@article{AMJ12373,
author = {Jennifer Jörger and Stefanie Schwanda and Marianne Elisabeth Schönherr and Thomas Herren},
title = {Thyrotoxic crisis complicated by cardiogenic shock after laparoscopy for suspected acalculous cholecystitis and its successful medical treatment: a case report},
journal = {AME Medical Journal},
volume = {11},
number = {0},
year = {2026},
keywords = {},
abstract = {Background: The diagnosis of patients with acute abdominal pain is challenging. Diseases that can cause a “medical” acute abdomen include thyrotoxic crisis (TC), a life-threatening manifestation of thyrotoxicosis. Multifactorial abdominal pain may predominate over the classical signs of TC [sinus tachycardia or atrial fibrillation (AFib), heart failure, mental alterations, and hyperthermia]. Here, we report a patient with suspected acalculous cholecystitis, in whom TC and heart failure including cardiogenic shock were diagnosed postoperatively.Case Description: A previously healthy, anxious and febrile woman of African descent was admitted with upper abdominal pain spanning a two-week duration, and recurrent vomiting. She was hypertensive and had tachycardic atrial fibrillation without clinical signs of heart failure. The upper abdomen was tender to the touch with scant bowel sounds. Elevated inflammatory markers and a thickened gallbladder wall suggested acalculous cholecystitis. During the induction of anesthesia for planned cholecystectomy the patient became hypotensive, necessitating treatment with norepinephrine. Thyroid function tests, not available preoperatively, revealed overt thyrotoxicosis. TC with initially unrecognized Graves’ disease was diagnosed. Right heart failure, confirmed by echocardiography, has contributed to the abdominal pain, since intraoperatively the gallbladder was not inflamed, and the surgeon noted mild serous ascites. Beta-blockers were given to slow the heart rate, and diuretics to achieve a negative fluid balance. In the intensive care unit (ICU), cardiogenic shock was diagnosed, requiring optimized heart failure therapy including the inotrope levosimendan. Initial multimodal thyrostatic treatment consisted of betablockers, inhibitors of thyroid peroxidase (carbimazole), an iodine uptake inhibitor, and corticosteroids. Despite a theoretical recurrence risk of 40% the patient remained euthyreotic, and carbimazole treatment ended after 2 years. The medical therapy was effective and well tolerated.Conclusions: TC is a rare cause of the “medical” acute abdomen with a complex pathophysiology, including heart failure, and must be ruled out before a surgical intervention is indicated. The diagnosis of TC remains clinical. The routine measurement of thyroid-stimulating hormone (TSH) levels prior to surgery is recommended as a screening test. Once diagnosed, multimodal thyrostatic treatment of TC must be started immediately. Surgery can exacerbate a TC and may induce a cardiogenic shock, which needs targeted treatment in the ICU.},
issn = {2520-0518}, url = {https://amj.amegroups.org/article/view/12373}
}