Primary hypothyroidism is a common diagnosis, affecting 3%-4.5% of the general population and may present in a variety of ways. Myxedema ascites is also a rare cause of hypothyroidism seen in less than 1% of new onsets. In these cases, the use of thyroid hormone replacement usually leads to a progressive decrease in ascites, which ultimately disappear. We present a case of a patient with that had a history of chronic diarrhoea and weight loss who presented with ascites and was found to have laboratory findings consistent with hypothyroidism.
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62-year-old female with a past medical history of hypothyroidism (off replacement therapy) and chronic diarrhoea presents to the emergency department with acute onset abdominal pain associated with nausea and vomiting concerning for small bowel obstruction. She has noticed progressive increased abdominal girth for the past year. CT abdomen and pelvis suggested partial small bowel obstruction from an internal hernia and a large number of ascites. Blood count and electrolytes were stable. Thyroid Stimulating hormone level was 43.7 with <0.1 T4 level and was started on replacement therapy. A nasogastric tube was placed on low intermittent suctioning for decompression. A paracentesis done had a negative cytology. Serum-ascites albumin gradient was 1.3 suggesting portal hypertension. Cultures of ascites fluid were negative. Urine analysis was positive for trace protein. A cardiac echocardiogram was unremarkable. The patient continued to have multiple loose bowel movements daily. Gastroenterology was consulted for evaluation of protein-losing enteropathy. Faecal alpha 1 antitrypsin level, Ceruloplasmin level and anti-transglutaminase antibody were negative. A push enteroscopy with small bowel biopsy was negative. 3 weeks after starting thyroid replacement her faecal consistency improved. TSH and T4 levels improved as well. She was discharged with parenteral nutrition with close endocrine follow up
Hypothyroidism is a rare cause of ascites. However, the importance of its diagnosis is that the use of thyroid hormone replacement results in complete resolution. If there are new onset ascites, diagnostic workup should begin with the analysis of the ascitic fluid. Usually, total protein in the ascitic fluid and the SAAG value give a useful framework for the analysis of whether the ascitic fluid is a transudate or an exudate. Once all causes of ascites are excluded and symptoms improve one can conclude that the ascites is likely from hypothyroidism.
Conclusion : Ascites as a cause of uncontrolled hypothyroid showed always be kept in the differential and replacement started early for improvement of symptoms.
University of Missouri- Kansas city, Missouri
University of Missouri- Kansas City, Missouri