Introduction

Thyroid storm is a dangerous and fatal medical condition that develops as a complication of poorly treated or untreated hyperthyroidism, where thyroid hormones are produced in excess amounts by the thyroid glands of the human body.¹

Thyroid storm can be triggered when you suddenly stop taking your anti-thyroid medicine, due to thyroid surgery or surgery involving any body part, infections, being pregnant or injury to the brain, such as a stroke.²

Although thyroid storm is rare, it is a medical emergency that requires urgent and immediate diagnosis and treatment. This condition presents with signs and symptoms that are usually intense, involving many body systems and organs, such as the digestive system, heart and brain. 

Immediate and proper treatment is required to avoid complications, such as failure of body organs, heart problems or loss of life. Due to the severity of thyroid storm, its accurate early diagnosis is essential. Thyroid storm should not be confused with conditions such as sepsis, heart failure or drug misuse

Several standardised scales and tools are available to assist healthcare professionals in diagnosing thyroid storm. The tools, however, do not work in isolation. Diagnosis is reached through thorough examination, signs and symptoms, and laboratory investigations. Such scales include the Burch-Wartofsky Point Scale, Japanese Thyroid Association Guidelines, Akamizu Scale and the Adapted Burch-Wartofsky Criteria. 

Treatment includes the use of medicines such as beta blockers, medicines for treating thyroid and supportive care. Treatment may also require admission into the intensive care unit (ICU) for days or even weeks. Prompt intervention remains paramount to positive patient outcomes. 

Thyroid storm is life-threatening with unfavourable outcomes. Mortality from thyroid storm arises from complications such as heart failure and multi-organ failure. Factors that increase the risk of death include older age, non-compliance with the treatment plan, necessity of dialysis or life-support machine and presence of brain or nerve problems at the time of hospital admission.²

Signs and symptoms of thyroid storm

Thyroid storm is marked by signs and symptoms affecting numerous organs of the body, such as the heart, brain, liver and gastrointestinal (GI) digestive system.³ These include:

• Increased heart rate
• Increased body temperature
• Increased blood pressure (hypertension)
• Yellowish colouration of the eyes and skin (jaundice)
• Confusion and restlessness
• Decreased level of consciousness
• Congestive heart failure
• Liver and digestive problems
• Seizures
• Loose watery stools (diarrhoea)
• Loss of appetite
• Vomiting¹

Gastrointestinal (GI) manifestations of thyroid storm

Thyroid storm affects multiple body organs and systems, including the GI system. Symptoms of GI involvement in thyroid storm include:

• Diarrhoea
• Nausea and vomiting 
• Liver dysfunction

Diarrhoea and vomiting

Diarrhoea is the passage of frequent, loose, watery stools. Diarrhoea may be accompanied by abdominal pain, a feeling of nausea and vomiting. On the other hand, vomiting is when the muscles in the stomach contract to force its contents up and out through the mouth. These are the common GI challenges in thyroid storm. 

Signs and symptoms of diarrhoea include:

• Abdominal pain
• Feeling bloated
• Nausea and vomiting
• Increased body temperature
• Blood-stained stool
• Mucus in the stool (mucoid stool)
• Feeling of urgency to visit the toilet

Complications of diarrhoea and vomiting 

Dehydration 

Complications of excessive vomiting and diarrhoea include increased loss of body fluid, resulting in severe dehydration, which can be life-threatening if not treated immediately. 

Signs and symptoms of dehydration include:

• Overwhelming need to drink water (thirst)
• Absent or little urine
• Dryness of the mouth and skin
• Feeling weak or dizzy
• Loss of consciousness 
• Feeling the heart race (palpitations)
• Urine that is dark in colour

Vomiting

Thyroid storm can cause GI disturbances such as vomiting. Stomach muscles contract, and stomach content is forcefully thrown up by the mouth. Vomiting may be accompanied by nausea and/or abdominal pain.

Treatment of vomiting in thyroid storm involves immediate and rapid replacement of fluid loss by mouth or through veins. 

Complications of vomiting

Vomiting has its own consequences, which include:

• Dehydration
• Worsening of symptoms of thyroid storm

Liver dysfunction

The liver is an important part of the GI system. This interesting organ is often affected in thyroid storm. A healthy liver is responsible for:

• Improving the function of thyroid hormones, known as T3 (triiodothyronine) and T4 (Thyroxine)
• Production of a green substance called bile, which helps with digestion
• Breakdown and storage of vitamins 
• Breakdown of medications
• Breakdown of bilirubin, a waste product from the breakdown of red blood cells

These functions are greatly reduced in thyroid storm, leading to the manifestation of signs and symptoms such as:

• Tiredness
• Confusion
• Poor appetite for food
• Nausea and vomiting
• Yellowish discolouration of the skin (jaundice)
• Itchy skin (as a result of jaundice)
• Easily bruising
• Abdominal pain, especially around the region where the liver is located
• Swollen abdomen and legs
• Dark urine
• Pale stools

Complications of liver dysfunction in thyroid storm

There are serious complications of liver dysfunction, some of which may be life-threatening.

These include:

• Confusion
• Reduction in function or shutdown of the kidney (kidney failure)
• Reduce immunity, which can lead to infections 
• Increased risk of bleeding and bruising
• Internal bleeding
• Swelling in the brain (oedema)
• Swelling in the abdomen (ascites)
• Liver and multi-organ failure

Treatment of diarrhoea, vomiting, and liver dysfunction in a thyroid storm

Diarrhoea

Treatment of diarrhoea includes

• Increased oral intake of fluids 
• Administration of fluids through the vein (intravenous) if taking by mouth is not possible or insufficient
• Targeted treatment of the direct cause of diarrhoea, which is thyroid storm

Vomiting

Treatment of vomiting in thyroid storm includes

• Immediate and rapid replacement of fluid loss through the veins
• Avoid fluid intake by mouth until vomiting is controlled

Liver dysfunction

Treatment include 

• Medicines to treat liver problems
• Surgery (transplantation) in cases of irreversible liver damage

FAQs

How does thyroid storm affect the GI system?

Thyroid storm causes a rise in body metabolism. This causes GI symptoms such as diarrhoea, vomiting, and liver dysfunction.

How does thyroid storm cause diarrhoea and vomiting?

It increases the stomach and intestinal movement, resulting in diarrhoea and vomiting.

Is diarrhoea and vomiting in thyroid storm dangerous?

Yes, it can be. It can lead to excessive loss of body fluid and worsen the general condition.

How is liver function affected in thyroid storm? 

In a thyroid storm, the body produces thyroid hormones in excess. This affects liver function, such as the breakdown of toxins and the medicines we take. If this continues, the liver can be damaged. 

How do I know my liver is dysfunctional? 

Symptoms that may manifest are yellowish skin colour, pain, nausea and vomiting, and loss of appetite.

Can my liver regain its function?

The liver is a regenerative organ, meaning it can repair itself. If damage is extensive, it can lead to permanent damage. However, thyroid storm treatment can improve liver function.

How is dehydration in diarrhoea and vomiting in thyroid storm treated?

Through the use of fluids taken either by mouth or through the veins to replace loss of body fluid.

Will I be cured if I have thyroid storm accompanied by diarrhoea and vomiting?

Early recognition and treatment are vital to recovery from complications of thyroid storm. Diarrhoea and vomiting should subside or even stop completely within a day or two. Recovery from thyroid storm can, however, take several weeks.²

Is thyroid storm fatal?

Yes. Adverse health conditions such as heart failure and multiple organ dysfunction that result from poorly treated thyroid storm can increase the death rate associated with the condition. Prompt diagnosis and treatment, however, increase the rate of survival.

Who is most at risk for thyroid storm?

The list of people at most risk of thyroid storm is as follows

• People with hyperthyroidism that is not well-treated
• People who do not take their medications as prescribed
• People who are prepared for surgery or who experience trauma
• Women who are pregnant and also have hyperthyroidism that is not controlled⁴

How long does it take to recover from thyroid storm?

When the right treatment is initiated, symptoms improve within a day or two. More days or even weeks in the ICU may be required to achieve full recovery. 

Is there any possibility of thyroid storm recurrence?

Yes. A person can experience another thyroid storm if long-term treatment is ignored. Targeted treatment using iodine or performing surgery is vital in decreasing the risk of recurrence.⁵

How common is thyroid storm?

It is a rare but extremely fatal medical condition. The American Thyroid Association says each year, it affects about 1 in every 100,000 women and about 1 in every 150,000 men.

What is the result of untreated thyroid storm?

Untreated thyroid storm can lead to 

• Multi-organ failure
• Loss of consciousness and death

Can I treat thyroid storm at home?

No. Immediate admission to a hospital is required. Do not attempt to keep anyone with a suspected thyroid storm at home.

Summary

Thyroid storm is a medical emergency, necessitating immediate hospital admission. Specialist care in the intensive care unit (ICU) is often required for this condition. Thyroid storm is a fatal condition as it affects multiple body organs, including the GI system, development of diarrhoea, vomiting and liver dysfunction. Diarrhoea and vomiting can cause severe dehydration. Body fluid replacement, electrolyte replacement, treatment of the underlying trigger and use of drugs (such as Propranolol, iodine, hydrocortisone, and anti-thyroid) can greatly improve well-being in thyroid storm. Fatal complications associated with thyroid storm can be averted through early detection and prompt treatment. When all treatment options remain unsuccessful, thyroid removal surgery should be considered.