TITLE:
Adrenal insufficiency and bowel obstruction: An overlooked association
AUTHORS:
Ryan A. Kunjal, Ria R. Ramadoo, Surujpal Teelucksingh, Vijay Naraynsingh
KEYWORDS:
Pseudo-Obstruction; Steroids; Adrenal Insufficiency
JOURNAL NAME:
Case Reports in Clinical Medicine,
Vol.2 No.2,
May
9,
2013
ABSTRACT: Bowel obstruction is a documented but rare
presentation of adrenal insufficiency (AI). We report a case of acute AI
manifesting as intestinal pseudo-obstruction (IPO) in a patient with
underlying iatrogenic adrenal suppression. An 83 years old female was admitted
for partial small bowel obstruction that failed to resolve with conservative
management. She then underwent exploratory laparotomy where no mechanical
obstruction was found and the small bowel was manually decompressed. Postoperatively she
developed acute swelling of her right ankle which was similar to mono-articular
attacks in the past. This was diagnosed clinically as gout. Her obstruction
failed to settle and a second laparotomy was done which yielded the same as the
first. Given her past account of arthritic pain, direct questioning of steroid
use unearthed a history of multiple intra-articular corticosteroid injections
for analgesia. She also described several short courses of high dose oral
steroids for respiratory tract infections, including a recent course which
was abruptly stopped two days prior to presentation. Clinical suspicion of AI
was supported by biochemical testing of stress cortisol levels and change in
the serum cortisol in response to 250 μg of synthetic adrenocorticotropic
hormone. Moreover, her improvement
following a therapeutic trial of steroid replacement was dramatic and strongly supports this diagnosis.
It is therefore worthwhile to consider a diagnosis of AI in cases of bowel obstruction in patients with comorbidities that predispose to steroid use and
especially in settings where steroid abuse is prevalent.