What other autoimmune diseases in a patient with Hashimoto's (Hashimoto's thyroiditis) thyroiditis may cause chronic nausea?

Autoimmune Diseases Associated with Hashimoto's That May Cause Chronic Nausea

In patients with Hashimoto's thyroiditis presenting with chronic nausea, celiac disease and autoimmune hepatitis are the most important autoimmune conditions to investigate, as both are significantly more prevalent in this population and directly cause gastrointestinal symptoms including nausea. 1

Primary Autoimmune Conditions to Consider

Celiac Disease

• Celiac disease occurs in 2.8-3.5% of patients with autoimmune hepatitis (AIH), which is substantially higher than the general population 1
• Among Italian children with AIH, celiac disease was present in 16% 1
• Nausea is a prominent gastrointestinal symptom of celiac disease, along with malabsorption that can affect medication absorption 1
• Laboratory and serological features of celiac disease can overlap with AIH, potentially complicating diagnosis 1

Autoimmune Hepatitis

• AIH is one of the most common concurrent autoimmune diseases in patients with autoimmune thyroid disorders, accounting for approximately 10.2-14.1% of all concomitant autoimmune diseases 2
• Nausea is often a prominent symptom in AIH patients, frequently accompanied by anorexia, weight loss, and general ill health 1
• Nausea can be present even in asymptomatic patients with AIH who have cirrhosis 1
• In acute presentations of AIH, nausea may be preceded by influenza-like symptoms and can be severe 1

Inflammatory Bowel Disease (IBD)

• Ulcerative colitis is among the most common immune-mediated disorders associated with AIH in North American adults 1
• IBD is a recognized extrahepatic manifestation of autoimmune disease in patients with AIH 1
• Chronic nausea can occur as part of the gastrointestinal symptom complex in IBD patients 1

Secondary Autoimmune Conditions Associated with Hashimoto's

Type 1 Diabetes Mellitus

• Development of nausea and vomiting should prompt investigation for possible type 1 diabetes mellitus (T1DM) 1
• T1DM is one of the most common concurrent disorders in European patients with autoimmune liver disease 1
• Diabetic gastroparesis can cause chronic nausea in patients with poorly controlled T1DM 1

Addison's Disease (Primary Adrenal Insufficiency)

• Autoimmune thyroiditis is frequently associated with Addison's disease, often as part of polyglandular autoimmune syndrome type 2 3
• Nausea and vomiting are cardinal symptoms of adrenal insufficiency 1
• This can present insidiously with chronic nausea, fatigue, and weight loss 1

Clinical Approach to Evaluation

Initial Screening Tests

• Celiac serology: Tissue transglutaminase antibodies (tTG-IgA) with total IgA level 1
• Liver function tests: AST, ALT, alkaline phosphatase, bilirubin, and serum IgG levels to screen for AIH 1
• Fasting glucose and HbA1c: To evaluate for diabetes mellitus 1
• Morning cortisol and ACTH: If adrenal insufficiency is suspected 1

Additional Autoantibody Testing

• ANA, SMA, and anti-LKM1 for autoimmune hepatitis if liver enzymes are elevated 1
• Anti-endomysial antibodies if celiac disease is suspected 1
• Consider screening for other autoimmune conditions based on clinical presentation 2

Important Clinical Considerations

Concurrent Disease Patterns

• 14-44% of patients with AIH have concurrent immune diseases 1
• Patients with HLA DRB1*04:01 or a family history of autoimmune disease in first-degree relatives have higher rates of concurrent autoimmune conditions 1
• Extended diagnostic screening for other autoimmune diseases should be conducted both at diagnosis and at regular intervals during follow-up 2

Age-Related Patterns

• Patients aged ≥60 years have autoimmune thyroid and rheumatic diseases more commonly than adults ≤30 years (42% versus 13%) 1
• Young adults more often have IBD and autoimmune hemolytic anemia (13% versus 0%) 1

Critical Pitfalls to Avoid

• Do not attribute all symptoms to hypothyroidism alone, even if thyroid function tests are normal 4
• Malabsorption from celiac disease can affect absorption of thyroid hormone replacement and other medications 1
• Concurrent celiac disease may contribute to the degree of liver damage in patients with AIH 1
• Pediatric patients with AIH and celiac disease who avoided gluten had higher frequencies of sustained remission (33% versus 8%) 1