“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.
Graphic by Don Foley
The pea-size pituitary gland (pink) lies at the base of the brain and regulates the function of the thyroid gland (red). Growth, metabolism, and cell differentiation all depend on thyroid hormones.
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.