S4481 Non-Specific GI Symptoms: A Facade for Unsuspecting Adrenal Insufficiency

Introduction: Adrenal insufficiency (AI) is a rare endocrine disorder that can present with nonspecific and insidious gastrointestinal (GI) symptoms, including abdominal pain, nausea, vomiting, diarrhea, and weight loss. These symptoms often prompt an extensive GI workup before the correct diagnosis is made. When initial GI testing fails to reveal a clear etiology, gastroenterologists must consider broader differentials including endocrine causes. GI symptoms can be the primary manifestation of Addison’s disease, which is the most common cause of primary AI in developed countries. This case focuses on a challenging diagnosis of Addison’s disease in a young woman with progressive GI symptoms and substantial weight loss. Case Description: An 18-year-old woman with a history of atopy, recent postpartum status, and anxiety/depression initially presented to the emergency department (ED) with progressive sharp, left upper quadrant (LUQ) abdominal pain, nausea, emesis, diarrhea, poor oral intake and 30 lb weight loss over 3-4 months. A computed (CT) abdomen/pelvis showed splenic atrophy and constipation, and she had a normal random cortisol level. She was prescribed laxatives, referred to outpatient GI, and discharged. However, due to worsening abdominal pain, she presented to the ED 4 days later with normal vital signs, labs revealing leukocytosis with eosinophilia, normal basic metabolic panel, and no acute abdominal process on repeat CT abdomen/pelvis. Physical exam revealed severe LUQ tenderness and no visible skin hyperpigmentation. She was placed on intravenous (IV) fluids, IV antiemetics, and IV pain medications. GI was consulted and performed an upper endoscopy and colonoscopy, however, random bowel biopsies and Helicobacter pylori stool antigen were negative. Due to her persistent symptoms, endocrinology was consulted and an 8:00 am cortisol level was low, which was concerning for AI. She was prescribed hydrocortisone for physiologic replacement dosing with close outpatient endocrinology follow-up. Endocrinology testing revealed an appropriate adrenocorticotropic hormone stimulation test and positive 21-hydroxylase antibodies, which are indicative of Addison’s Disease. Discussion: This case highlights the diagnostic challenge of isolated GI symptoms in adrenal insufficiency. Despite extensive testing, including endoscopy and imaging, the patient’s diagnosis remained elusive until endocrine evaluation was pursued. For gastroenterologists, maintaining a broad differential that includes endocrine pathology is essential to avoid diagnostic delays and prevent progression to adrenal crisis.