MON-363 Severe Intolerance to Oral Intake, Requiring Total Parenteral Nutrition, as the Only Presenting Symptom of Adrenal Insufficiency

Background: Adrenal insufficiency presents with non-specific symptoms and the diagnosis can be frequently delayed due to this. It is our role as endocrinologists to promote a high level of awareness of this disorder in all physicians. Case: 73-year-old man with past medical history of diabetes mellitus, hypertension, chronic kidney disease stage III, prolactinoma and Budd Chiari syndrome status post orthotopic liver transplant two years ago. Patient presented with two months of nausea, vomiting, abdominal pain and decreased appetite. During this time symptoms worsened to the point where he was unable to tolerate any oral intake leading to a 30-pound weight loss. He required multiple hospital admissions with extensive gastrointestinal work-up including abdominal CT and MRI, upper endoscopy, upper gastrointestinal series and small bowel follow through which were all unremarkable. Due to persistent nausea and vomiting, he was not able to tolerate enteral feeding via a nasogastric tube and thus required total parenteral nutrition (TPN). On physical exam, vital signs had been stable throughout his hospital admissions and the rest of his physical exam was unremarkable as well as basic laboratory testing. On further questioning, before presentation patient had been tapered off steroids for his liver transplant and so adrenal insufficiency was considered. Initial 8 am cortisol level was found to be 0.7 mcg/dl and ACTH 8 pcg/dl (NR: 6-59pcg/dl). The diagnosis of central adrenal insufficiency was made, and he was started on steroid replacement. Patient started tolerating oral diet within 48 hours after initiation of steroids and TPN was no longer required. Given significant improvement in gastrointestinal symptoms after treatment, the cause of his symptoms were attributed to adrenal insufficiency. The etiology was thought to be the tapering of his chronic steroid dose with suppressed hypothalamic-pituitary-adrenal axis. Conclusion: Adrenal insufficiency frequently presents with gastrointestinal symptoms and most patients will not be initially seen by endocrinologists. This emphasizes the need for physicians of all specialties to maintain a high level of suspicion of this disorder in high risk patients with gastrointestinal symptoms, even if this is their only complaint.