Most Likely Cause of UGIB in Concurrent Thyroid Storm and DKA
In a patient presenting with both thyroid storm and diabetic ketoacidosis, the most likely cause of upper gastrointestinal bleeding is stress-related mucosal disease (gastroduodenal erosions), which develops secondary to the severe physiologic stress of these concurrent endocrine emergencies.
Primary Etiology
Stress-related gastroduodenal erosions are the predominant cause in this clinical scenario because:
- Critically ill patients with severe metabolic derangements are particularly susceptible to stress-related mucosal disease 1
- Both thyroid storm and DKA create a hypermetabolic, hypercatabolic state that predisposes to mucosal breakdown 2, 3
- The combination represents dual endocrine emergencies with profound physiologic stress 4, 5
Differential Considerations
While stress erosions are most likely, other causes must be considered based on epidemiologic data:
Common UGIB Causes (in descending frequency):
- Peptic ulcer disease (35-50%): Most common cause of nonvariceal UGIB overall, related to H. pylori or NSAID use 6, 7
- Gastroduodenal erosions (8-15%): Elevated risk in critically ill patients with metabolic derangements 6, 1
- Mallory-Weiss tears (15%): Relevant given the frequent vomiting associated with both DKA and thyroid storm 6, 4
- Esophagitis (5-15%): Can occur with repeated vomiting 6
Clinical Context Supporting Stress-Related Bleeding
The concurrent presentation creates unique risk factors:
- Metabolic acidosis from DKA impairs mucosal defense mechanisms 2, 4
- Hyperthermia and tachycardia from thyroid storm increase metabolic demands and reduce splanchnic perfusion 4, 5
- Gastrointestinal symptoms (nausea, vomiting, abdominal pain) are prominent in both conditions and can precipitate Mallory-Weiss tears 2, 4, 5
- Poor medication compliance is documented in most reported cases, potentially indicating lack of PPI prophylaxis 5
Critical Diagnostic Pitfalls
Each condition can mask the other, creating diagnostic challenges:
- DKA symptoms (tachycardia, altered mental status, fever) overlap with thyroid storm features 2, 4
- Thyroid storm may be the precipitating factor for DKA rather than a coincidental finding 2, 4
- Mortality reaches 15% when both conditions coexist, emphasizing the need for simultaneous recognition and treatment 5
Management Implications
Esophagogastroduodenoscopy remains the first-line diagnostic and therapeutic investigation once hemodynamic stability is achieved 6, 1. However, initial management priorities include:
- Simultaneous treatment of both endocrine emergencies (insulin for DKA; thionamides, beta-blockers, and iodine for thyroid storm) 4, 5
- Aggressive fluid resuscitation and hemodynamic stabilization 6, 1
- PPI therapy for stress ulcer prophylaxis in this critically ill population 1
The combination of thyroid storm and DKA represents a life-threatening dual endocrine emergency where stress-related mucosal injury is the most probable bleeding source, though peptic ulcer disease and Mallory-Weiss tears remain important differential considerations 6, 1, 4, 5.