Hypothyroidism as a cause of ileus after laparoscopic appendectomy

Nausea, vomiting, anorexia, and constipation are frequent symptoms of hypothyroidism with ileus and megacolon being rare and dangerous manifestations. Ileus and pseudo-obstruction have been described in newborns and infants with congenital hypothyroidism. In adults only limited data on hypothyroid-associated postoperative ileus are available.

A 53-year-old Caucasian woman presented with acute right lower quadrant pain. Computed tomography (CT) scan revealed appendicitis and the patient underwent laparoscopic appendectomy. She was discharged on postoperative day one with antibiotics for an incidentally noted Urinary tract infection (UTI) and antifungals for candida vaginosis. On postoperative day three, she developed abdominal distention and pain and nausea. She returned to the emergency department, where imaging demonstrated dilated bowel loops suggestive of small bowel obstruction or ileus. She was placed on bowel rest and a nasogastric tube (NGT) drained ample gastric contents. After initial improvement, she refused to keep the NGT. Within 24 hours she again developed abdominal distention and pain and chest discomfort, and cardiac workup was initiated. Troponins were negative and electrocardiogram (ECG) was negative for myocardial ischemia; however, low voltage QRS complexes were noted. Upon further questioning, the patient revealed that she had a diagnosis of mild hypothyroidism but had been weaned off her thyroxine three months ago. Her thyroxine stimulating hormone (TSH) was found elevated. Intravenous thyroid hormone replacement therapy was started and the patient improved overnight, passed ample gas and had multiple bowel movements. She was discharged with restored bowel function and much improved clinical condition with follow-up with endocrinology.

Hypothyroidism should be considered in patients with protracted postoperative ileus after abdominal surgery.