Thyrotoxicosis and Choledocholithiasis Masquerading as Thyroid Storm

A 26-year-old female, thirteen months postpartum, presented to the emergency department for four weeks of epigastric abdominal pain, pruritus, new onset jaundice, and 11.3 kgs (25 lbs) unintentional weight loss. On examination, she was afebrile, tachycardic, alert, and oriented and had jaundice with scleral icterus. Labs were significant for undetectable TSH, FT4 that was too high to measure, and elevated total bilirubin, direct bilirubin, alkaline phosphatase, and transaminases. Abdominal ultrasound revealed cholelithiasis without biliary ductal dilation. Treatment for presumed thyroid storm was initiated. Further work-up with magnetic resonance cholangiopancreatography (MRCP) revealed an obstructing cholelith within the distal common bile duct. With the presence of choledocholithiasis explaining the jaundice and abdominal pain, plus the absence of CNS alterations, the diagnosis of thyroid storm was revised to thyrotoxicosis complicated by choledocholithiasis. Endoscopic retrograde cholangiopancreatogram (ERCP) with sphincterotomy was performed to alleviate the biliary obstruction, with prompt symptomatic improvement. Thyroid storm is a rare manifestation of hyperthyroidism with a high rate of morbidity and mortality. The diagnosis of thyroid storm is based on clinical examination, and abnormal thyroid function tests do not correlate with disease severity. Knowledge of the many manifestations of thyroid storm will facilitate a quick and accurate diagnosis and treatment.

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Sphincter of Oddi Dysfunction: A Perplexing Presentation

Case Reports in Gastroenterology ◽

10.1159/000452736 ◽

2016 ◽

Vol 10 (3) ◽

pp. 714-719 ◽

Cited By ~ 3

Author(s):

Sana Ahmad Din ◽

Iman Naimi ◽

Mirza Beg

Keyword(s):

Abdominal Pain ◽

Magnetic Resonance Cholangiopancreatography ◽

Sphincter Of Oddi ◽

Abdominal Ultrasound ◽

Sphincter Of Oddi Dysfunction ◽

Sphincter Pressure ◽

Abdominal Symptoms ◽

Biliary Sphincterotomy ◽

Bile Drainage ◽

Oddi Dysfunction

Sphincter of Oddi dysfunction is caused by stenosis or dyskinesia of the sphincter of Oddi, leading to blockage of bile drainage from the common bile duct. We present the case of a 16-year-old female with chronic abdominal pain who underwent laparoscopic cholecystectomy for cholelithiasis but continued to experience abdominal pain, nausea, and vomiting along with persistently elevated ALT and AST levels. Postoperative abdominal ultrasound was nondiagnostic. Esophagogastroduodenoscopy showed mild reflux esophagitis and mild chronic Helicobacter pylori-negative gastritis. Omeprazole was started, but it did not decrease the frequency and severity of the abdominal symptoms. Magnetic resonance cholangiopancreatography did not reveal any pathology. Endoscopic retrograde cholangiopancreatography with manometry confirmed an elevated biliary sphincter pressure. Biliary sphincterotomy was performed, and the symptoms improved.

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Congenital or acquired? Obstructive jaundice in reoperated duodenal atresia

BMJ Case Reports ◽

10.1136/bcr-2019-231021 ◽

2019 ◽

Vol 12 (8) ◽

pp. e231021 ◽

Cited By ~ 2

Author(s):

Mervin Feng Ji Goh ◽

Malcolm Han Wen Mak ◽

Yee Low ◽

Caroline Choo Phaik Ong

Keyword(s):

Obstructive Jaundice ◽

Intestinal Obstruction ◽

Magnetic Resonance Cholangiopancreatography ◽

Abdominal Ultrasound ◽

Postoperative Recovery ◽

Duodenal Atresia ◽

Emergency Laparotomy ◽

Type I ◽

Diagnostic Dilemma ◽

Distal Common Bile Duct

A 55-day-old boy was transferred to our unit with intestinal obstruction and obstructive jaundice after two neonatal operations for duodenal atresia and intestinal malrotation. Abdominal ultrasound showed dilated intrahepatic and extrahepatic ducts with cut-off at the distal common bile duct (CBD). He underwent emergency laparotomy for adhesive intestinal obstruction with a contained abscess from mid-jejunal perforation. Biliary dissection was not attempted due to poor preoperative nutritional status. Tube cholecystostomy was created for biliary decompression. Postoperative magnetic resonance cholangiopancreatography showed dilated CBD with cut-off at the ampulla but did not demonstrate pancreaticobiliary maljunction (PBMJ). The diagnostic dilemma was whether our patient had congenital PBMJ or had developed biliary stricture from perioperative ischaemic scarring. He underwent definitive surgery at 7 months: excision of dilated CBD with Roux-en-Y hepaticojejeunal reconstruction, excisional tapering duodenoplasty and jejunostomy creation. Intraoperative finding was type I choledochal cyst and subsequently confirmed on histology. Postoperative recovery was uneventful and bilirubin levels normalised.

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SUN-523 Thyroid Storm: A Rare Presentation of HCG Producing Metastatic Choriocarcinoma

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa046.1432 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

Author(s):

Krishna Karthik Chivukula ◽

David Toro-Tobón ◽

Banafsheh Motazedi ◽

Rachna Manju Goyal

Keyword(s):

Abdominal Pain ◽

Lung Metastases ◽

Germ Cell Tumors ◽

Symptomatic Improvement ◽

Response To Treatment ◽

Thyroid Storm ◽

Contrast Imaging ◽

Rare Presentation ◽

Hook Effect ◽

Iodinated Contrast

Abstract Background: The beta subunit of human Chorionic Gonadotropin (hCG) and TSH are very similar and hCG is known to weakly bind the TSH receptor. hCG induced hyperthyroidism has been previously reported as a rare paraneoplastic syndrome in non-seminomatous germ-cell tumors and usually presents with subclinical thyrotoxicosis. We present a noteworthy case of thyroid storm in a patient with hCG producing testicular Choriocarcinoma. Clinical case: A 19-year-old Hispanic man presented to an outside emergency department (ED) with one day of abdominal pain, nausea, recurrent emesis and subjective fever. He had presented to the same ED 9 days prior with similar symptoms which prompted contrasted CT Abdomen/Pelvis demonstrating hepatic masses and a large right testicular mass, suspicious for primary testicular malignancy. On return evaluation, he was noted to have tachycardia with HR 165, mild scleral icterus, tenderness to palpation of right upper quadrant, abdominal pain and a right scrotal mass (5x5 cm). CBC revealed; WBC 12.0 k/uL (n: 4-10.8), AST: 428 u/L (n: 3-34); ALT: 176 u/L (n: 15-41); total bilirubin: 6.3 mg/dL (n: 0.2-1.3), TSH <0.005 uIU/mL (n: 0.4-4.0) and FT4 5.02 ng/dL (n: 0.7-1.4). Clinical scenario was consistent with thyrotoxicosis concerning for thyroid storm (Burch-Wartofsky Point Scale: 50) requiring intensive care for which he was transferred to our institution. Thyroid US revealed increased thyroid vascularity without nodularity. Laboratory workup revealed negative TG Ab, Anti-TPO Ab, TRAb, and TSIG. Conversely, TBG was elevated at 31.2 mcg/ml (n: 13-30). Initial hCG level was obtained as 6,074. After re-testing with dilution was specifically requested, initial hCG was corrected to 6,760,713. Oncologic workup confirmed diagnosis of hCG producing testicular choriocarcinoma with liver and lung metastases. On admission, he was started on oral methimazole and propranolol as well as intravenous steroids which led to marked symptomatic improvement and normalization of FT4 to 1.37 allowing for discontinuation of antithyroid medication on 7th day of hospitalization. He completed 1 cycle of cisplatin/etoposide and experienced marked reduction of his hCG level to 951,460 which correlated with improvement of his TFTs and resolution of his hyperthyroid symptoms. Conclusion: A low threshold of suspicion should be maintained for the possibility of hyperthyroidism in patients with suspected testicular choriocarcinoma, particularly in the context of recent iodinated contrast imaging. If the clinical picture does not support a primary etiology of hyperthyroidism and hCG is not concordantly elevated, re-assessment of hCG by dilution should be considered as hCG assay is also subject to prozone (hook) effect. Hyperthyroidism should be actively managed and closely monitored as response to treatment can be rapid.

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Impact of Endoscopic Ultrasound in Evaluation of Upper Abdominal Pain

Medicine Today ◽

10.3329/medtoday.v33i1.52148 ◽

2021 ◽

Vol 33 (1) ◽

pp. 1-6

Author(s):

Bimal Chandra Shil ◽

Madhusudan Saha ◽

Md Royes Uddin ◽

ANM Saifullah ◽

Md Rehan Habib ◽

...

Keyword(s):

Abdominal Pain ◽

Endoscopic Ultrasound ◽

Epigastric Pain ◽

Magnetic Resonance Cholangiopancreatography ◽

Abdominal Ultrasound ◽

Cross Sectional Study ◽

Cross Sectional ◽

Presenting Symptoms ◽

Medicine Today ◽

Upper Abdominal

Introduction: Upper abdominal pain is found to be one of the most common presenting symptoms. Endoscopic ultrasound may be a useful tool to yield a specific diagnosis. Aim of our study was to find the etiology of upper abdominal pain with normal endoscopic findings and compare the findings of endoscopic ultrasound with those of trans-abdominal ultrasound. Materials and Methods: This was a cross sectional study conducted in the department of gastroenterology, Sir Salimullah Medical College from January 2015 to December 2019. Total 238 patients suffering from upper abdominal pain who previously underwent endoscopy with normal results and trans abdominal ultrasound with doubtful findings were enrolled in this study. All patients were evaluated properly with history, clinical examination and relevant blood investigations. Then the patients underwent endoscopic ultrasound with conscious sedation. Computed tomorgraphy, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography were done in cases where needed and correlated with endoscopic ultrasound results. Results: Among the total 238 patients, 137 were male and 101 were female. Most predominant age range was 31-40 years. Pain was moderate in severity in 43.27%, epigastric pain was in 59.66% and pain referred to back was in 37.39% patients. Comparison with trans abdominal ultrasound regarding etiologies of upper abdominal pain was statistically significant (P=0.000). Comparative analysis between the two modalities regarding gall bladder, common bile duct, pancreas were also found significant with P values of 0.040, 0.005, 0.000 respectively. Forty two patients were diagnosed as chronic pancreatitis based on Rosemont criteria by endoscopic ultrasound. Conclusion: Endoscopic ultrasound is a modern diagnostic tool which can detect hepato-pancreato-biliary pathologies and also mucosal irregularities of stomach and esophagus. So, it can be considered as a first line investigation to diagnose the underlying etiology of upper abdominal pain. Medicine Today 2021 Vol.33(1): 1-6

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Crucial role of physiotherapy in treating COVID-19 patients

International Journal of Research in Pharmaceutical Sciences ◽

10.26452/ijrps.v11ispl1.3300 ◽

2020 ◽

Vol 11 (SPL1) ◽

pp. 967-971

Author(s):

Poonam Thakre ◽

Waqar M. Naqvi ◽

Trupti Deshmukh ◽

Nikhil Ingole ◽

Sourabh Deshmukh

Keyword(s):

Public Health ◽

Distress Syndrome ◽

Public Health Problem ◽

Public Health Emergency ◽

High Rate ◽

Major Public Health Problem ◽

Front Line ◽

The Many ◽

Sixth International

The emergence in China of 2019 of severe acute respiratory syndrome coronavirus2 (SARS-CoV-2) previously provisionally names 2019-nCoV disease (COVID19) caused major global outbreak and is a major public health problem. On 30 January 2020, the WHO declared COVID19 to be the sixth international public health emergency. This present pandemic has engrossed the globe with a high rate of mortality. As a front line practitioner, physiotherapists are expected to be getting in direct contact with patients infected with the virus. That’s why it is necessary for understanding the many aspects of their role in the identification, contains, reduces and treats the symptoms of this disease. The main presentation is the involvement of respiratory system with symptoms like fever, cough, sore throat, sneezing and characteristics of pneumonia leads to ARDS(Acute respiratory distress syndrome) also land up in multiorgan dysfunction syndrome. This text describes and suggests physiotherapy management of acute COVID-19 patients. It also includes recommendations and guidelines for physiotherapy planning and management. It also covers the guidelines regarding personal care and equipment used for treatment which can be used in the treatment of acute adult patients with suspected or confirmed COVID-19.

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Fanconi Bickel syndrome: clinical phenotypes and genetics in a cohort of Sudanese children

International Journal of Pediatric Endocrinology ◽

10.1186/s13633-020-00091-5 ◽

2020 ◽

Vol 2020 (1) ◽

Author(s):

Salwa A. Musa ◽

Areej A. Ibrahim ◽

Samar S. Hassan ◽

Matthew B Johnson ◽

Asmahan T. Basheer ◽

...

Keyword(s):

Glucose Transporter ◽

Novel Mutation ◽

Wide Spectrum ◽

Rare Condition ◽

Neonatal Diabetes ◽

Abdominal Ultrasound ◽

Sub Saharan Africa ◽

High Rate ◽

Genetic Characteristics ◽

Sub Saharan

Abstract Background Fanconi-Bickel syndrome (FBS) is a rare condition of carbohydrate metabolism, caused by a recessive defect in the facilitative glucose transporter GLUT2 encoded by the SLC2A2 gene and characterized by a wide spectrum of phenotypical features. There is a paucity of reported data on FBS from Sub-Saharan Africa. Here, we describe the clinical, biochemical and genetic characteristics of our patients with FBS from Sudan, a country with a high consanguinity rate. Patients & methods Eleven patients from ten unrelated Sudanese families were included. Clinical & biochemical data were documented and imaging studies done including bone survey and abdominal ultrasound. Liver biopsy was done to confirm the pathological diagnosis in 45% of cases and molecular genetics was performed through contribution with the Exeter genomics laboratory for ten patients. Results Reported consanguinity was 70% among our patients. Growth was significantly impaired at presentation with mean weights of (-5.3 ± 1.8) SD and heights (-5.4 ± 2.5) SD. Severe chest deformity was present in (27%) and all patients showed features of rickets at presentation. Three patients had neonatal diabetes requiring insulin therapy of which one has been reported before. Six families lost undiagnosed siblings with similar clinical presentations. We identified a total of four homozygous pathogenic SLC2A2 variants in our patients, one of whom had a novel mutation. Conclusions FBS is not uncommon in Sudan where there is a high rate of consanguinity. Many cases are likely missed because of variable presentation and lack of public and professionals’ awareness. This is the first series to describe this condition from Sub-Saharan Africa.

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Intrabiliary and abdominal rupture of hepatic hydatid cyst leading to biliary obstruction, cholangitis, pancreatitis, peritonitis and septicemia: a case report

Journal of Medical Case Reports ◽

10.1186/s13256-021-02822-5 ◽

2021 ◽

Vol 15 (1) ◽

Author(s):

Manouchehr Aghajanzadeh ◽

Mohammad Taghi Ashoobi ◽

Hossein Hemmati ◽

Pirooz Samidoust ◽

Mohammad Sadegh Esmaeili Delshad ◽

...

Keyword(s):

Abdominal Pain ◽

Hydatid Cyst ◽

Hydatid Disease ◽

Biliary Obstruction ◽

Abdominal Ultrasound ◽

Sporadic Case ◽

Gallbladder Wall ◽

Liver Cyst ◽

Biliary Duct ◽

Wall Thickening

Abstract Background Hydatid cysts are fluid-filled sacs containing immature forms of parastic tapeworms of the genus Echinococcus. The most prevalent and serious complication of hydatid disease is intrabiliary rupture, also known as cystobiliary fistulae. In this study, a sporadic case of biliary obstruction, cholangitis, and septicemia is described secondary to hydatid cyst rupture into the common bile duct and intraperitoneal cavity. Case presentation A 21-year-old Iranian man was admitted to the emergency ward with 5 days of serious sickness and a history of right upper quadrant abdominal pain, fatigue, fever, icterus, vomiting, and no appetite. In the physical examination, abdominal tenderness was detected in all four quadrants and in the scleral icterus. Abdominal ultrasound revealed intrahepatic and extrahepatic biliary duct dilation. Gallbladder wall thickening was normal but was very dilated, and large unilocular intact hepatic cysts were detected in segment IV and another one segment II which had detached laminated membranes and was a ruptured or complicated liver cyst. Conclusion Intrabiliary perforation of the liver hydatid cyst is an infrequent event but has severe consequences. Therefore, when patients complain of abdominal pain, fever, peritonitis, decreased appetite, and jaundice, a differential diagnosis of hydatid disease needs to be taken into consideration. Early diagnosis of complications and aggressive treatments, such as endoscopic retrograde cholangiopancreatography and surgery, are vital.

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Report of a Young Female With Severe Abdominal Pain: Mesenteric Venous Thrombosis

ACTA MEDICA IRANICA ◽

10.18502/acta.v57i7.2337 ◽

2020 ◽

Author(s):

Ahmad Hormati ◽

Faezeh Alemi ◽

Rouhollah Taghavi ◽

Mohammadreza Ghasemian ◽

Mahsa Besharati

Keyword(s):

Abdominal Pain ◽

Venous Thrombosis ◽

Young Female ◽

Term Treatment ◽

Severe Abdominal Pain ◽

High Rate ◽

Oral Contraceptive Pills ◽

Delay In Diagnosis ◽

Long Term Treatment ◽

Drug History

Mesenteric ischemia is a rare disease with a high rate of mortality because of the non-specific symptoms which lead to delay in diagnosis and intervention. The main symptom is abdominal pain, which has a broad list of differential diagnoses. This study introduces a 17-year-old girl who presents to the emergency department with severe abdominal pain and hematemesis. Further evaluations revealed thrombosis in the mesenteric vein which leads to ischemia and gangrene of the small intestine. Her past medical history and drug history were negative, except she was taking levonorgestrel and cyproterone acetate for a 5 months period. Since long-term treatment with oral contraceptive pills, counts as a risk factor for venous thrombosis, this case seems to be uncommon. © 2019 Tehran University of Medical Sciences. All rights reserved. Acta Med Iran 2019;57(7):468-470.

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DIAGNOSTIC FEATURES OF COMPLICATED CHOLELITHIASIS IN PREGNANT WOMEN

Kuban Scientific Medical Bulletin ◽

10.25207/1608-6228-2019-26-1-168-174 ◽

2019 ◽

Vol 26 (1) ◽

pp. 168-174

Author(s):

Karen D. Antinyan ◽

Evgenii S. Babenko ◽

Vladimir M. Durleshter

Keyword(s):

Pregnant Women ◽

Conflict Of Interest ◽

Magnetic Resonance Cholangiopancreatography ◽

Abdominal Ultrasound ◽

Perinatal Complications ◽

Laparoscopic Ultrasonography ◽

Endoscopic Retrograde ◽

Diagnostic Features ◽

Ultrasound Diagnostics ◽

Long Time

The aimis to describe modern approaches used in the diagnostics of cholelithiasis in pregnant women.Results.Cholelithiasis diagnostics in pregnant women is a rather difficult task, frequently taking a long time and significantly worsening the prognosis for both the mother and the fetus. Abdominal ultrasound is the “gold standard” for the diagnosis of cholelithiasis in pregnant women, allowing the diagnosis to be clarified and the treatment tactics to be adjusted. The possibilities of such modern methods as endoscopic ultrasound diagnostics, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, and laparoscopic ultrasonography used in difficult diagnostic cases are presented.Conclusion.The use of a maximal range of diagnostic studies in pregnant women makes it possible to establish the diagnosis as soon as possible and to reduce the frequency of surgical and related perinatal complications. As a result, the prolongation of pregnancy and a decrease in maternal and intrauterine mortality can be achieved.Conflict of interest: the authors declare no conflict of interest.

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SAT-380 A Case of Primary Hyperparathyroidism on the Third Trimester of Pregnancy

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa046.1884 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

Author(s):

Maria Alexandra Carranceja Villapol ◽

Maria Princess L Kanapi

Keyword(s):

Blood Pressure ◽

Abdominal Pain ◽

Primary Hyperparathyroidism ◽

Parathyroid Adenoma ◽

Elevated Serum ◽

Stable Condition ◽

Abdominal Ultrasound ◽

Pressure Control ◽

Ibandronic Acid ◽

The Right

Abstract Introduction: This is the case of a pregnant woman on her 3rd trimester who was diagnosed with primary hyperparathyroidism. Since there are two patients involved, the potential complications that can be brought about by the diagnostic tests and the treatment had to be weighed against the benefits. Case: The patient is SA, a 34-year old female on her 29th week of pregnancy, admitted due to a month history of abdominal pain described as intermittent, crampy, generalized, non-radiating, and mild-to-moderately severe in intensity. She was advised to do tests but did not comply. In the interim, there was recurrence of symptoms but with resolution. However, the crampy abdominal pain recurred, now localized at the right upper quadrant and epigastric areas, radiating to the right upper back, moderate in intensity, and with associated nausea and vomiting, leading to admission. She was first managed under OB-Gynecology, given hydration, pain management and Betamethasone. She was also referred to Cardiology for blood pressure control, and Surgery for evaluation of the abdominal pain. Due to an increasing trend of her blood glucose, she was referred to Endocrinology and started on insulin. Mild bilateral nephrocalcinoses seen in an abdominal ultrasound prompted work-up showing an elevated serum ionized calcium at 1.88 meq/L (n 1.12-1.32 meq/L), elevated intact PTH at 451.13 pg/ml (n <67.9 pg/ml), and low Vitamin D at 10.96 ng/ml (n >30ng/ml). Parathyroid ultrasound showed nonthyroidal tissue measuring 0.4 x 0.6 cm at the right inferior area. Saline hydration and diuresis with Furosemide were started to manage the hypercalcemia. A multi-disciplinary meeting was held to discuss the options for management and risks involved. The goal was to deliver the baby in stable condition possibly to term, while keeping maternal calcium levels and blood pressure normal. However on her 30th week of gestation, she had persistent elevated blood pressure and underwent emergency caesarian section. After delivery, the patient was advised against breastfeeding for adequate management of her hypercalcemia. She was started on Cinacalcet, Calcitonin, and Ibandronic Acid. A Parathyroid Sestamibi Scan done showed a parathyroid adenoma on the right inferior lobe, and she underwent right inferior parathyroidectomy, with left thyroidectomy and isthmusectomy. Findings showed a right inferior parathyroid adenoma and a benign follicular nodule on the left thyroid. She was started on Calcium Carbonate and Calcitriol, and discharged stable. Conclusions: This case shows that when two lives are at stake every step of the management, whether diagnostic or therapeutic, must be communicated well to the patient and to the other members of the team. It is ultimately a choice made by the expectant mother but through the proper guidance and updated knowledge of the team, combined with a good clinical eye especially in the treatment of pregnant women.

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