting, and altered bowel habits, can be the only presentation of hyperthyroidism in the absence of cardinal features of the disease.7 Such presentations can be misdiagnosed with bowel obstruction from the first encounter. In a recent study, a young patient with undiagnosed gut malrotation presented with signs and symptoms suggestive of bowel obstruction, and turned out to have thyrotoxicosis.8 The authors hypothesized that the obstruction may have resulted from increased small bowel motility due to high levels of thyroid hormones, which predispose to obstruction.8 However, in our case, the diagnosis was made after excluding all other possible diagnoses, including pelvic inflammatory disease, which can also give similar intraoperative findings of fibrinous adhesions and perihepatitis. We speculate that the patient might have developed serositis during her thyroid storm, causing fibrinous adhesions that resulted in SBO. This is why we consider this case to be rare. Pan serositis is one of the entities associated with autoimmune endocrinopathies, including Graves’ disease.9 In 3–6% of cases, it can cause pericardial effusion in isolated ascites, and in < 4% of cases, it can cause translocation of intestinal bacteria causing peritonitis, and eventually leading to conditions including SBO, intra-abdominal complications, and pleural effusion. However, some of these occurrences tend to be underestimated due to their low clinical significance.10 To our knowledge, isolated Graves’ disease has not been reported as a cause of polyserositis, and it is usually part of the polyglandular autoimmune syndrome. However, our patient was negative for other autoimmune diseases.

We have presented a rare case of small bowel obstruction in a virgin abdomen, associated with uncontrolled hyperthyroidism. Bowel obstruction is a rare complication of autoimmune endocrinopathies. The diagnosis (often missed by clinicians in emergency settings) is by exclusion, especially in patients with multiple adhesions causing small bowel obstruction in the absence of other common etiologies. Disclosure The authors declare no conflicts of interest.

- 1. Sia ZK, Trautman J, Yabe TE, Wykes J. A rare case of small bowel obstruction in a patient with endosalpingiosis, fitz-hugh-curtis syndrome, and chlamydia trachomatis pelvic inflammatory disease. Case Rep Surg 2022 Oct;2022:2451428. - 2. Bouomrani S, Lassoued N, Ben Hamad M, Regaïeg N, Belgacem N. Recurrent intestinal obstruction revealing hypothyroidism. Archives of Gastroenterology and Hepatology 2018;1(1):22-25. - 3. Hjardem E, Jørgensen LN. [Severe ileus due to hypothyroidism]. Ugeskr Laeger 2008 Sep;170(40):3144-3145. - 4. Hernández-Ramírez DA, Castellanos-Juárez JC, Romero T, Barragan-Rincón Á, Blanco-Benavides R. [Mixedematous ileus; acute abdomen exacerbate]. Rev Gastroenterol Mex 2008;73(4):231-234. - 5. Karanikolas M, Velissaris D, Karamouzos V, Filos KS. Thyroid storm presenting as intra-abdominal sepsis with multi-organ failure requiring intensive care. Anaesth Intensive Care 2009 Nov;37(6):1005-1007. - 6. Pokhrel B, Aiman W, Bhusal K. Thyroid storm. In: StatPearls. 2023 [cited 2023 May 2]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448095/. - 7. Daher R, Yazbeck T, Jaoude JB, Abboud B. Consequences of dysthyroidism on the digestive tract and viscera. World J Gastroenterol 2009 Jun;15(23):2834-2838. - 8. Bashir K, Bakhsh ZK, Gad HA, Bashir MT, Elmoheen A. An unusual case of thyroid storm masquerading as an intestinal obstruction in a patient with malrotation of the gut. Cureus 2021 Mar;13(3):e13948. - 9. Harris E, Shanghavi S, Viner T. Polyserositis secondary to COVID-19: the diagnostic dilemma. BMJ Case Rep 2021 Sep;14(9):e243880. - 10. Bhatia J, Kamath V, Radhika B. A rare case of hypothyroidism in a male presenting as polyserositis. APIK Journal of Internal Medicine. 2019;7(2):25-29.