Cushing’s causes bowel perforation in young man
Report describes rare case that required emergency surgery
Cushing’s disease caused a bowel perforation — a rare complication in which a hole in the intestine allows its contents to leak — requiring a young man in Japan to undergo emergency surgery.
His case was described in the report “Bowel perforation associated with Cushing’s disease: a case report with literature review,” published in the Endocrine Journal.
Cushing’s disease occurs when the body produces too much cortisol, a steroid hormone. Excess cortisol can weaken the bowel wall, making it more prone to tearing or bursting.
Although it is rare, bowel perforation can cause severe abdominal pain. Emergency surgery is required to fix the weakened bowel wall and prevent further complications such as infection.
Until now, there had been only eight reported cases of bowel perforation due to Cushing’s disease, the case report authors wrote. All previous cases had a history of diverticular disease, which occurs when small bulges push outward through weakened spots in the bowel wall.
Half of them had low blood potassium, resulting from excess cortisol. Five were women and three were men, and their median age at the time of bowel perforation was 61.
While body tissue usually becomes more fragile as people age, “the risk of bowel perforation is difficult to determine in patients with [Cushing’s disease] based on age alone,” the researchers wrote.
Cushing’s, bowel perforation case report details
Here, researchers described the case of young Japanese man, age 24, with bowel perforation due to Cushing’s disease.
He was admitted to the hospital because he had been gaining weight and noticed stretch marks on his skin. He also felt very tired. His body was swollen, his muscles were weak, and his hands were shaky and covered with warts.
A physical examination revealed a rounded (moon) face and acne on both cheeks. The abdomen was swollen and felt soft without any pain. Bowel movements also appeared to be normal.
Blood testing revealed high sodium and low potassium levels. The levels of adrenocorticotropic hormone (ACTH), a hormone that stimulates the production and release of cortisol, was higher than normal, as was cortisol.
As doctors suspected ACTH-dependent Cushing’s disease, they ran additional tests after the man was admitted to the hospital.
Blood cortisol levels remained high at night, when they normally drop, and after taking a low dose of dexamethasone, a steroid that normally suppresses cortisol production. These findings were consistent with Cushing’s disease.
An MRI scan revealed a two-millimeter tumor in the brain’s pituitary gland, which is the typical cause of Cushing’s disease.
About one week after the man was admitted to the hospital, he experienced sudden, severe pain in the lower part of the abdomen. A CT scan showed there was air outside the sigmoid colon, an S-shaped part of the bowel.
Doctors made a diagnosis of bowel perforation and the man underwent emergency surgery.
The submucosa, which is a layer of the bowel wall, had signs of chronic inflammation, but it was unclear whether this was caused by excessive cortisol or by peritonitis, an inflammation of the abdomen, following perforation.
Removing the pituitary tumor
To lower cortisol, the man was given metyrapone (sold as Metopirone). He also underwent transsphenoidal surgery to remove the pituitary tumor, which was later found to be benign, through the nose. After surgery, both blood cortisol and ACTH levels returned to normal.
“This is the youngest reported case with bowel perforation due to [Cushing’s disease],” the researchers wrote. It also is “the first report of bowel perforation in a patient without a history of diverticular disease.”
According to authors, this suggests that bowel perforation can occur in anyone with Cushing’s disease, regardless of age and whether they have low potassium levels, diverticular disease, or abdomen inflammation.