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The majority of cases with dyspepsia usually have normal gastroscopic finding, so some unusual causes may be easily neglected under the umbrella of nonulcer dyspepsia as in this case. We report a 64-year-old Thai patient who suffered from dyspepsia and fatigue for many years. Her latest physical examination was unremarkable. Although she did not have any warning signs, many abdominal investigations including the ultrasonography, computerized tomography, barium enema with air contrast, esophagogastroduodenoscopy, and colonoscopy were repeatedly performed in different hospitals and all revealed unremarkable. The last esophagogastroduodenoscopy showed only mild acute gastritis that was not expected to account for the many-year dyspepsia and fatigue. The unusual and rare causes of long term dyspepsia were extensively investigated. Finally, she was found to have serum cortisol less than 0.8 , normal serum calcium, phosphorus, and electrolytes but minimally abnormal thyroid function test. Therefore, she was diagnosed as having adrenal insufficiency and concurrent subclinical hyperthyroidism. She was fully treated with many dyspeptic drugs such as pantoprazole, sucralfate, simethicone, ondansetron, and intravenous hydrocortisone infusion 300 mg a day. She responded well to therapy in 2 days and was discharged home with oral prednisolone 15 mg a day with many dyspeptic drugs. Adrenal insufficiency is a very rare entity and most cases have no specific signs and symptoms, so it could be easily overlooked as the very rare and unusual cause of chronic dyspepsia. In this report, the association between the adrenal insufficiency and the gastrointestinal upset is discussed.
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