BACKGROUND Hypothyroidism is the second most common endocrine disorder following diabetes. Appropriate hormone replacement therapy is the cornerstone of its management and is typically in the form of oral preparations of levothyroxine. Intravenous replacement is a well-known alternative in patients who are unable to take medication orally for long periods. However, effective and safe alternatives to oral preparations of levothyroxine should be sought in the absence of the parenteral alternative. The aim of this report is to describe an alternative route for levothyroxine supplementation when the oral and parenteral routes are not available. CASE REPORT This study reports a hypothyroid patient with symptomatic malignant gastric outlet obstruction requiring surgery. However, the patient's surgical condition precluded oral administration of levothyroxine and the parenteral alternative was unavailable. Hormone replacement therapy was administered rectally in the form of enemas in preparing the patient for surgery. CONCLUSIONS Rectal administration of levothyroxine using enemas can be a safe and effective alternative for patients in whom administration via the oral route is not feasible, especially when parenteral formulas are unavailable.