摘要
BACKGROUND Thyroid storm is an uncommon condition manifesting in severe thyrotoxicosis with a high mortality rate.The concurrence of peptic ulcer disease and hyperthyroidism is rare due to concurrent activation of both the sympathetic and parasympathetic pathways.We present a case of perforated giant gastric ulcer with concurrent thyroid storm who underwent damage control surgery with emergency patch repair with falciform ligament and recovered well.CASE SUMMARY A 53-year-old male chronic smoker,with no previous medical history,presented with severe generalized abdominal pain and vomiting for one day duration.Further history revealed weight loss,diarrhea,and anxiety over the past three months.On clinical examination,patient was febrile with temperature of 38.6 Degrees Celsius and tachycardic at 130-140 beats per minute,his blood pressure was low at 90/50mmHg.His abdomen was tender with generalized peritonism.In view of his clinical history,a thyroid screen was ordered which showed raised thyroxine(T4)levels of 90.3 pmol/L and low thyroxine stimulating hormone(TSH)levels of 0.005μU/mL.Chest X-ray showed no sub-diaphragmatic free air,but contrasted CT scan revealed pneumoperitoneum with large amount of intraabdominal free fluid.The working diagnosis was perforated peptic ulcer complicated by thyroid storm.An urgent endocrinologist consult was made,and patient was started on beta blocker and intravenous steroids pre-operatively.The patient underwent emergency laparotomy with washout and patch repair of the perforated gastric ulcer.Patient was monitored post-operatively in intensive care unit and required IV hydrocortisone and Lugol’s iodine.Histology of the ulcer edges showed no malignancy.On post-operative day seven,T4 decreased to 20.4 pmol/L,TSH was 0.005 mLU/L.His thyroid function test subsequently normalized 3 mo post-operatively with T418.1 pmol/L,TSH 1.91 mLU/L.Patient’s recovery was otherwise uneventful.Thyroid receptor antibody subsequently was positive,and patient was managed for Grave’s disease by the endocrinologist.CONCLUSION This case highlights the rare but life-threatening clinical emergency of peptic ulcer perforation complicated by thyroid storm.Multidisciplinary perioperative management is crucial to optimize patient for surgery and damage control principles should be taken for an acute surgical patient with concurrent endocrine crisis.
