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Abdominal Pain, Bowel Issues, Nausea, Done ACTH Stimulation Test, Thyroid Test, Gall Bladder Removal

Posted on Tue, 2 Oct 2012

Question: I'm a 31-year-old female, 5'3" , 158 lbs suffering from recurring symptoms for 10 months: abdominal pain (upper right quadrant underneath rib cage), neck pain/discomfort, lower back pain, fatigue, bowel issues (frequent BM, minimal diarrhea/constipation), headache, feel "hot" most of the time but no fever, occasional chest pain (right side), problems concentrating, lightheadedness upon standing, nausea, menstrual irregularities, intolerance to alcohol, some skin hyperpigmentation (under breasts, near groin, some spots on face). I originally went to a gastro doc and after colonoscopy and other tests, eliminated celiac disease and other gastro causes, and although all gallbladder tests were negative, had gallbladder removed anyway. Referred myself to endocrinologist and had following test results: T3, Total 89 (60-181 ng/dL), Free T4 1.0 (0.8-1.8 ng/dL), Thyroxine, Total, S: 7.6 (5.0 to 12.5 mcg/dL), % UPTAKE 0000: 32 (Reference range: 20 to 37%), Free Thyroxine Index: 2.4, 25OH Vitamin D Tot 28.4 ng/ml ( <10 ng/ml: Deficient 10-30 ng/ml: Insufficient 30-100 ng/ml: Sufficient >100 ng/ml: Toxic), Fasting bloodwork, taken at 7:30 am: Cortisol: 9 ug/dl (7-9a.m.=4.3-22.4), ACTH,Plasma 8.5 (10 to 60 (a.m. draw) pg/mL (abnormal)). With the ACTH being below the reference range and the a.m. cortisol being fairly low, the endocrinologist ordered an ACTH stimulation test, but according to my research didn't follow the guidelines. She said I didn't have to fast and I had my first draw at 11 a.m (I also didn't see a baseline ACTH level). ACTH stimulation test: baseline cortisol: 13, 30-minute: 19, 60-minute: 24 (ug/dl). aldosterone baseline: 5.2, 30-minute: 13, 60-minute: 11 ng/dL. My endocrinologist is telling me there's nothing wrong with my thyroid or adrenals and to go back to the gastro for answers after gastro doc said they couldn't find a problem. I do not agree with her interpretation of the results. Should I get a second opinion?

Answered by Dr. V. Kumaravel (3 hours later)

Hello,

Thanks for posting your query.

I can understand that you have varied abdominal symptoms and had been extensively evaluated to find a cause, but unfortunately none had been figured out.

Your thyroid function testing has been normal as evidenced from your TSH, FT4, T3 and T4 levels. Your cortisol at 7.30am is 9 and your ACTH is also 8.5.

If your morning cortisol is above 15, it suggestes normalcy. Otherwise you have to get your ACTH stimulation test as rightly done by your endocrinologist. Fasting and Base line ACTH and Cortisol may not be really required in your case as you already have one. Your cortisol with ACTH stimulation is more than 18 and hence normal.

"I strongly concur with your endocrinologist, and with the available reports, thyroid and adrenals are normal".

Considering your menstrual irregularities and feel of hot most of the times, it is worth testing your LH, FSH and prolactin hormone levels too.

Hope this answers your query. I will be available for follow up queries if any.

Regards.

Above answer was peer-reviewed by : Dr. Prasad

Follow up: Dr. V. Kumaravel (1 hour later)

I appreciate your response. It's difficult to find reliable information on how to interpret the ACTH stimulation test results online. Most of the information I've found indicates that a healthy adrenal response starts with a baseline around 20-30 which doubles after 60 minutes.

With the ACTH,Plasma being abnormal at 8.5 with the ACTH stimulation test results as "normal," is there still a possibility the problem is not with the adrenals but with the pituitary not producing enough ACTH? Most of my research indicates the ACTH stimulation test showing a production of cortisol from the adrenals from the injected ACTH, but having a low baseline ACTH initially could indicate a problem with the creation of the ACTH itself. I know the ACTH plasma test is often messed up, but would you normally just throw out the abnormal ACTH plasma result rather than ordering a new one?

My concern is having a low a.m. cortisol and ACTH without any medication going into the flu season with kids in daycare. From what I've ready, low cortisol is a serious situation and not something to ignore. I'd appreciate your thoughts on this.

Thanks,
XXXXXXX

Answered by Dr. V. Kumaravel (9 hours later)

Hello madam,

I do understand your concern.

Low ACTH and low cortisol suggests a possibility of central hypocortisolism, where there could be a problem with pituitary gland. As you are aware pituitary gland is responsible for secretion of many hormones like TSH, LH, FSH, Prolactin , GH and so on.

It is very unlikely for the pituitary gland to affect only your ACTH. That is the reason why i wanted to get your LH, FSH and prolactin levels also. Your TSH and T4 are normal.

ACTH assay itself is difficult as it has so many precaution to be taken. I do agree that low cortisol cannot be ignored, but in your case the low cortisol status has not been unequivocally proved and inadvertent use of cortisol treatment is also not good.

Considering the concerns about your flu season, what i personally feel is to repeat your 8.00am ACTH, cortisol along with LH, FSH and Prolactin and also to image your pituitary gland. If every thing is normal just ignore your cortisol issue.

If still ACTH and cortisol is low, i would suggest you to take stress dosing of steroid during any illness in consult with your physician or endocrinologist.

Hope this answers your query.

Regards

Above answer was peer-reviewed by : Dr. Radhika

Follow up: Dr. V. Kumaravel (7 hours later)

Thank you for your response. I have one last question. My current endocrinologist has referred me back to my primary doctor and after I questioned her about my ACTH and a secondary adrenal issue (prior to reading your last response). She said "as you have menstrual cycles, you do not have a pituitary loss." Do you agree that in order for me to have an issue with my pituitary gland, I would have to have a complete loss of my menstrual cycle? I just need to decide if in the event that my other pituitary-based hormones come back abnormal with my primary doctor, if I should seek another endocrinologist for more testing. Please let me know.

Thanks, XXXXXXX

Answered by Dr. V. Kumaravel (2 hours later)

Hello XXXXXXX:

As said before, pituitary is a master gland that regulates many hormone producing glands.

I would partly agree that if you have menstrual cycle, many of your pituitary hormones are normal. But in partial or subtle abnormality of your ACTH, you can still be menstruating.

I feel that you could repeat your 8.00 am ACTH, cortisol, LH ( Luteinizing Hormone), FSH (Follicular Stimulating Hormone), Prolactin. If it comes normal, just forget these issues and you are fine.

It is always suggested to consult the one doctor, as they have complete follow up of your case. In case of doubt, you can have second opinion from other Endocrinologist also.

I hope this answers your query.

Wish you good health.

Regards,

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Above answer was peer-reviewed by : Dr. Jyoti Patil