Abdominal Distention and Weight Gain Flashcards

1
Q

Why can a pituitary tumour affect vision?

A

The optic chiasm is located directly above the sella turcica of the sphenoid bone, which contains the pituitary gland. Therefore, pituitary tumours can push/compress the optic nerve or other nerves nearby related to the extraocular muscles.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What signs on examination are indicative of Cushing’s Disease? (7)

A

Abdominal/truncal obesity
Abdominal striae
Neck fat (hump)
Skin bruising
High BP
Proximal myopathy
Facial plethora

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What signs on examination are indicative of hypothyroidism? (2)

A

Bradycardia
Dry skin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What clinical features suggest Cushing’s Syndrome as a differential diagnosis? (2)

A

The physical findings of cushingoid appearance and presence of cardiovascular risk factors (BP, Glycosuria).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

How can the complications of obesity be broadly classified?

A

Metabolic
Cardiorespiratory
Other

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is metabolic syndrome?

A

The triad of diabetes, hypertension, and obesity.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What BMI range is considered to be a healthy weight?

A

18.5–24.9 kg/m2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Which BMI ranges categorise the three classifications of obesity?

A

Obesity I: 30–34.9 kg/m2
Obesity II: 35–39.9 kg/m2
Obesity III: 40 kg/m2 or more.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

When is medical management of obesity considered?

A

If there is a BMI of 28kg/m2 with associated risk factors, or a BMI 30kg/m2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is Orlistat?

A

A pancreatic lipase inhibitor that causes reduced fat absorption.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is Liraglutide (Saxenda)?

A

A GLP1 analogue that slows gastric emptying, subsequently increasing satiety

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are the indications for surgical management of obesity? (3)

A

-If patient has BMI > 40 or BMI 35-40 with other significant weight-related disease
-Patient has tried all non-surgical approaches
-Patient has been or is willing to receive Tier 3 weight management services

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What four initial screening tests for Cushing’s Syndrome are used to establish underlying hypercortisolaemic state?

A

-Urinary Free Cortisol (UFC) - at least two measurements
-Late-night salivary cortisol - two measurements
-1-mg overnight Dexamethasone Suppression Test (DST)
-Longer low-dose DST (2 mg/d for 48 h)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is Dexamethasone?

A

An exogeneous steroid that causes suppression of the pituitary gland through negative feedback, inhibiting ACTH secretion.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is normally seen in the dexamethasone suppression test (DST)?

A

In a normal subject, there is reduction in cortisol levels following administration of low-dose dexamethasone.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is seen in a patient with Cushing’s Syndrome in the dexamethasone suppression test (DST)?

A

No reduction in cortisol output after low-dose dexamethasone, but inhibition of cortisol output following high-dose dexamethasone.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is seen in a patient with an adrenal tumour or ectopic ACTH in the dexamethasone suppression test (DST)?

A

No reduction in steroid production after low or high dose dexamethasone.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What are the main causes of ACTH-Independent Cushing’s Syndrome? (3)

A

Adrenal adenoma
Adrenal carcinoma
Adrenal hyperplasia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What are the main causes of ACTH-Dependent Cushing’s Syndrome? (3)

A

Pituitary adenoma
Ectopic ACTH (bronchial carcinoid commonest)
Unknown source of ACTH

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What is the next step once hypercortisolemic state is confirmed using initial tests for Cushing’s Syndrome?

A

Arrange ACTH levels to determine ACTH Dependent CS OR ACTH-Independent CS, to help differentiate the underlying cause.

21
Q

What should be the first further investigation once ACTH-Independent Cushing’s Syndrome has been established?

A

Arrange CT Adrenals to assess adrenal tumour or hyperplasia.

22
Q

What should be the next further investigations once ACTH Dependent (pituitary dependent) Cushing’s Syndrome has been established? (2)

A

-Arrange a pituitary MRI; presence of pituitary adenoma > 6mm, is highly consistent with Cushing’s Disease.
-Arrange non-invasive tests (High-Dose Dexamethasone Suppression Test (HDDST) and Corticotropin-Releasing Hormone (CRH) stimulation test); if consistent confirms Cushing’s Disease.

23
Q

What are the consequences of removing all or part of the anterior pituitary gland? (4)

A

Hormone replacement may be needed for any of the hormones produced from the anterior pituitary gland:
-TSH (Thyroxine)
-GH (growth hormone therapy in selected few)
-ACTH (hydrocortisone therapy)
-FSH/LH (Testosterone or Oestrogen/Progesterone hormone replacement).

[The posterior pituitary hormones (ADH, Endorphins, Oxytocin) should not need replacement as they are not secreted by the pituitary gland, just stored.]

24
Q

What are pituitary tumours?

A

Benign adenomas of the anterior pituitary, broadly classified by size and the cell of origin.

25
Q

What are the five classifications of pituitary adenomas based on cell of origin?

A

Gonadotroph adenoma - mostly non-functioning
Thyrotroph adenoma - TSH producing
Corticotroph adenoma - ACTH producing (Cushing’s disease)
Lactotroph adenoma - prolactin producing
Somatotroph adenoma - GH producing (acromegaly)

26
Q

What is Metyrapone?

A

A glucocorticoid synthesis inhibitor used to reduce adrenal steroid output by inhibiting 11-beta-hydroxylase.

27
Q

What are the hormonal consequences of removing both adrenal glands?

A

Glucocorticoid and mineralocorticoid hormone deficiencies, requiring replacement therapy.

28
Q

What immediate action should be taken if you suspect established or developing adrenal crisis in a patient?

A

Immediate injection of 100mg hydrocortisone i.v. or i.m., followed by rapid rehydration with i.v. administration of 0.9% saline solution (or equivalent).

29
Q

What are the ‘sick day rules’ with regards to glucocorticoid replacement therapy?

A

The patient should double the dose of their glucocorticoids in the event of any medical illness; physical and mental stress; and trauma including any surgical procedure.

30
Q

What are the three types of adrenal insufficiency?

A

-Primary (due to adrenocortical disease – adrenal glands are not able to respond to ACTH)
-Secondary (pituitary dysfunction – lack of ACTH needed to stimulate the adrenal glands)
-Tertiary (hypothalamus – lack of corticotrophic releasing hormone [CRH])

31
Q

Why are secondary and tertiary adrenal insufficiency associated with cortisol but not mineralocorticoid deficiency?

A

Aldosterone (mineralocorticoid) is primarily regulated by renin-angiotensin system, which is independent of pituitary and hypothalamus action.

32
Q

What does NICE Guidance suggest if serum cortisol is below 100nmol/l?

A

Admit patient to hospital, as adrenal insufficiency is highly likely. Urgency depends on severity of symptoms and serum cortisol level.
(Postural hypotension and/or electrolyte disturbance are indications for urgent referral or admission.)

33
Q

What is the Short Synacthen Test (aka Short ACTH stimulation test)?

A

A test that assesses adrenocortical functional activity in response to the injection of exogenous ACTH (tetracosactrin).
—>Cortisol levels fail to increase in response to exogenous ACTH in patients with chronic adrenal insufficiency.

34
Q

What main signs are highly indicative of Addison’s Disease? (3)

A

Hyperpigmentation - only seen in Addison’s, due to elevated levels of ACTH.
Electrolyte disturbance and significant postural hypotension - due to lack of mineralocorticoids causing hypovolaemia and sodium loss, hence commonly noticed in Addison’s Disease.

35
Q

What is the difference between Cushing’s Syndrome and Cushing’s Disease?

A

Cushing’s Syndrome - a syndrome characterised by excess glucocorticoids from any cause.
Cushing’s Disease - pituitary dependent Cushing’s Syndrome (due to a pituitary ACTH producing adenoma)

36
Q

What is corticotropin-releasing hormone (CRH)?

A

A hypothalamic peptide, which acts on pituitary corticotrophs to stimulate secretion of ACTH.

37
Q

What features are always indicative of Adrenal Crisis? (3)

A

A sick patient with hypotension and hyponatraemia.

38
Q

What is Adrenal Insufficiency?

A

Adrenal insufficiency is primarily inadequate secretion of cortisol and/or aldosterone to maintain normal physiological function.

39
Q

What main symptoms are highly indicative of Addison’s Disease? (5)

A

Weakness
Weight loss
Severe fatigue
Loss of appetite
Dizziness and blackouts

[WWSLD]

40
Q

How is Addison’s Disease managed? (2)

A

The individual takes replacement steroids, titrated to severity of disease: hydrocortisone (a glucocorticoid) replaces cortisol and fludrocortisone (a mineralocorticoid) can replace aldosterone if this is also insufficient.

41
Q

How is a diagnosis of Chronic Adrenal Insufficiency confirmed?

A

A short ACTH (Synacthen) Stimulation Test, followed by subsequent investigations to explore underlying cause.

42
Q

What is the difference between adrenal insufficiency and Addison’s Crisis?

A

Adrenal insufficiency is chronic and presents insidiously with non-specific symptoms; Addisonian Crisis (or acute adrenal crisis) is an acute crisis in patients with existing adrenal insufficiency.

43
Q

Which region of the adrenal gland is Cushing’s Syndrome related to?

A

The zona fasiculata.

44
Q

What substance are hormones produced by the adrenal glands synthesised from?

A

Cholesterol

45
Q

What additional investigation can help determine the cause of hyponatraemia?

A

Blood volume - if patient is euvolaemic, hypovolaemic or hypervolaemic.

46
Q

What are the potential causes of hyponatraemia in a hypervolaemic patient? (4)

A

Heart failure
Nephrotic syndrome
Cirrhosis
Chronic kidney disease

47
Q

What is the first indicator of diabetic nephropathy?

A

Microalbuminuria

48
Q

Briefly describe the HPA axis for glucocorticoid release.

A

Hypothalamus releases corticotropin releasing factor (CRF) which stimulates the anterior pituitary to release adrenocorticotropic hormone (ACTH), which stimulates the adrenal cortex to release cortisol, corticosterone and other exogenous steroids.