Constipation as a Chief Complaint of Uncontrolled Hypothyroidism

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.

A 61-year-old African American female (AAF) was admitted to the hospital with a chief complaint (CC) of bilateral (B) knee pain for 2 weeks. She was diagnosed with severe osteoarthritis (OA) and opioid pain medications were started.

The patient's last bowel movement (BM) was one week prior to admission and she did not have any BM after that despite multiple laxatives. She also admitted to feeling depressed.

Past medical history (PMH)

Hypertension (HTN), gout, COPD, hypothyroidism following a radioactive iodine treatment for hyperthyoridism in the remote past.

Medications

Telmisartan/hydrochlorothiazide (Micardis), furosemide (Lasix), levothyroxine (Synthroid) 100 mcg p.o. q.d, indomethacin, lorazepam.

Family history (FH)

Gout, stroke.

Physical examination

Obese lady in NAD.
VS 36.9-16-53-170/95.
Chest: CTA (B).
CVS: Clear S1S2.
Abdomen: Soft, NT, ND, absent BS.
Extremities: the knee examination showed bilateral knee swelling, left greater than right. No joint fluid. Joint tenderness was present. No pitting edema or cyanosis.

What happened?

The right knee X-rays showed severe degenerative joint disease and several loose bodies in the joint. An orthopedics consultation was called and the patient agreed to a total knee replacement at a later date.

Laboratory results


TSH and T4 levels.

What happened next?

TSH was 41.40 mU/L, and her Synthroid dose was increased to 150 mcg po qd. A selective serotonin reuptake inhibitor (SSRI) was started for depression.

The patient constipation persisted despite multiple medications prescribed for the problem.


A list of medications given for the constipation without success.

Her constipation gradually resolved with T4 replacement and lactulose. She will need a recheck of her TSH in 6-8 weeks.

Final diagnosis

Hypothyroidism.

What did we learn from this case?

Constipation is a classic presenting symptom of uncontrolled hypothyroidism.

Uncontrolled HTN and bradycardia are also common presenting symptoms of hypothyroidism.

Opiods, prescribed to this patient for knee pain, made the constipation worse. Most inpatients on opioid therapy will require a stimulant laxative such as senna 2 tabs PO QHS for regular BM.

References

Hypothyroidism. Bharaktiya et al. eMedicine Specialties, Endocrinology, Thyroid.
Hypothyroidism. Merck Manual.
Treatment of Hypothyroidism. AFP, November 15, 2001.
Constipation. Basson et al. eMedicine Specialties, Gastroenterology, Colon.
Approach to a low TSH level: Patience is a virtue — Cleveland Clinic Journal of Medicine, 2010 http://goo.gl/xY6r4

Published: 03/12/2004
Updated: 12/28/2009

2 comments:

  1. I saw that the recommendation for constipation due to chronic opiate use was Senna..however, doesn't senna lead to patients having complete dependency on it for BM due to melanosis colon? Wouldn't it be better to have pt's use something such as Zelnorm, so as to not have the pathological changes...just incase the chronic opiods can somehow be discontinued?

    ReplyDelete
  2. Zelnorm will be pulled from the market due to increase in CVS mortality:

    http://www.kevinmd.com/blog/2007/03/zelnorm-rip.html

    http://www.cbsnews.com/stories/2007/03/30/health/main2629037.shtml

    ReplyDelete