Case Report
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Surg Proced. Jul 15, 2022; 12(1): 8-12
Published online Jul 15, 2022. doi: 10.5412/wjsp.v12.i1.8
Rare case of perforated giant gastric ulcer with concurrent thyroid storm: A case report
Jasper Xiangwei Wang, Lin Seong Soh, Dinesh Carl Junis Mahendran, Chang Yi Woon, Clement Luck Khng Chia
Jasper Xiangwei Wang, Lin Seong Soh, Clement Luck Khng Chia, Department of General Surgery, Khoo Teck Puat Hospital, Singapore 768828, Singapore
Dinesh Carl Junis Mahendran, Department of Endocrinology, Khoo Teck Puat Hospital, Singapore 768828, Singapore
Chang Yi Woon, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
Author contributions: Wang JX, Soh LS, and Chia LKC were the patient’s general surgeons, reviewed the literature and contributed to manuscript drafting; Mahendran D performed the endocrinological consult for the patient, reviewed the literature, and contributed to manuscript drafting; Woon CY was responsible for the revision of the manuscript; all authors issued final approval for the version to be submitted.
Informed consent statement: Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Chang Yi Woon, MD, Doctor, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore 117597, Singapore 117597, Singapore. e0345822@u.nus.edu
Received: February 3, 2022
Peer-review started: February 3, 2022
First decision: March 12, 2022
Revised: March 27, 2022
Accepted: April 8, 2022
Article in press: April 8, 2022
Published online: July 15, 2022
Processing time: 159 Days and 15.9 Hours
Abstract
BACKGROUND

Thyroid storm is an uncommon condition manifesting in severe thyrotoxicosis with a high mortality rate. The concurrence of peptic ulcer disease and hyperthyroidism is rare due to concurrent activation of both the sympathetic and parasympathetic pathways. We present a case of perforated giant gastric ulcer with concurrent thyroid storm who underwent damage control surgery with emergency patch repair with falciform ligament and recovered well.

CASE SUMMARY

A 53-year-old male chronic smoker, with no previous medical history, presented with severe generalized abdominal pain and vomiting for one day duration. Further history revealed weight loss, diarrhea, and anxiety over the past three months. On clinical examination, patient was febrile with temperature of 38.6 Degrees Celsius and tachycardic at 130-140 beats per minute, his blood pressure was low at 90/50mmHg. His abdomen was tender with generalized peritonism. In view of his clinical history, a thyroid screen was ordered which showed raised thyroxine (T4) levels of 90.3 pmol/L and low thyroxine stimulating hormone (TSH) levels of 0.005 μU/mL. Chest X-ray showed no sub-diaphragmatic free air, but contrasted CT scan revealed pneumoperitoneum with large amount of intraabdominal free fluid. The working diagnosis was perforated peptic ulcer complicated by thyroid storm. An urgent endocrinologist consult was made, and patient was started on beta blocker and intravenous steroids pre-operatively. The patient underwent emergency laparotomy with washout and patch repair of the perforated gastric ulcer. Patient was monitored post-operatively in intensive care unit and required IV hydrocortisone and Lugol’s iodine. Histology of the ulcer edges showed no malignancy. On post-operative day seven, T4 decreased to 20.4 pmol/L, TSH was 0.005 mLU/L. His thyroid function test subsequently normalized 3 mo post-operatively with T4 18.1 pmol/L, TSH 1.91 mLU/L. Patient’s recovery was otherwise uneventful. Thyroid receptor antibody subsequently was positive, and patient was managed for Grave’s disease by the endocrinologist.

CONCLUSION

This case highlights the rare but life-threatening clinical emergency of peptic ulcer perforation complicated by thyroid storm. Multidisciplinary perioperative management is crucial to optimize patient for surgery and damage control principles should be taken for an acute surgical patient with concurrent endocrine crisis.

Keywords: Peptic ulcer; Perforated viscus; Thyroid storm; Multidisciplinary; Grave’s disease; Case report

Core Tip: Concurrent peptic ulcer perforation and thyroid storm is a rare but life-threatening surgical emergency. Multidisciplinary perioperative management is crucial to optimize patient for surgery, and damage control principles should be taken for an acute surgical patient with concurrent endocrine crisis.