“You mind taking a look? I’m stumped.”
Roger had just joined the emergency department staff, so I took his question as a good sign that he wasn’t letting ego get in the way of good medicine.
“Kim, 27 years old,” he began. “Off-and-on belly pain for five years.”
“That’s what she says. She comes in complaining that it’s much worse over the past two days. Mainly epigastric.” Roger pointed to the pit of his own stomach. “Heart rate was 130. So I worried about sepsis or bleeding. But she has no fever, her blood pressure’s good, labs are normal, and she’s not pregnant.”
The human heart normally contracts 60 to 100 times a minute. In young women, belly pain plus tachycardia, or increased heart rate, suggests bleeding from either a tubal pregnancy or a ruptured ovarian cyst.
“Maybe I’ll ultrasound her, just to be sure,” I said.
Ultrasound can find blood in the abdomen in seconds. We wheeled the machine to Kim’s bedside.
“Hi,” I said, smiling. “We’re just going to make sure everything’s OK in there.”
“An ultrasound?” she asked. “I’ve had those. And CT scans too. They can never find anything.”
I held the gel container above the smooth skin of her midriff. “When was that?”
“About a year ago.”
“Completely normal?” I asked as the overhead cardiac monitor flashed 130.
The ultrasound showed no internal bleeding. In addition, the liver, kidneys, and uterus all looked normal.
“Mind if I feel around a bit?” I asked, pressing my hand from the pelvis to her ribs. Only the area above the belly button seemed a bit tender. “Her abdomen is benign,” I said. “But that heart rate. Something’s up.”
“Maybe it’s high due to pain.”
“Tell you what,” I said. “Give her some morphine. If the heart rate stays up, we know it’s not the pain.”
Twenty minutes after the morphine, we reconvened at the bedside. The pain was gone. But the monitor read 125.
“That high heart rate is real,” Roger muttered.
“You have to explain tachycardia. Always. What about thyroid?”
“I asked the questions: No weight loss, no heat intolerance, no hair thinning, no change in menstrual pattern. No sign of enlarged thyroid gland.”
“I’ve never heard of thyroid causing belly pain. Diarrhea and menstrual changes, yes. Abdominal pain, no,” I mused out loud.
The thyroid is the get-up-and-go gland. Perched at the base of the throat and winged like a butterfly, it weighs less than an ounce. It drives the body’s metabolism with two hormones that set the burn rate of every living cell. The thyroid, in turn, is regulated by the pituitary, the master gland that lies deep within the brain.
Hyperthyroidism — too much hormone — trips us into overdrive: Fat and muscle melt away, the heart rate speeds up, the room seems too hot, hands tremble, nerves jangle, osteoporosis accelerates, and anxiety — even paranoia — hits. At the extreme, a so-called thyroid storm can precipitate blistering fevers, delirium, seizures, even death. The opposite problem — hypothyroidism — puts the brakes on the metabolism. The waistline balloons, the room seems too cold, hands tingle, the voice coarsens, and everyday tasks loom like a slog up Mount Everest. Allowed to progress, severe hypothyroidism can drop the body into a deadly coma.
Diagnosis, doctors are taught, is straightforward — the speedup and slowdown symptoms are unmistakable. But the thyroid can play more tricks than Houdini. Besides the expected symptoms of jitteriness or fatigue, weight loss or gain, and personality changes (which can do a good job of mimicking the ups and downs of normal living), patients often complain of things that have nothing to do with metabolic rate: ear pain, voice alterations, facial swelling, constipation, and stomach upset.
Further muddying the diagnostic waters are the paradoxical reactions: The elderly may manifest hyperthyroidism as apathy, depression, and dementia, a slowing down rather than the expected speeding up. In one recent study, 55 women with suspected thyroid dysfunction were examined by three different endocrinologists. The three agreed on a diagnosis in only 60 percent of the cases. Yet some 13 million Americans, including the first President Bush, suffer from some form of thyroid disease, so even a modest rate of error can translate into tens of thousands of missed cases.
In this case abdominal pain did not ring a bell. Still, I told Roger I’d double-check. The chapter on hyperthyroidism in Harrison’s Principles of Internal Medicine lists a table of symptoms. I scanned it twice: No abdominal pain.
We returned to Kim’s bedside.
“And your periods have been regular?” I asked.
“Yes, doctor,” she replied.
“Do you ever get nervous, shaky?”
“Well, I worry about this pain.”
“Can you hold out your hands for me?”
She held them out like a diver on a board: No tremor. I gently propped up her right knee and tapped on the patellar tendon with my middle finger. The lower leg jerked, but it wasn’t a bounce-off-the-ceiling hyperthyroid reflex.
I felt her belly one more time: soft. I told Roger there was no need for a CT scan.
I told Kim, “You’re going to be OK.” She gave me a relieved smile and spared me the embarrassing question: Then why does my stomach hurt on and off?
Two hours later, I saw Roger preparing to discharge her. A sheepish grin played on his face.
“You were right,” he said. “The CT scan I took was negative.”
“Did you do the thyroid tests?”
“A thyroid problem seems like a stretch,” he said.
“But the tachycardia . . .”
“I sent ’em, I sent ’em,” he said, laughing. “They just take two days.”
Worldwide, the bulk of thyroid disease arises from iodine deficiency. The thyroid gland needs iodine to make its hormone, and if the diet is iodine-poor, the thyroid gland must work harder to produce an ever-dwindling amount of hormone. In the process, the gland often balloons into an unsightly neck mass called a goiter.
Nowadays, with iodine in common table salt, the vast majority of cases in the United States arise from a mysterious cause: autoimmunity in the form of antibodies that attack home turf. One type of autoantibody mimics the pituitary hormone that stimulates the thyroid, hoodwinking it—despite the pituitary’s shutting off its own secretion of thyroid-stimulating hormone—into massive overproduction.
The result is Graves’ disease, the most common form of hyperthyroidism, best known for the eye-bulging look it confers as a result of the antibodies stimulating connective-tissue cells behind the eyes. Another type of autoantibody can attack the thyroid itself, destroying the gland. So women—who are much more prone than men to autoimmune disorders—are 5 to 10 times more likely to suffer from various thyroid diseases.
Confusing as the clinical picture is, laboratory diagnosis has become a snap, thanks to sensitive new tests of the pituitary’s thyroid-stimulating hormone, or TSH: A low TSH means the pituitary is trying to rein in a runaway thyroid; high TSH equals hypothyroidism. Some experts even advocate routine screening of such high-risk groups as postmenopausal women. The mainstay of treatment for hyperthyroidism is radioactive iodine, which homes in on the gland and prunes it back; for hypothyroidism, a once-a-day supplement of thyroid hormone usually does the trick.
Two days later, I cornered Roger.
“Well?” I asked.
“TSH practically zero. The T4 was 26,” Roger said, meaning that Kim’s thyroid hormone was twice the normal level. He shook his head and muttered, “Remarkable.”
In 1931 the physician J. R. Verbrycke reported on 34 cases of “gastrointestinal hyperthyroidism” that he had diagnosed over three years. He admitted becoming clued in only after someone in his family had it, and he cringed at the misdiagnoses he might have committed up to that point.
I surveyed half a dozen medical textbooks. Some do mention abdominal pain as a possible symptom of hyperthyroidism. Those that don’t, keeping excellent company with two emergency doctors of my acquaintance, prove again the old adage “The only thing new is the history you don’t know yet.”
Three months later, I called Kim to ask how the treatment for Graves’ disease was going. Fine, she told me.
And the belly pain? “All gone, doctor.”
Tony Dajer is assistant director of the emergency department at New York University Downtown Hospital in Manhattan. The cases described in Vital Signs are true stories, but the authors have changed some details about the patients to protect their privacy.