Metabolic problems & Endocrinology

Question 1

Pancoast Tumours

Answer 1

• Rare & aggressive type of lung cancer - begins in the top part of lung
• Shoulder blade pain and upper back pain, esp if tumor is impacting the ribs, spine or nerves of the brachial plexus.
• Slow growing
• 40% present with Horner’s syndrome: ipsilateral ptosis, miosis, and anhidrosis.
• 5-yr survival 30-40%
• M>F
• 6th decade
• chemotherapy

Question 2

Causes: Hypo- and Hyperkalemia

Answer 2

Question 3

Acromegaly

Answer 3

Can be primary/ secondary

Due to GH producing tumours - pituitary adenoma (95%), ectopic production sites e.g pancreatic ca. 6% of patients have MEN-1

c/f: coarse facial appearance, spade-like hands, increase in shoe size, large tongue, prognathism, interdental spaces, excessive sweating and oily skin: caused by sweat gland hypertrophy
features of pituitary tumour: hypopituitarism, headaches, bitemporal hemianopia, raised prolactin in 1/3 of cases → galactorrhoea

complications: hypertension, diabetes (>10%), cardiomyopathy,
colorectal cancer

Question 4

Causes of Hypercalcaemia

Answer 4

Parathyroid mediated
1. Primary hyperparathyroidism (sporadic)
2. Inherited variants: Multiple endocrine neoplasia (MEN) syndromes, Familial isolated hyperparathyroidism, Hyperparathyroidism-jaw tumor syndrome
3. Familial hypocalciuric hypercalcemia
4. Tertiary hyperparathyroidism (kidney failure)
Non-parathyroid mediated
1. Hypercalcemia of malignancy: Secretion of PTHrP, Increased calcitriol (activation of extrarenal 1-alpha-hydroxylase), Osteolytic bone metastases and local cytokines
2. Vitamin D intoxication
3. Chronic granulomatous disorders or other illnesses characterized by granuloma formation: Increased calcitriol (activation of extrarenal 1-alpha-hydroxylase)
4. Medications
- Thiazide diuretics
- Lithium
- Teriparatide
- Abaloparatide
- Excessive vitamin A
- Theophylline toxicity
5. Miscellaneous
- Hyperthyroidism
- Acromegaly
- Pheochromocytoma
- Adrenal insufficiency
- Immobilization
- Parenteral nutrition
- Milk-alkali syndrome

Question 5

Causes of Hyperkalaemia

Answer 5

Addison’s disease
Acute renal failure
ACE inhibitors
Angiotensin 2 receptor blockers
Ciclosporin
spironolactone
Massive blood transfusion
Metabolic acidosis
Rhabdomyolysis

Question 6

Side effects of Steroids

Answer 6

& mineralocorticoid effects
Glucocorticoid effects
Endocrine: impaired glucose regulation, increased appetite/weight gain, hirsutism, hyperlipidaemia, Cushing’s syndrome -moon face, buffalo hump, striae, suppression of growth in children
Musculoskeletal: osteoporosis, proximal myopathy, avascular necrosis of the femoral head
Immunosuppression, increased susceptibility to severe infection, reactivation of tuberculosis
Psychiatric: insomnia, mania, depression, psychosis
Gastrointestinal: peptic ulceration, acute pancreatitis
Ophthalmic: glaucoma, cataracts
CNS: intracranial hypertension
Haematology: neutrophilia
Mineralocorticoid side-effects
fluid retention, hypertension

Question 7

Bariatric Surgery

Answer 7

Criteria:

BMI of >=40 kg/m2 , or 35 kg/m2 - 40 kg/m2 PLUS other significant disease (e.g. T2DM or HTN) that could be improved with weight loss.

All appropriate non-surgical measures have been tried but adequate, clinically beneficial weight loss - not achieved/ maintained .

Receiving or will receive intensive management in a tier 3 obesity management service

Generally fit for anaesthesia and surgery.

Commits to the need for long-term follow-up

There is however wide variation across the UK in the availability of bariatric surgery.