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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 11  |  Issue : 2  |  Page : 76-77

'Graves' disease: A rare cause of cholestasıs


1 Department of Gastroenterology, Sakarya Unıversity, Sakarya, Turkey
2 Department of Internal Medicine, Sakarya Unıversity, Sakarya, Turkey
3 Department of General Surgery, Sakarya Unıversity, Sakarya, Turkey
4 Department of Endocrinology, Sakarya Unıversity, Sakarya, Turkey

Date of Web Publication31-Mar-2014

Correspondence Address:
Ahmet Tarik Eminler
Department of Gastroenterology, Faculty of Medicine, Sakarya University, Korucuk Campus - 541 00, Sakarya
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-0354.129735

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  Abstract 

Rarely, intrahepatic cholestasis may occur during the course of Graves' disease. It is important to rule out other causes of intrahepatic cholestasis for diagnosis. In this article, we present a case of intrahepatic cholestasis due to Graves' disease in a 52-year-old male patient with jaundice, pruritus, and weight loss.

Keywords: Cholestasis, graves′disease, thyroidectomy


How to cite this article:
Eminler AT, Olt S, Uslan MI, Ozkan OV, Yaylaci S, Garip T, Celebi F. 'Graves' disease: A rare cause of cholestasıs. Thyroid Res Pract 2014;11:76-7

How to cite this URL:
Eminler AT, Olt S, Uslan MI, Ozkan OV, Yaylaci S, Garip T, Celebi F. 'Graves' disease: A rare cause of cholestasıs. Thyroid Res Pract [serial online] 2014 [cited 2019 Oct 15];11:76-7. Available from: http://www.thetrp.net/text.asp?2014/11/2/76/129735


  Introduction Top


Cholestasis is a condition that can occur for many reasons. After the decrease in bile flow, it is histopathologically characterized by the increase of bile pigment in hepatocytes and bile ducts, and clinically characterized by the accumulation of substances such as bilirubin, bile acids and cholesterol in serum and various tissues, which are normally excreted into bile. Impaired bile formation in hepatocytes, intrahepatic or extrahepatic obstruction of bile channels lead to cholestasis. Causes of cholestasis include viral hepatitis, metabolic, autoimmune, toxic, and idiopathic reasons and obstruction of the bile ducts.

Graves' disease is a thyroid gland disorder with hyperthyroidism and intrahepatic cholestasis rarely can be seen during the course of this disease. [1],[2] In this report, we presented a case with intrahepatic cholestasis due to Graves' disease.


  Case Report Top


A 52-year-old male patient was admitted to our gastroenterology clinic with a history of jaundice which affected the whole body, itching, and weight loss for 3 months and increased for the last 10 days. The patient was diagnosed as Graves' disease one month ago and methimazole and propranolol were prescribed 10 mg every eight hours and 40 mg twice daily, respectively. But the patient discontinued the treatment on the second day, and the scleras of the patient were icteric for the beginning of treatment. His vital signs were stable: blood pressure was 120/80 mmHg, pulse rate 80 per minute, and fever 37.2°C. Physical examination was normal except for jaundice and no signs of chronic liver disease were observed. The patient's laboratory tests showed overt hyperthyroidism and cholestasis [Table 1]. Thyroid scintigraphy showed diffuse 99m Tc pertechnetate distribution with an increased uptake of 37.1%. Thyroid ultrasound determined the findings in favor of with thyroiditis, and consequently Graves' disease was diagnosed.
Table 1: Laboratory parameters of the patient

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A dilatation of the bile ducts was not detected in abdominal sonography, computerized tomography and magnetic resonance cholangiography and extrahepatic cholestasis was excluded. For the diagnosis of intrahepatic cholestasis, toxic reasons were ruled out due to lack of history of drug use and toxic substances. Serologies for Hepatitis B, Hepatitis C, Cytomegalovirus, Herpes Simplex Virus, Toxoplasma, Rubella, Leptospira and Brucella were negative. Antinuclear antibody, smooth muscle antibody, liver/kidney microsomal antibody type 1 were also negative and ferritin, ceruloplasmin and reticulocyte count were within normal limits. Echocardiographic evaluation of cardiac function was completely normal. We considered that the diagnosis was Graves' disease-induced cholestasis. Dexamethasone 8 mg every six hours, methimazole 5 mg twice daily, Lugol's 5 drops every eight hours and propranolol 20 mg twice daily were started. After 10 days of the treatment, tests for thyroid functions and chloestasis improved [Table 1].

In the stage of subclinical hyperthyroidism of the patient, we requested a general surgery consult and total thyroidectomy was performed. After thyroidectomy, markers for cholestasis ​​decreased to nearly normal limits.


  Discussion Top


The role of thyroid disease are rare in the pathogenesis of cholestatic syndrome. Thyrotoxicosis induced cholestasis should be considered in case of hyperthyroidism and cholestasis occuring at the same time after exclusion of congestive heart failure, infective, toxic, and obstructive liver damage. Hyperthyroidism may rarely present as severe cholestasis.

Thyroid disease and liver disease association rarely reported in the literature. [2],[3],[4] In patients with Graves' disease and subacute thyroiditis, elevation of liver enzymes and liver damage due to elevated thyroid hormones can be seen. [2] Although liver injury associated with thyroid hyperfunction is known for a long time, the underlying mechanism are unknown. Possible explanations could be direct toxic effects of thyroid hormones on hepatocytes, distant organ dysfunction affecting liver and hepatic ischemia due to peripheral vasodilation. [5],[6] Liver disease associated with hyperthyroidism may range from mild liver enzyme elevations to serious hepatic ischemia. [5],[7] In literature, it has been reported that cases showed an improvement in clinical and laboratory findings after antithyroid therapy and/or thyroidectomy. [8],[9],[10]

In our case, Graves' disease was considered as a cause of intrahepatic cholestasis after excluding other reasons by blood tests and imaging methods for the differential diagnosis of cholestasis. After treatment, improvement in the patient's jaundice has strengthened this opinion. Consequently, we intended to highlight Graves' disease may present with intrahepatic cholestasis, and medical or surgical antithyroid therapy may improve all clinical and laboratory parameters.

 
  References Top

1.Raviolo P, Rizzetto M, Tabone M, De La Pierre M, Recchia S, Verme G. Intrahepatic cholestasis in hyperthyroidism. Recenti Prog Med 1991;82:319-23.  Back to cited text no. 1
    
2.Malik R, Hodgson H. The relationship between the thyroid gland and the liver. QJM 2002;95:559-69.  Back to cited text no. 2
    
3.Dooner HP, Parada J, Aliaga C, Hoyl C. The liver in thyrotoxicosis. Arch Intern Med 1967;120:25-32.  Back to cited text no. 3
[PUBMED]    
4.Loria P, Carulli L, Bertolotti M, Lonardo A. Endocrine and liver interaction: The role of endocrine pathways in NASH. Nat Rev Gastroenterol Hepatol 2009;6:236-47.  Back to cited text no. 4
    
5.Choudhary AM, Roberts I. Thyroid storm presenting with liver failure. J Clin Gastroenterol 1999;29:318-21.  Back to cited text no. 5
    
6.Jiang YZ, Hutchinson KA, Bartelloni P, Manthous CA. Thyroid storm presenting as multiple organ dysfunction syndrome. Chest 2000;118:877-9.  Back to cited text no. 6
    
7.Inoue T, Tanigawa K, Furuya H, Nakano A, Notsu K, Note S, et al. A case of thyroid crisis complicated with acute hepatic failure. Nihon Naika Gakkai Zasshi 1988;77:564-7.  Back to cited text no. 7
[PUBMED]    
8.Abdel Khalek M, Abd ElMageed Z, Khan A, Broussard G, Kandil E. Cholestatic hepatitis in a patient with Graves' disease resolved with total thyroidectomy. Trop Gastroenterol 2011;32:328-30.  Back to cited text no. 8
    
9.Regelmann MO, Miloh T, Arnon R, Morotti R, Kerkar N, Rapaport R. Graves' disease presenting with severe cholestasis. Thyroid 2012;22:437-9.  Back to cited text no. 9
    
10.Soysal D, Tatar E, Solmaz S, Kabayegit O, Tunankan M, Unsal B, et al. A case of severe cholestatic jaundice associated with Graves' disease. Turk J Gastroenterol 2008;19:77-9.  Back to cited text no. 10
    



 
 
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