What can cause epigastric pain in a thyroid storm?

Causes of Epigastric Pain in Thyroid Storm

In thyroid storm, epigastric pain can result from gastrointestinal manifestations including vomiting, diarrhea, and abdominal cramping, which are common symptoms of this extreme hypermetabolic state. 1

Gastrointestinal Manifestations in Thyroid Storm

• Thyroid storm is characterized by a combination of signs and symptoms including fever, tachycardia out of proportion to fever, altered mental status, vomiting, diarrhea, and cardiac arrhythmia 1
• The extreme hypermetabolic state in thyroid storm affects multiple organ systems, including the gastrointestinal tract, leading to increased gastrointestinal motility 2
• Abdominal cramping and epigastric distress are recognized adverse effects of the hypermetabolic state and can manifest as epigastric pain 3

Specific Gastrointestinal Complications

• Gastric ulceration: Severe thyrotoxicosis can lead to increased acid production and reduced mucosal protection, potentially causing gastric ulcers that present with epigastric pain 4
• Acute gastritis: The hypermetabolic state can cause inflammation of the gastric mucosa 1
• Ischemic colitis: Beta-blocker treatment (commonly used in thyroid storm) can rarely cause mesenteric arterial thrombosis or ischemic colitis, which may present with abdominal pain 3

Diagnostic Considerations

• Diagnosis of thyroid storm is based on clinical presentation including fever, tachycardia, altered mental status, and gastrointestinal symptoms 1
• Laboratory confirmation includes suppressed TSH and elevated free T3 and T4 levels 5
• When epigastric pain is present, consider both thyroid storm-related causes and other potential etiologies such as:
  • Peptic ulcer disease 1
  • Gastroesophageal reflux disease 1
  • Gastritis 1
  • Pancreatitis (which can coexist with or be precipitated by thyroid storm) 1

Management Approach

• Treatment of thyroid storm should be initiated immediately and includes:

  • Antithyroid medications (propylthiouracil or methimazole) to block hormone synthesis 1
  • Beta-blockers (typically propranolol) to control hyperadrenergic symptoms 1
  • Iodide solutions to block thyroid hormone release 1
  • Corticosteroids to reduce T4 to T3 conversion 1
  • Supportive care including oxygen, antipyretics, and appropriate monitoring 1

• For epigastric pain specifically:

  • Identify and treat the underlying cause of thyroid storm 1
  • Consider gastric protection with proton pump inhibitors or H2 blockers 4
  • Evaluate for potential complications such as gastric perforation if pain is severe 4

Special Considerations and Pitfalls

• Beta-blockers, while essential in managing thyroid storm, can cause gastrointestinal side effects including epigastric distress, abdominal cramping, and nausea 3
• In rare cases, cardiovascular collapse can occur following beta-blocker administration in thyroid storm, particularly in patients with compromised cardiac function 6
• Calcium channel blockers (diltiazem or verapamil) may be considered as alternatives when beta-blockers are contraindicated 1
• Avoid delaying treatment of thyroid storm while waiting for laboratory confirmation, as mortality without treatment ranges from 80-100% 2