Advertisement

Sign up for our daily newsletter

Advertisement

Mechanism ascites hypothyroidism vs hyperthyroidism: Myxedema Ascites: An Unusual Presentation of Uncontrolled Hypothyroidism

We report a yr-old man with clinical ascites that was the first manifestation of hypothyroidism, and which resolved completely in response to thyroid hormone replacement therapy. Total protein levels exceeded 2.

Liam Adams
Monday, October 7, 2019
Advertisement
  • Myxedema coma is rare but often fatal.

  • Keywords: Myxedema, Ascites, Hypothyroidism. Symptoms usually resolve with treatment of the thyroid disease.

  • Recent studies showed that low nitric oxide levels and high vascular endothelial growth factor VEGF levels can lead to an increase in capillary permeability causing extravasation of plasma proteins.

  • Horm Res ; 48 : — Endocr Rev ; 14 : —

INTRODUCTION

A paracentesis removed 4 liters of hazy fluid. Mechanism ascites hypothyroidism vs hyperthyroidism report a young female with reported thyroid disease and medication noncompliance presenting with atrial fibrillation, severe atrioventricular regurgitation, severely dilated hypertyroidism heart with reduced function, and moderate pulmonary hypertension PHwhich was further complicated by congestive liver injury with ascites and pancytopenia. Hypothyroidism in patients with thalassemia syndromes. We describe a case of myxedema ascites in a year-old male with a history of hypothyroidism noncompliant with medical therapy who presented with syncope, hematemesis, melena, and abdominal distension. Nature ; : —9.

Clinical associations between thyroid and liver diseases. Thyroid gland size and function in patients with cirrhosis of the liver. Mol Cell Biol ; 20 : — Ultrasound of the abdomen was suggestive of liver cirrhosis and ascites, which was thought to be cardiac cirrhosis, after multiple negative work-ups for alternate causes of cirrhosis.

Here, we report a yr-old man with myxedema ascites that resolved hypothyyroidism with thyroid hormone replacement therapy. Myxedema: a study of cases. We report a yr-old man with clinical ascites that was the first manifestation of hypothyroidism, and which resolved completely in response to thyroid hormone replacement therapy. Address for correspondence: Hiun-Suk Chae, M. Ascites due to hypothyroidism in a patient with alcoholic cirrhosis. Treatment with thyroid hormone replacement therapy leads to complete regression of the ascites. Von Knorring J, Friman C.

Publication types

ISSN Conclusions: The differential diagnosis for ascites includes hepatic, cardiac, nephrotic, malignant or infectious pathology. Ascitic fluid was notable for elevated total protein 3. Recent Prog Horm Res.

Mechanism ascites hypothyroidism vs hyperthyroidism, the importance of its diagnosis is ascitea use of thyroid hormone replacement results in complete resolution. Find articles by Jeong-Seon Ji. Once routine evaluation of ascites excludes common causes such as liver cirrhosis, peritoneal malignancies and infections, congestive heart failure and pancreatic ascites, thyroid function tests should be performed on patients with high protein levels in the ascites fluid. Hypothyroidism is a relatively rare cause of ascites. SAAG is usually high in patients with liver cirrhosis and congestive heart failure. External link.

MRI and CT scans are the best diagnostic modalities. Ascites as preeminent manifestation of primary hypothyroidism: clinical case. Abstract Thyroid disease is common, and its effects on the gastrointestinal system are protean, affecting most hollow organs. However, it could interact with albumin to form complexes that prevent the lymphatic drainage of extravasated albumin

Intracellular signalling

Hypothyroidism is also an uncommon cause of ascites and is seen in only one to five mechanism ascites hypothyroidism vs hyperthyroidism of patients with ascites [ 3 ]. The patient underwent a second diagnostic and therapeutic ascitic tap at our facility that revealed exudative fluid with elevated total protein of 3. Larsen PR. Free T 3 and T 4 enter all cells through the plasma membrane and bind to a nuclear T 3 receptor.

  • It is important to note that the liver biopsy does potentially indicate other possible etiologies for an elevated SAAG, including pre-sinusoidal hypertension.

  • His initial chest radiograph showed normal without findings of cardiomegaly or pulmonary edema. Therefore, a low gradient ascites should initiate an evaluation for primary peritoneal process, most importantly infections and malignancies.

  • Table 1 Causes of ascites. He was given two units of blood and was started on intravenous IV levothyroxine and hydrocortisone.

  • The triad of reduced bilirubin excretion, hypercholesterolaemia and hypotonia of the gall bladder seen in hypothyroidism increases the incidence of gallstones. From Wikipedia, the free encyclopedia.

  • A review of the literature revealed 51 well-documented cases of myxedema ascites. Mixedema with thyroid antibodies presenting with ascites.

The ascitic fluid showed elevated total protein and a low SAAG value, as found mechanism ascites hypothyroidism vs hyperthyroidism. There has been a suggestion that the SAAG may exceed 1. Moreover, the patient reported here showed a low SAAG. His initial chest radiograph showed normal without findings of cardiomegaly or pulmonary edema. Runyon BA. We were interested in the high protein component of the ascites fluid, so we performed thyroid function testing.

Since the differential diagnosis for ascites is broad, myxedema ascites should be considered in a patient with a history of hypothyroidism and ascites. The steroid and thyroid hormone receptor superfamily. All content published within Cureus is intended only for educational, research and reference purposes. Pathology 4th ed. Blumgart and H. Gut ; 42 : —

  • A prominent feature of ascitic fluid in hypothyroidism is its elevated protein content but SAAG value varies and can be low or high. Severe ascites with hypothyroidism and elevated CA concentration: a case report.

  • Thyroid hormone replacement therapy was started with gradually increasing doses of levothyroxine, from 0.

  • External link. Thyroid replacement therapy was initiated, with a resolution of his ascites [ 2 ].

  • Cell ; 65 : — Support Center Support Center.

On a follow-up visit at four weeks, there was no clinical evidence of ascites and the TSH was decreasing Cavros, W. Acta Endocrinol Copenh ; : —3. Myxedema is a term used synonymously with severe hypothyroidism. Article Navigation. Journal List Cureus v.

Article Navigation. Currently the treatment of viral hepatitis with alpha interferon has added another dimension to the hyperthyroidism of thyroid function seen in chronic liver diseases. Categories : Endocrine-related cutaneous conditions Skin conditions resulting from errors in metabolism. Ascites secondary to hypothyroidism is an exudative process with a SAAG of less than 1. Biochemical abnormalities including macrocytic anemia, abnormalities in lipid panel and elevation of CK, ALT and AST secondary to thyroid myopathy in our patient were further clues that pointed towards uncontrolled hypothyroidism. Dweik, and A. Adv Clin Path.

Navigation menu

Adv Clin Path. A second hypothesis involves a direct hygroscopic effect caused by hyaluronic acid accumulation in the skin with resulting edema. Received Oct 9; Accepted Dec 2. The clinical features of hyperthyroidism are diverse, involving nearly every system in the body.

Mechanism ascites hypothyroidism vs hyperthyroidism rare complication of hypothyroidism: myxedema ascites. Levothyroxine reaches a steady state at six weeks; therefore re-accumulation of ascites hypothyoidism expected until resolution of uncontrolled hypothyroidism. This article is about skin changes that occur in hypothyroidism. One study suggested that patients with hypothyroidism have low levels of nitric oxide and high levels of vascular endothelial growth factor VEGFwhich can also synergistically increase the permeability of capillaries and, thus, further allow plasma proteins to be lost from the intravascular space [ 3 ]. Serum enzyme disturbances in thyrotoxicosis and myxoedema.

Liver abnormalities in thyroid disease. Primary hypothyroidism masquerading as hepatic encephalopathy: case report and review of the literature. An extensive workup had been done at the other hospital to elucidate the underlying etiology of ascites. She was counseled about the need for compliance. Primary thyroid lymphoma is a heterogeneous disease.

Paracentesis removed 4. Abnormalities of liver function tests in tyrotoxicosis. References F. Clin Pediatr Phila.

Rationale, development, and clinical outcomes of a multidisciplinary amiodarone clinic. The connective fibres are separated by an increased amount of protein and mucopolysaccharides. Other notable labs included elevated alkaline phosphatase, bilirubin, and international normalized ratio with normal transaminases. A male person of 55 years with hypothyroidism, ascites and heart failure. Amyloid goiter: the first evidence in secondary amyloidosis: report of five cases and review of literature.

Mechanism ascites hypothyroidism vs hyperthyroidism ascites: a rare nypothyroidism of uncontrolled hypothyroidism. The nuclear receptor superfamily: the second decade. Published 09 Dec Pauci-symptomatic widespread nodal extra-pulmonary tuberculosis in end-stage kidney disease. Ascitic fluid analysis is the key in guiding the course of investigations needed to establish the diagnosis. Am J Gastroenterol ; 95 : —9. Introduction Primary hypothyroidism is a common clinical condition that can manifest in different ways.

ALSO READ: Lipogen Slim Control Diet

There are two main hypotheses. Diarrhea in medullary carcinoma of the thyroid MCT may be due to elevated calcitonin, prostaglandins, or 5-hydroxyindoleacetic acid. Find articles by Jeong-Seon Ji. Am Fam Physician. However, the importance of its diagnosis is that use of thyroid hormone replacement results in complete resolution. J Lab Clin Med.

Download other formats More. No palmar erythema, asterixis, jaundice, or spider angiomata were appreciated. All content published within Cureus is intended only for educational, research and reference purposes. Myxedema ascites with high CA case and a review of literature.

Case Reports in Cardiology

Thyroid ultrasonograph revealing atrophic change of both thyroid lobes arrowheads. The latest follow-up thyroid function studies showed a free T 4 level of A yr-old man presented with abdominal distension and anorexia that had lasted for 10 days.

Informed consent was obtained from the patient for this study. Sherlock S, Scheuer PJ. Please review our privacy policy. Lancet ; : 24 —9. Case Report A year-old female presented with abdominal distention, leg swelling, and dyspnea on exertion.

Myxedema ascites with high CA- case and a review of literature. J Gastroenterol Hepatol. The authors declare that there is no conflict of interest regarding the publication of this article. Sick euthyroid syndrome. These include macrocytic anemia and high creatine kinase and cholesterol levels. Dig Dis Sci.

Old, F. Hypothyroidism is also an uncommon cause of ascites and is seen in only one to five percent of patients with ascites [ 3 ]. Symptomatic ascites in a patient with hypothyroidism of short duration.

However, amylase and lipase were not checked on the fluid. The patient was discharged home on a beta-blocker and diuretics. Namespaces Article Talk. Oxford Academic. Skip Nav Destination Article Navigation. Semin Neurol. Brandt, A.

Sub-Category: Adult. Comput Biol Med. Castro, and H. Once it is diagnosed, treatment of hypothyroidism leads to quick clinical improvement in ascites. Thyroid function in men taking carbamazepine, oxcarbazepine, or valproate for epilepsy. Articles from Cureus are provided here courtesy of Cureus Inc.

Introduction

Myxedema ascites in the posttransplant setting: case report. Am J Med. Find articles by Jeong-Seon Ji. Of the various causes, peritoneal malignancies, tuberculous peritonitis, pyogenic peritonitis and pancreatic ascites can all lead to high-protein ascites.

His initial chest radiograph showed normal without findings of cardiomegaly or pulmonary edema. The first is that low levels of circulating mechanism ascites hypothyroidism vs hyperthyroidism hormones cause increased extravasation of plasma proteins because of abnormal capillary permeability and the lack of a compensatory increase in lymph flow and protein return rate Mechanisms of edema formation in myxedema increased protein extravasation and relatively slow lymphatic drainage. Reduced acid production may be due to autoimmune gastritis or low gastrin levels. Support Center Support Center.

The first is that low levels of circulating thyroid hormones cause increased extravasation of plasma proteins because of abnormal capillary permeability and mechanism ascites hypothyroidism vs hyperthyroidism lack of a compensatory increase in lymph flow and protein return rate A yr-old man presented with abdominal distension and anorexia that had lasted for 10 days. Myxedema: a study of cases. A consistent feature is the good response to thyroid hormone replacement therapy, which has always led to resolution of the ascites. We then evaluated the possibility of a cardiogenic origin.

  • Pathology 4th ed. BMC Public Health.

  • There are two main hypotheses. This article has been cited by other articles in PMC.

  • Arch Biochem Biophys.

Table 1 Characteristics of reported patients with myxedema ascites. Ascites fluid associated hypothyroidism hyperthyroidism portal hypertension shows a low total albumin level, and the SAAG is greater than 1. To prevent activation of the renin-angiotensin-aldosterone system and sodium retention from a vicious cycle of ascites, we prescribed an aldosterone antagonist spironolactone 50 mg daily and an inhibitor of proximal renal tubule sodiumabsorption furosemide 20 mg daily. Find articles by Hiun-Suk Chae. Over the following three months, he became euthyroid with complete resolution of his ascites, and the liver function tests returned to normal. Thyroid disease is common, and its effects on the gastrointestinal system are protean, affecting most hollow organs.

Vz findings necessitated further thyroid tests. Myxedema ascites in the posttransplant setting: case report. Mechanism of myxedema formation. Dyalisis Transplant. N Engl J Med. A laparoscopic biopsy of the peritoneum and liver was performed to rule out any common cause of high protein, low SAAG ascites such as peritoneal malignancies, tuberculosis or infections.

Eur J Nucl Med. Mol Cell Endocrinol. Endocrinology ; : — Support Center Support Center.

Find articles by Jeong-Seon Ji. However, there was no evidence of congestive heart failure as the cause of the ascites. Compared with discharge, his body weight had increased by 3 kg and the abdominal circumference by 5 cm. Here, we report a yr-old man with myxedema ascites that resolved completely with thyroid hormone replacement therapy.

ALSO READ: Thoits Insurance Acquired Hypothyroidism

Propylthiouracil hepatotoxicity: a review and case presentation. Received 11 Sep Ch, cholestasis black pigment ; N, nucleus; M, mitochondria. EMBO J. Permissions Icon Permissions. Drug Des Devel Ther. Symptomatic ascites in a patient with hypothyroidism of short duration.

Cerini, R. It has been suggested that this syndrome may confer a survival advantage, which adapts an organism to bmi ideal weight calculator malena illness hypothyroidissm reducing the basal metabolic rate within cells and thereby reducing caloric requirements. J Clin Gastroenterol ; 27 : — The low total and free T 3 levels may be regarded as an adaptive hypothyroid state that serves to reduce the basal metabolic rate within hepatocytes and preserve liver function and total body protein stores.

The nuclear receptor superfamily: the second decade. We report a case of a female patient who presented with ascites secondary to severe hypothyroidism and discuss the diagnostic characteristics of the ascitic fluid in myxedema ascites on the basis of literature review. Phillips G, Jr. Acta Haematol ; 84 : 72 —6.

  • It is often possible to diagnose myxedema on clinical grounds alone. Advance article alerts.

  • Given these negative findings, we performed imaging studies to evaluate the possible cause of the ascites.

  • Also, it is very rare for hyperthyroidism-driven heart failure to lead to cirrhosis, and cirrhosis has been reported mostly in chronic right heart failure [ 18 ].

  • The ascitic fluid showed elevated total protein and a low SAAG value, as found previously.

  • A review of the literature revealed 51 well-documented cases of myxedema ascites. Try out PMC Labs and tell us what you think.

Rarely, a persistent hepatitis occurs with clinical, biochemical elevated bilirubin, AST and ALT and histological features of hepatocellular necrosis. J Clin Gastroenterol ; 14 : —4. The relationship between the thyroid gland and the liver R. Heterodimer formation is thought to enhance DNA binding affinity as well as providing target gene specificity. Mol Cell Endocrinol ; : 37 — Differential recognition of target genes by nuclear receptor monomers, dimers, and heterodimers. J Clin Gastroenterol ; 24 : —3.

Hashimoto disease, the most common cause of hypothyroidism, may be associated with an esophageal motility disorder presenting as dysphagia or heartburn. Hoefs JC. There was no pretibial edema. Find articles by Kyu-Yong Choi.

Am J Hematol. Ascites fluid associated with portal hypertension shows a low total albumin level, and the SAAG is greater than 1. Please review our privacy policy. Published online Aug

Moreover, a peritoneal biopsy showed nonspecific findings. His body weight decreased by 9 kg and the abdominal circumference was reduced by 28 cm. We then evaluated the possibility of a cardiogenic origin. MRI and CT scans are the best diagnostic modalities. Diarrhea in medullary carcinoma of the thyroid MCT may be due to elevated calcitonin, prostaglandins, or 5-hydroxyindoleacetic acid. Myxedema with inappropriate antidiuresis and hyperaldosteronism. Samples of ascitic fluid showed elevated total protein 3.

  • Subsequent ultrasound of the abdomen showed moderate ascites with liver architecture suggestive of cirrhosis.

  • References 1.

  • Isolated serum CK elevation is the most common abnormality. The authors have declared that no competing interests exist.

  • Retinoid X receptor interacts with nuclear receptors in retinoic acid, thyroid hormone and vitamin D3 signalling. Gut ; 34 Suppl.

  • Myxedema ascites: report of two cases and review of the literature.

Diarrhea in medullary carcinoma of the thyroid MCT may be due to elevated calcitonin, prostaglandins, or 5-hydroxyindoleacetic acid. Abstract Myxedema ascites caused by hypothyroidism is rare, so its diagnosis is often delayed and patients frequently receive unnecessary procedures such as liver biopsies and exploratory laparotomies. We report a yr-old man with clinical ascites that was the first manifestation of hypothyroidism, and which resolved completely in response to thyroid hormone replacement therapy. National Center for Biotechnology InformationU. Thyroid ultrasonograph revealing atrophic change of both thyroid lobes arrowheads. His initial chest radiograph showed normal without findings of cardiomegaly or pulmonary edema.

Hypothyroidism in patients with thalassemia syndromes. The transvaginal US showed no cyst or mass involving the uterus or adnexae. N Engl J Med. The thyroid receptor is part of the nuclear superfamily group of receptors retinoic acid, retinoid X, vitamin D and peroxisome proliferator receptor. Article Navigation. BMC Public Health ; 2 : 6.

Myxedema ascites is thus rare but easy to treat; it should be borne in mind, especially if the ascites fluid has a high protein content. Find articles by Kang-Moon Lee. Steatorrhea is due to hyperphagia and stimulation of the adrenergic system. Find articles by Bo-In Lee.

Mecbanism did not believe the ascites was secondary to hepatic dysfunction in the setting of normal labs and mechanism ascites hypothyroidism vs hyperthyroidism. Liver abnormalities in thyroid disease. It is considered to be an allergic host response, which generally resolves over a protracted period of time. Physicians should be aware of these minor biochemical abnormalities and should include hypothyroidism as the differential diagnosis in the presence of these abnormalities. Volume

Biochem Pharmacol. It has been suggested that this syndrome may confer a survival advantage, which adapts an organism to chronic illness by reducing the basal metabolic rate within cells and thereby reducing caloric requirements. Postgrad Med J. More on this topic Adequacy of thyroid hormone replacement in a general population. It can also be thought as nonpitting edema, in contrast to pitting edema. Conclusions Myxedema ascites should be considered in patients with hypothyroidism and ascites, even in the setting of elevated SAAG and low protein in an ascites analysis. To prevent further fluid retention, the patient was treated with diuretics, with poor response and persistent symptoms.

Ultrasonography revealed atrophic change to both thyroid lobes Fig. Compared with discharge, his body weight had increased by 3 kg and the abdominal circumference by 5 cm. Skinner J.

Abnormalities of hyperthyroidis, function tests in tyrotoxicosis. Myxedema is a term used synonymously with severe hypothyroidism. Casual coincidence, common link, or fundamental genetic disturbance? A year-old female presented with abdominal distention, leg swelling, and dyspnea on exertion. The abdominal ultrasound showed normal liver parenchyma and the CT scan did not reveal any abdominal masses. Try out PMC Labs and tell us what you think. In different studies assessing patients treated with alpha interferon for hepatitis C, 2.

Diagnostic paracentesis: a potent clinical tool. However, mecchanism was no evidence of congestive heart failure as the cause of the ascites. Histology of the peritoneum yielded nonspecific findings. Laparoscopy showed that the surface of the liver was slightly irregular and the peritoneum was normal in appearance. Corresponding author. These findings necessitated further thyroid tests.

Gastroenterology bmi ideal weight calculator malena not believe the ascites was secondary to hepatic dysfunction in the setting of normal labs and imaging. Also, in hyperthyroidism, there is an accelerated metabolism of intrinsic and extrinsic pulmonary vasodilators prostacyclin, nitric oxide, and acetylcholine and an impaired metabolism of pulmonary vasoconstrictors serotonin, thromboxane, and endothelin-1 [ 1415 ]. The patient improved significantly within a few weeks and lived another 28 years while taking the sheep thyroid extract.

  • The neuromuscular effects of hypothyroidism. These agents induce cholestasis, as an idiosyncratic reaction to the drug.

  • J Korean Med Sci.

  • The patient was restarted on antithyroid medication with gradual improvement of thyroid function and in clinical and echocardiogram findings.

  • The diagnosis of myxedema ascites secondary to longstanding hypothyroidism was presumed based on the history of untreated hypothyroidism and lack of portal hypertension or cirrhosis.

Thyroid storm presenting with liver failure. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Mymensingh Med J. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional.

Because so few cases have hypothyroidism hyperthyroidism studied and portal hypertension or heart failure do not seem to be the mechanisms causing ascites in patients with myxedema, we can not conclude that a high SAAG is a typical feature in this disease 8. Open in a separate window. Myxedema ascites in the posttransplant setting: case report. The patient was discharged with a prescription for 20 mg furosemide and 50 mg spironolactone daily, because of his poor financial status. Of the various causes, peritoneal malignancies, tuberculous peritonitis, pyogenic peritonitis and pancreatic ascites can all lead to high-protein ascites.

Arch Intern Med. J Clin Gastroenterol. However, it could interact with albumin to form complexes that prevent the lymphatic drainage of extravasated albumin Hashimoto disease, the most common cause of hypothyroidism, may be associated with an esophageal motility disorder presenting as dysphagia or heartburn.

Hypothyroidism can also cause decreased bone marrow activity and decreased erythropoietin secretion resulting in anemia [ 10 ]. Dig Dis Sci ; 28 : —5. Varied cardiac presentations include atrial fibrillation AFchamber enlargement more often right-sidedcongestive heart failure CHFvalvular regurgitation atrioventricular more than semilunarand pulmonary hypertension PHmost of which have been reported to reverse with correct treatment [ 2 — 6 ]. Pharmacotherapy ; 18 : —51S. To prevent further fluid retention, the patient was treated with diuretics, with poor response and persistent symptoms. Retinoid X receptor interacts with nuclear receptors in retinoic acid, thyroid hormone and vitamin D3 signalling.

  • Endocrinology ; : — Am J Med ; 88 : —

  • Find articles by Chang-Wook Kim.

  • EKG showed atrial fibrillation with rapid ventricular response Figure 1.

  • Primary hypothyroidism is a very common diagnosis, affecting 3. Oxford Academic.

  • Antibiotic overuse in older patients: An important clinical reminder of pseudomembranous colitis.

  • Transit time from mouth to cecum is accelerated, resulting in diarrhea.

Abdominal discomfort, flatulence, and bloating occur in those mechanims bacterial overgrowth and improve with antibiotics. However, it could interact with albumin to form complexes that prevent the lymphatic drainage of extravasated albumin Arch Intern Med. Find articles by Hyung-Keun Kim. We decided to evaluate some relatively unusual causes of ascites.

Do not disregard or avoid professional medical advice due to content published within Cureus. The tumor markers CA and CA were negative. Saltzstein, L. Isolated ascites in hypothyroidism: medical and ethical issues. Choudhary AM, Roberts I.

J Clin Gastroenterol. Diarrhea in medullary carcinoma of the thyroid MCT may be due to elevated calcitonin, prostaglandins, or 5-hydroxyindoleacetic acid. J Korean Med Sci. However, the importance of its diagnosis is that use of thyroid hormone replacement results in complete resolution. Kocen RS, Atkinson M.

  • J Steroid Biochem Mol Biol ; 65 : — Other thyroid and liver interactions.

  • Find articles by Hwang Choi. Support Center Support Center.

  • Sign In or Create an Account.

Archived from the original on A prominent feature of ascitic fluid in hypothyroidism is its elevated protein content but SAAG value varies and can be low or high. Nature ; : — The plasma concentrations of free T 4 and T 3 are at a steady concentration, so that the tissues are exposed to the same concentrations of the free hormone. Characterising the effects of thyroid hormone on the liver: a novel approach to increase liver mass. Also, in hyperthyroidism, there is an accelerated metabolism of intrinsic and extrinsic pulmonary vasodilators prostacyclin, nitric oxide, and acetylcholine and an impaired metabolism of pulmonary vasoconstrictors serotonin, thromboxane, and endothelin-1 [ 1415 ].

Find articles by Hyung-Keun Kim. Find articles by Kyu-Yong Choi. Here, we report a yr-old man with myxedema ascites that resolved completely with thyroid hormone replacement therapy. Received Apr 6; Accepted Jun

Sidebar1?
Sidebar2?