What is the best course of action for an elderly patient with a history of thyroid cancer compressing on the dural canal, currently on dexamethasone (DEXA) twice a day, who has developed a perforated bowel and testicular edema?

Immediate Management of Perforated Bowel in a Dexamethasone-Treated Elderly Patient with Thyroid Cancer

This patient requires immediate surgical consultation for perforated bowel, discontinuation of dexamethasone, and initiation of stress-dose hydrocortisone to prevent adrenal crisis during the acute surgical emergency.

Critical First Steps

Discontinue dexamethasone immediately and transition to stress-dose hydrocortisone given the perforated bowel—a life-threatening complication directly linked to chronic glucocorticoid use 1. The perforation is likely secondary to the twice-daily dexamethasone regimen, as glucocorticoids significantly increase peptic ulceration risk, particularly in elderly patients 1.

Immediate Actions (Within Hours)

• Emergency surgical consultation for perforated bowel management—this is a surgical emergency requiring urgent intervention 1
• Start stress-dose hydrocortisone: 100 mg IV bolus, then 50 mg IV every 6-8 hours during the acute surgical period 2
• NPO status with nasogastric decompression if bowel obstruction present 1
• Broad-spectrum antibiotics for peritonitis
• Aggressive fluid resuscitation with isotonic saline for hypotension and electrolyte abnormalities 3

Dexamethasone Management

The dexamethasone must be stopped, not tapered, in this emergency setting, but glucocorticoid coverage must continue to prevent adrenal crisis 1, 3. The patient has been on dexamethasone twice daily for spinal cord compression from thyroid cancer, creating suppression of the hypothalamic-pituitary-adrenal axis 1.

Stress-Dose Steroid Protocol

• Intraoperative: Continue hydrocortisone 50 mg IV every 6-8 hours throughout surgery 2
• Postoperative days 1-2: Hydrocortisone 50 mg IV every 8 hours 2
• Days 3-5: Taper to hydrocortisone 25 mg IV every 8 hours if clinically stable
• Transition to oral: Once tolerating oral intake, switch to hydrocortisone 20 mg morning, 10 mg afternoon (physiologic replacement) 3

Testicular Edema Management

The testicular edema is likely multifactorial—related to both chronic dexamethasone use causing fluid retention and potential hypoalbuminemia from critical illness 1.

• Assess for scrotal wall involvement in peritonitis—examine for erythema, warmth, or crepitus suggesting extension of intra-abdominal infection
• Check serum albumin and nutritional status 1
• Avoid diuretics until hemodynamically stable and surgical intervention complete 3
• Supportive care with scrotal elevation once acute crisis resolved

Spinal Cord Compression Considerations

Do not restart high-dose dexamethasone for spinal cord compression after the acute surgical crisis, given the catastrophic complication of bowel perforation 1.

Alternative Management for Dural Canal Compression

• Urgent radiation oncology consultation for palliative external beam radiation therapy (EBRT) to the compressive thyroid mass—this is the definitive treatment for spinal cord compression from thyroid cancer 1
• Consider surgical decompression if neurologically unstable, though anaplastic thyroid carcinoma has poor prognosis and surgical morbidity is high in elderly patients 1
• Use lowest effective dexamethasone dose if neurologic symptoms worsen: 4 mg once daily maximum, not twice daily 1

Long-Term Glucocorticoid Strategy

After recovery from perforated bowel, the patient should receive only physiologic glucocorticoid replacement (hydrocortisone 15-25 mg daily in divided doses) rather than pharmacologic doses 1, 3.

If Vasogenic Edema Recurs

• Maximum dexamethasone: 4-8 mg once daily, not divided doses 1
• Duration: Minimize to shortest possible period, with aggressive taper 1
• Prophylaxis: Proton pump inhibitor mandatory if dexamethasone restarted 1
• Alternative: Consider bevacizumab or other anti-VEGF therapy for refractory vasogenic edema to avoid chronic steroids 1

Critical Pitfalls to Avoid

• Never abruptly stop all glucocorticoids in a patient on chronic dexamethasone—this causes adrenal crisis with cardiovascular collapse 3
• Do not restart dexamethasone BID after this complication—the risk of recurrent perforation or other serious adverse events (infections, neuropsychiatric symptoms) is unacceptably high in elderly patients 1, 4
• Avoid NSAIDs and anticoagulation until bowel integrity restored 1
• Do not delay surgery for perforated bowel—mortality increases dramatically with delayed intervention 1

Prognosis Discussion

Given the combination of thyroid cancer with spinal cord compression, perforated bowel, and elderly age, early palliative care consultation is essential 1. Anaplastic thyroid carcinoma (if that is the histology) has median survival of 5 months, and this patient has developed a life-threatening complication from treatment 1. Goals of care discussion should occur urgently with the patient and family regarding tracheostomy, aggressive interventions, and quality of life priorities 1.