Central congestive fibrosis of the liver in myxedema ascites

Retrospective study of the influence of hypothyroidism on liver function before radioiodine therapy in China: a comparison analysis based on patients with differentiated thyroid cancer

PURPOSE

The aim of the present study is to investigate the risk factors for hepatic dysfunction before radioiodine therapy in patients with differentiated thyroid cancer (DTC).

METHODS

996 patients (314 men, 682 women; age of 45.07±12.98 years) with postoperative DTC were recruited and divided into two groups including patients with and without hepatic dysfunction. The changes in baseline data and traced liver function levels, together with other metabolic profiles, were compared between the two groups.

RESULT

Overall, 31.6% of patients had hepatic dysfunction. Higher aspartate aminotransferase and/or alanine aminotransferase was the most common abnormality (the prevalence rate was 47.5%). The percentages of mild and moderate hepatic dysfunction were 80.0% and 20.0%, respectively. Univariate analyses demonstrated that the most prominent risk factors for hepatic dysfunction (OR=0.324-3.171, p<0.01) were male sex with levothyroxine discontinuation and free triiodothyronine <2.01 pmol/L, free thyroxine (FT₄) <4.78 pmol/L, thyroid-stimulating hormone >78.195 µIU/mL, total cholesterol >5.17 mmol/L, triglycerides (TG) >1.71 mmol/L and more than 21 days of thyroid hormone withdrawal. Multivariate analyses demonstrated that for men, FT₄ <3.80 pmol/L and TG ≥1.28 mmol/L were the most prominent risk factors.

CONCLUSIONS

Patients with minor hepatic dysfunction and ortholiposis are more likely to recover to normal liver function. Patients with moderate hepatic dysfunction should be treated with hepatoprotective drugs. For men, FT₄ and TG levels tended to be associated with hepatic dysfunction, and the prognosis of hepatic dysfunction was closely related to the TG level.

Beyond MELD Predictors of Post TIPSS Acute Liver Failure the Lesson Learned

TIPSS is safe and effective procedure for relieving portal hypertension by creating a low resistance portosystemic shunt. TIPSS reduces portal perfusion by 80 to 100% which then gradually gets partially compensated by increased flow from hepatic artery. Post TIPSS liver function shows brief deterioration which tends to start recovering in few weeks. However, progressive liver failure requiring emergency transplant or death remains a serious concern after TIPSS creation. The causes of post TIPSS liver failure are diverse and difficult to predict. Due to its rarity the definition of post TIPSS liver decompensation is also not well described in literature. Till date MELDNa score has been considered as the most reliable predictor of post TIPSS liver decompensation. In common practice post TIPSS liver failure is less likely in patients with model for end-stage liver disease (MELD) score less than 18. We have experienced two unusual cases of post-TIPSS liver failure (PTLF) in patients with initial acceptable/low MELD score and the importance of non-MELD factors that may negatively influence post TIPSS outcome. Most of these can be routinely investigated prior to creating shunt thereby identifying patients at high risk of developing PTLF.

Case of acute mixed liver injury due to hypothyroidism

The effects of hypothyroidism on the liver are not well understood. A 77-year-old woman with Hashimoto's thyroiditis had stopped taking levothyroxine on her own for 6 months. Her thyroid stimulating hormone (TSH) level was consistent with severe hypothyroidism. She resumed thyroid replacement therapy. The following month, her liver function tests were significantly elevated. Seven weeks after resumption of therapy, her TSH and liver tests had returned to normal. We attribute the mixed hepatocellular injury to hypothyroidism that resolved on correction of the hypothyroid state. This case reminds us that thyroid disease should be considered when evaluating acute liver injury.

Liver abnormalities and endocrine diseases

The liver and its pleotropic functions play a fundamental role in regulating metabolism, and is also an inevitable target of multiple metabolic disorders. The numerous and constant relationships and feedback mechanisms between the liver and all endocrine organs is reflected by the fact that an alteration of one oftentimes results in the malfunction of the other. Hypo- and hyperthyroidism are frequently associated with hepatic alterations, and thyroid diseases must be excluded in transaminase elevation of unknown cause. Drugs such as propylthiouracil, used in the treatment of hyperthyroidism, may induce liver damage, and other drugs such as amiodarone, carbamazepine, and several chemotherapeutic agents can lead to both thyroid and liver abnormalities. Liver diseases such as hepatitis, hepatocellular carcinoma, and cirrhosis may cause altered levels of thyroid hormones, and alcoholic liver disease, both due to the noxious substance ethanol as well as to the hepatic damage it causes, may be responsible for altered thyroid function. Both excess and insufficiency of adrenal function may result in altered liver function, and adrenocortical dysfunction may be present in patients with cirrhosis, especially during episodes of decompensation. Again an important player which affects both the endocrine system and the liver, alcohol may be associated with pseudo-Cushing syndrome. Sex hormones, both intrinsic as well as extrinsically administered, have an important impact on liver function. While oestrogens are related to cholestatic liver damage, androgens are the culprit of adenomas and hepatocellular carcinoma, among others. Chronic liver disease, on the other hand, has profound repercussions on sex hormone metabolism, inducing feminization in men and infertility and amenorrhoea in women. Lastly, metabolic syndrome, the pandemia of the present and future centuries, links the spectrum of liver damage ranging from steatosis to cirrhosis, to the array of endocrine alterations that are features of the syndrome, including insulin resistance, central obesity, and hyperlipidaemia. Clinical practice must integrally evaluate the effects of the intricate and tight relationship between the liver and the endocrine system, in order to better address all manifestations, complications, and prevent deterioration of one or the other organ-system.

Comparison of the Influence on the Liver Function Between Thyroid Hormone Withdrawal and rh-TSH Before High-Dose Radioiodine Therapy in Patients with Well-Differentiated Thyroid Cancer

PURPOSE

An elevated thyroid stimulating hormone level (TSH) is essential to stimulate the uptake of radioiodine into thyroid remnants and metastases of thyroid cancer when a patient undergoes high-dose radioiodine therapy. Nowadays, recombinant human thyroid stimulating hormone (rh-TSH) is increasingly used instead of the classic method of thyroid hormone withdrawal (THW). However, beyond the therapeutic effects, clinical differences between the two methods have not yet been clearly demonstrated. The aim of this work was to investigate the effects of the two methods, especially on liver function.

METHODS

We identified 143 evaluable patients who were further divided into two groups: THW and rh-TSH. We first reviewed the aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels, which were measured during the admission period for total thyroidectomy. We called these liver enzyme levels "base AST" and "base ALT." We also assessed other chemistry profiles, including AST, ALT, total cholesterol, LDL cholesterol, alkaline phosphatase (ALP), total bilirubin (TB), and triglyceride (TG), which were measured on admission day for high-dose radioiodine therapy. We called these liver enzyme levels "follow-up AST" and "follow-up ALT." We compared the changes in base and follow-up liver enzyme levels and the other chemistry profiles between the two groups.

RESULTS

The base AST and base ALT levels of the two groups were within normal range, and there was no significant difference between the two groups. In contrast to these base liver enzyme levels, follow-up liver enzyme levels between the two groups showed significant differences. Patients in the THW group had higher follow-up AST and ALT levels than did the rh-TSH group. Patients in the THW group also had higher levels of total cholesterol and LDL cholesterol than did the patients in the rh-TSH group. However there were no statistically significant differences in ALP, total bilirubin, and triglyceride levels between the two groups.

CONCLUSIONS

In this retrospective analysis of liver function, the use of rh-TSH for high-dose radioiodine therapy had less of an effect on liver function and cholesterol levels than dose thyroid hormone withdrawal. This suggests that rh-TSH can be used effectively and safely especially for patients with metabolic syndrome.

Endocrine diseases and the liver

Liver disease and endocrine disorders, both common in the general population, have a bidirectional and complex relationship. Certain liver diseases are more commonly associated with endocrine disorders, including nonalcoholic fatty liver disease, autoimmune hepatitis, and primary biliary cirrhosis. There may be an association between hepatitis C and type 2 diabetes mellitus as well as thyroid disorders, and sex hormonal preparations may cause specific hepatic lesions. The presence of relative adrenal insufficiency in patients with end-stage liver disease may have therapeutic implications in patients admitted with acute-on-chronic liver failure. The objective of this review is to focus on the effect of endocrine disorders on liver.

Consequences of dysthyroidism on the digestive tract and viscera

Thyroid hormones define basal metabolism throughout the body, particularly in the intestine and viscera. Gastrointestinal manifestations of dysthyroidism are numerous and involve all portions of the tract. Thyroid hormone action on motility has been widely studied, but more complex pathophysiologic mechanisms have been indicated by some studies although these are not fully understood. Both thyroid hormone excess and deficiency can have similar digestive manifestations, such as diarrhea, although the mechanism is different in each situation. The liver is the most affected organ in both hypo- and hyperthyroidism. Specific digestive diseases may be associated with autoimmune thyroid processes, such as Hashimoto’s thyroiditis and Grave’s disease. Among them, celiac sprue and primary biliary cirrhosis are the most frequent although a clear common mechanism has never been proven. Overall, thyroid-related digestive manifestations were described decades ago but studies are still needed in order to confirm old concepts or elucidate undiscovered mechanisms. All practitioners must be aware of digestive symptoms due to dysthyroidism in order to avoid misdiagnosis of rare but potentially lethal situations.

Severe ascites with hypothyroidism and elevated CA125 concentration: a case report

Ascites caused by hypothyroidism is rare and the pathogenesis is unclear. Several reports have presented cases of progressive ascites with hypothyroidism and elevated tumor markers. We report a 31-year-old female case with massive ascites and elevated serum CA 125 concentrations. The patient had no typical feature of hypothyroidism except an accumulation of ascitic fluid which showed elevated total protein concentration and a high serum-ascites albumin gradient (SAAG). There was no finding of malignancy. Following thyroid hormone replacement, the ascites was completely resolved accompanied by reduced concentrations of serum CA125. In general, primary hypothyroidism with ascites presents with coexisting massive pericardial or pleural effusion. The massive ascites and increased serum CA125 concentrations may have led us to make the incorrect diagnosis of ovarian malignancy. The evaluation of thyroid function is useful to determine the pathology of high-protein ascites or elevated tumor markers, and ascites may be treatable by thyroid replacement therapy.

Hyperammonemic coma--barking up the wrong tree

Hepatic encephalopathy and myxedema coma share clinical features: coma, ascites, anemia, impaired liver functions, and a "metabolic" electroencephalogram (EEG). Hyperammonemia, a hallmark of hepatic encephalopathy, has also been described in hypothyroidism. Differentiation between the 2 conditions, recognition of their possible coexistence, and the consequent therapeutic implications are of utmost importance. We describe a case of an 82-year-old woman with a history of mild chronic liver disease who presented with hyperammonemic coma unresponsive to conventional therapy. Further investigation disclosed severe hypothyroidism. Thyroid hormone replacement resulted in gain of consciousness and normalization of hyperammonemia. In patients with an elevated ammonia level, altered mental status, and liver disease, who do not have a clear inciting event for liver disease decompensation, overwhelming evidence of hepatic decompensation, or who do not respond to appropriate therapy for hepatic encephalopathy, hypothyroidism should be considered and evaluated.

Symptomatic ascites in a patient with hypothyroidism of short duration

Symptomatic ascites as a presenting symptom of hypothyroidism is quite rare. In most of the case reports, patients with ascites requiring therapeutic abdominal paracentesis have long-standing hypothyroidism. We present a case of symptomatic ascites in a subject with hypothyroidism following radioiodine therapy for Graves disease. A 70-year-old African-American man presented with increasing weakness, shortness of breath, weight gain, constipation, and abdominal distention. Past history was significant for coronary artery disease, diabetes, hypertension and history of radioiodine therapy for Graves disease 9 months prior to the presentation. He was taking levothyroxine at 50 microg per day for 3 months prior to the presentation. Physical examination findings were significant for puffiness around the eyes, decreased breath sounds at the lung bases, and distended abdomen with free fluid, hung-up reflexes, and cold extremities. The thyroid-stimulating hormone level at the time was 64 with a free T4 less than 0.4 ng/dL. Analysis of the ascitic fluid revealed an exudative effusion with a serum to ascitic fluid albumin gradient of 1.2. The patient required therapeutic abdominal paracentesis twice, with 4 L each time, to relieve the symptoms. Work-up to rule out other causes did not reveal any other relevant abnormality. After initiation of thyroid hormone replacement, the patient responded very well and the ascites resolved within 2 months. We conclude that ascites associated with hypothyroidism is rare but must be recognized early, since thyroid replacement is the definitive therapy.

The liver in other (nondiabetic) endocrine disorders

The liver has a major role in the proper maintenance of intermediate metabolism and endocrine homeostasis. It contains enzymes that are essential for hormonal biotransformation and the regulation of numerous metabolic reactions, which control hormone metabolism. The liver also manufactures several proteins, which carry circulating hormones to their effector sites. The endocrine system exerts tight control of the metabolic reactions within the liver, which also can be disturbed by endocrine disorders. These types of interactions and the effects of the exogenous hormones and the drugs that are used as treatment for hormonal disorders are discussed.

Myxedema ascites in the posttransplant setting: case report

Ascites is a rare but important complication of hypothyroidism. Because of the rarity of the disease and the inconsistency of symptoms associated with hypothyroidism, patients often go undiagnosed for months. Institution of thyroid replacement hormone results in rapid and complete resolution of ascites. Here we present a case of myxedema ascites that presented in a 52-year-old man 4 months after allogeneic bone marrow transplant (BMT). Diagnoses initially considered in the differential included the common post-BMT complications, namely, hepatic veno-occlusive disease, graft vs. host disease, and infection. However, posttransplant patients are also at risk for illnesses unrelated to their underlying diagnosis or transplant procedure, including hypothyroidism. This case illustrates the importance of considering a broad differential diagnosis in posttransplant patients, especially those in whom the clinical course is atypical.

Clinical associations between thyroid and liver diseases

The liver has an important role in thyroid hormone metabolism and the level of thyroid hormones is also important to normal hepatic function and bilirubin metabolism. Besides the associations between thyroid and liver diseases of an autoimmune nature, such as that between primary biliary cirrhosis and hypothyroidism, thyroid diseases are frequently associated with liver injuries or biochemical test abnormalities. For example, thyroid diseases may be associated with elevation of alanine aminotransferase and alkaline phosphatase, which is mainly of bone origin, in hyperthyroidism and aspartate aminotransferase in hypothyroidism. Liver diseases are also frequently associated with thyroid test abnormalities or dysfunctions, particularly elevation of thyroxine-binding globulin and thyroxine. Hepatitis C virus infection has been connected with thyroid abnormalities. In addition, antithyroid drug therapy may result in hepatitis, cholestasis or transient subclinical hepatotoxicity, whereas interferon (IFN) therapy in liver diseases may also induce thyroid dysfunctions. These thyroid-liver associations may cause diagnostic confusions. Neglect of these facts may result in over of under diagnosis of associated liver or thyroid diseases and thereby cause errors in patient care. It is suggested to measure free thyroxine (FT4) and thyroid-stimulating hormone (TSH) which are usually normal in euthyroid patients with liver disease, to rule out or rule in coexistent thyroid dysfunctions, and consider the possibility of thyroid dysfunctions in any patients with unexplained liver biochemical test abnormalities. It is also advisable to monitor patients with autoimmune liver disease or those receiving IFN therapy for the development of thyroid dysfunctions, and patients receiving antithyroid therapy for the development of hepatic injuries.

Value of clinical features for distinguishing myxedema ascites from other forms of ascites

The diagnosis of myxedema ascites is often difficult and delayed, from our experience and the reports of other investigators. To address this situation, previous reports on the diagnosis of ascites were pooled in order to distinguish the features of myxedema ascites from other forms of ascites. These features were confined to variables that would be obtained routinely from patients with ascites requiring paracentesis. The data of 26 patients with myxedema ascites, and 61 patients with ascites from another cause were analyzed. Discriminant analysis was used to select the variables that best separated patients into myxedema and non-myxedema groups. The variables selected were if the ascites was straw-colored or with a protein content less than 2.5 g/dl, if the patient was over age 40, and if there was periorbital edema or hepatomegaly. These variables correctly classified 90.8% of patients. However, considering the roughly 1% prevalence of myxedema ascites among patients with ascites, the predictive value of these variables, in combination, is only 8.7%. With this low rate, these variables should probably not be used to screen for myxedema ascites.

Effect of propylthiouracil on liver cell development in the male albino mouse: protective effect against ethanol-induced alterations

The aim of the present study is to analyze whether the addition of propylthiouracil reverts the influence of ethanol on the development of periportal and pericentral hepatocytes and their nuclei in male albino mice. Propylthiouracil-treated animals showed decreased cellular and nuclear areas when compared with the control animals, except for the 180-day-old animals, whose pericentral cells and nuclei were greater than those of the controls and exhibited fatty infiltration. Pericentral hepatocytes and nuclei of the ethanol-fed animals showed an increase of their sizes, especially in 180-day-old animals. In contrast, hepatocyte and nuclear sizes of the animals treated with both propylthiouracil and ethanol were similar to those of the control group, suggesting a protective effect of propylthiouracil against the ethanol-induced alterations.

Ethanol, thyroid hormones and acute liver injury: is there a relationship?

Alcoholic liver disease continues to be an important cause of morbidity and mortality, and the hypermetabolic hypothesis continues to be an attractive area for research. However, the current state of knowledge does not allow unequivocal acceptance or rejection of the role of thyroid hormone and antithyroid medication in alcoholic hepatitis. Clinical trials will help to establish or disprove the veracity of this hypothesis. What has been established is that chronic ethanol ingestion enhances EMR (19-22) which probably reflects the degree of hepatocellular necrosis, at least when relatively mild (25). The influence of thyroid hormone or a hyperthyroid-like state on EMR would be established if it could be shown that different antithyroid medications inhibit the enhanced EMR in chronic alcoholics. This effect has been shown in rats (125), but not in man. It is not apparent that events in the rat model can be readily applied to man. Furthermore, proof that antithyroid medications can inhibit enhanced EMR in chronic ethanol-consuming patients may allow this feature to be used to select patients who may best benefit from such treatment. A controlled randomized clinical trial using different anti-thyroid medications in alcoholic hepatitis may shed light on this important question. At the very least, demonstration of inhibition of enhanced EMR by antithyroid medications may provide the rationale for research concerning the role of thyroid hormone (or a similar hypermetabolic factor) in alcohol-mediated hepatocellular injury.

Myxedema ascites

A 74-year-old man presented with mental obtundation and massive ascites without evidence of significant impairment of liver function. Thyroid function studies suggested hypothyroidism. Aspirated ascitic fluid had the characteristics of an exudate. Thyroid replacement therapy resulted in rapid clinical improvement with resolution of the ascites. Prompt recognition of myxedema ascites may prevent the inappropriate use of diuretic agents, therapeutic paracentesis, and sometimes unnecessary laparotomy.