Endo Flashcards
Define acromegaly
Constellation of signs and symptoms caused by hypersecretion of GH in adults
note: most are caused by a pituitary adenoma
Outline the signs of acromegaly
coarsening of facial features
soft-tissue and skin changes - rings and shoes becoming tight
carpal tunnel syndrome
joint pain and dysfunction
snoring
alterations in sexual functioning
Can also get hyperprolactinaemia symptoms
List some appropriate investigations for acromegaly
serum insulin-like growth factor 1 (IGF-1) [lacks specificity]
oral glucose tolerance test (OGTT) - CONFIRMATORY [failure of GH suppression after 75g glucose load]
random serum growth hormone (GH)
Consider visual field testing
Consider MRI pituitary
Generate a management plan for acromegaly
1st line = transphenoidal surgery + consider radiotherapy
2nd line = somatostatin analogues (octreotide, lanreotide)
3rd line = dopamine agonists (cabergoline)
3rd line = GH receptor antagonists (pegvisomant - recombinant GH analogue)
What hormones does the adrenal gland produce and where are they produced?
CORTEX:
Mineralocorticoid (aldosterone) - zona glomerulosa
Glucocorticoids (cortisol) - zona fasciculata
Androgens (DHEA) - zona reticularis
MEDULLA:
adrenaline/noradrenaline
List some risk factors for adrenal insufficiency
Primary - Addison’s disease (usually autoimmune)
Secondary - hypothalamic/pituitary failure
Infections - TB
Infiltrative - mets, amyloidosis, lymphoma
Iatrogenic - sudden cessation of long term steroid therapy
Outline the presenting symptoms of adrenal insufficiency
Chronic Presentation - the symptoms tend to be VAGUE and NON-SPECIFIC
Dizziness
Anorexia
Weight loss
Diarrhoea and Vomiting
Abdominal pain
Lethargy
Weakness
Depression
INCREASED PIGMENTATION
Acute Presentation (Addisonian Crisis)
Acute adrenal insufficiency
Major haemodynamic collapse: shock, N+V, hypothermia and abdo pain
Precipitated by stress (e.g. infection, surgery)
List some appropriate investigations for adrenal insufficiency
morning serum cortisol (< 100 nmol/L is diagnostic)
plasma adrenocorticotrophic hormone (ACTH)
serum electrolytes
urea and creatinine
FBC
TFTs
What is the difference between the short synacthen and long synacthen test?
Short Synacthen Test
-Give IM 250 µg tetrocosactrin (synthetic ACTH)
-Serum cortisol < 550 nmol/L at 30 mins indicates adrenal failure
Long Synacthen Test
-1 mg synthetic ACTH administered
-Measure serum cortisol at 0, 30, 60, 90 and 120 minutes
-Then measure again at 4, 6, 8, 12 and 24 hours
-Patients with primary adrenal insufficiency show no increased after 6 hours
Generate a management plan for an Addisonian crisis
A-E approach
1. Rapid IV fluid rehydration
2. 50 mL of 5% dextrose to correct hypoglycaemia
3. IV or Im 100 mg hydrocortisone bolus
4. Followed by 100 mg 6 hourly hydrocortisone until BP is stable
5. Treat precipitating cause (e.g. antibiotics for infection)
Monitor
How is ongoing adrenal insufficiency managed?
Replacement:
-Glucocorticoids with hydrocortisone (3/day)
-Mineralocorticoids with fludrocortisone
[Hydrocortisone dosage needs to be increased during times of acute illness or stress]
Define carcinoid syndrome
Constellation of symptoms (esp liver mets) caused by systemic release of humoral factors from carcinoid tumours (slow-growing type of neuroendocrine tumours)
List the presenting symptoms of carcinoid syndrome
Paroxysmal FLUSHING
Diarrhoea
Crampy abdominal pain
Wheeze – due to bronchospasm
Sweating
Palpitations
Telangiectasia
List some appropriate investigations for carcinoid syndrome
serum chromogranin A/B (will be elevated)
urinary 5-hydroxyindoleacetic acid
metabolic panel
liver function tests
full blood count
CT/PET scan to localise tumour
Generate a management plan for carcinoid syndrome
Surgical resection + perioperative octreotide infusion
For unresectable - somatostatin analogue or interferon alpha
Consider chemotherapy, radiotherapy and immunotherapy
Consider palliative debulking
What are the risk factors for Cushing’s syndrome
ACTH dependent:
-pituitary adenoma (Cushing’s disease)
-ectopic ACTH from lung cancer/carcinoid tumours
ACTH independent
-adrenal adenoma
-adrenal carcinoma
Taking STEROIDS
Outline the presenting symptoms of Cushing’s syndrome
Myalgia
Thin skin/easy bruising
Poor wound healing
Weight gain - central obesity
Moon face
Interscapular fat bad
Hirsuitism
Acne
Menstrual irregularities
List the appropriate investigations for Cushing’s syndrome
- Urine pregnancy test (if appropriate)
- Bloods (U+Es, LFTs, BMs, CRP)
- 1 mg overnight dexamethasone suppression test
- Late-night salivary cortisol
- 24hr urinary free cortisol
Can also do low dose dexamethasone test (over 48hrs)
Consider ix for cause:
-pituitary MRI
-high dose dexamethasone suppression test
-petrosal sinus sampling
-ACTH levels
Generate a management plan for Cushing’s syndrome
If iatrogenic - discontinue steroids
Medical:
-inhibit cortisol synthesis with metyrapone or ketoconazole
Surgical:
-pituitary adenoma - trans-sphenoidal resection
-adrenal adenoma - surgical removal
If refractory Cushing’s disease - bilateral adrenalectomy
List some complications of Cushing’s syndrome
Diabetes
Osteoporosis
HTN
Pre-disposition to infections
Define diabetes insipidus
Diabetes insipidus is a metabolic disorder characterised by an absolute or relative inability to concentrate urine due inadequate secretion or of insensitivity to vasopressin (ADH)
List some causes of diabetes insipidus
Central:
-Idiopathic
-Tumours e.g. pituitary
-Infiltrative (e.g. sarcoidosis)
-Infection (e.g. meningitis)
-Vascular (e.g. aneurysms, Sheehan syndrome)
-Trauma (e.g. head injury, neurosurgery)
Nephrogenic:
-Idiopathic
-Drugs (e.g. lithium)
-Post-obstructive uropathy
-Pyelonephritis
-Pregnancy
-Osmotic diuresis (e.g. diabetes mellitus)
Outline the presenting symptoms of diabetes insipidus
Polyuria
Nocturia
Polydipsia
Enuresis (in children)
List some appropriate investigations for diabetes insipidus
- Bloods (U+Es - Na, Ca, K, glucose)
- urine osmolality (decreased)
- serum osmolality (increased)
- urine dipstick (negative for glucose)
- water deprivation test
Explain the results of a water deprivation test
Water restricted for 8 hrs and then desmopression given and osmolality measured.
Normally water restriction = increased urine osmolality (>600 mosmol/kg)
DI = urine osmolality is LOW (<400 mosmol/kg)
Cranial DI - urine osmolality rises >50% after desmopressin
Nephrogenic DI - osmolality rises <45% after desmopressin
Generate a management plan for diabetes insipidus
A-E
1. Give IV fluids if hypernatraemic (5% dextrose may be necessary)
2. Desmopressin
3. Maintenance of fluid balance
If nephrogenic then can give thiazide diuretics or NSAIDs (these inhibit prostaglandin synthesis and prostaglandin inhibits ADH)
What HLA associations are linked to T1DM?
HLA-DQ, HLA-DR3/4
List some causes of T2DM
MODY (maturity onset diabetes of the young) – autosomal dominant
Pancreatic disease e.g. chronic pancreatitis, pancreatic ca.
Endocrinopathies e.g. Cushing’s syndrome, acromegaly, PCOS
Drugs e.g. corticosteroids
Give some risk factors for T2DM
Genetic predisposition
Older age
Physical inactivity
Obesity - ↑FFAs, hyperglycaemia
Hypertension
Dysplipidaemia
Cardiovascular disease
List some appropriate investigations for suspected diabetes
- Urine dip
- Blood glucose
- HbA1c (>48 mmol/mol or 6.5%)
- Urine albumin:creatinine ratio
- eGFR
- U+Es
- Lipids
[If suspecting DKA then do ABG and ketones]
What are the blood glucose cut offs for diagnosing diabetes?
Fasting blood glucose >7
2hr post OGTT >11.1
Random >11.1
For diagnosis need:
-Symptomatic + 1 positive result
-Asymptomatic + 2 positive results
Generate a management plan for T1DM
Patient education
MDT
Diabetes specialist nurse
DAFNE (dose adjusted for normal eating)
Glycaemic control insulin (either basal bolus regimen or insulin pump)
Generate a management plan for DKA
IV fluid replacement with 0.9% saline
Start IV dextrose when glucose reaches 15mmol/l
Insulin infusion
Potassium (in fluids)
Monitor blood glucose, ketones, urine output and VBG
What advice is given for T2DM
Patient education
Lifestyle measures - diet, weight loss, exercise
BP control (ACEi +/- diuretic)
Statins
Smoking cessation
Outline the medication pathway for T2DM
- Metformin
(if C/I then usually start on sulfonylurea) - Metformin + sulfonylurea
(or sulfonylurea + DDP4i) - Metformin + sulfonylurea + SGLT2/DPP4i/Pioglitazone
- Substitute least effective of the three with GLP-1 (NOTE: do NOT give DPP4 and GLP 1 in combo)
- Add in insulin
Generate a management plan for HHS/HONK
IV isotonic saline fluid replacement (unless 0.45% saline if Na+ >155mmol/l)
Start IV dextrose when glucose reaches 15mmol/l
Insulin infusion 3 U/hour
Potassium (in fluids)
Monitor blood glucose, ketones, urine output and venous blood gases
Outline the main complications of diabetes
Diabetic kidney disease
Impaired vision (diabetic retinopathy)
Peripheral vascular disease
Peripheral neuropathy
IHD
Stroke/TIA
Gangrene
Infection
Impotence/ED
Define Grave’s disease
Hyperthyroidism due to presence of TSH receptor stimulating antibodies
(most common cause of hyperthyroidism in UK)
List the presenting symptoms of Grave’s disease
Heat intolerance
Sweating
Weight loss
Palpitations
Tremor
Exopthalmos
Pretibial myxoedema
Diffuse goitre
Anxiety
Oligomenorrhoea/Amenorrhoea
List some appropriate investigations for Grave’s disease
- Thyroid examination
- TFTs (low TSH + high T3/T4)
- Autoantibodies (Anti-TSHr, Anti-TPO, anti-thyroglobulin)
- Imaging (thyroid uptake scan - diffuse)
- CRP
Can do biopsy - will show tall follicles with scalloped borders
Generate a management plan for Grave’s disease
- Carbimazole or PTU (in pregs) - block organification of iodine - Risk of AGRANULOCYTOSIS
- Beta blocker for HR
- Radioactive iodine if treatment failure
- Consider thyroid surgery (risk of damage to recurrent laryngeal nerve)
Generate a management plan for a thyroid storm
- A-E approach
- IV fluids + analgesia
- Propranolol
- Steroids
- High dose carbimazole/PTU
What are the different types of hyperparathyroidism?
Primary - increased secretion of PTH independent to plasma Ca
Secondary - increased PTH secretion secondary to hypocalcaemia
Tertiary - autonomous PTH secretion following chronic secondary hyperparathyroidism
Outline some causes of primary hyperparathyroidism
Parathyroid adenoma
Parathyroid hyperplasia
Parathyroid carcinoma
MEN syndrome
Outline some causes of secondary hyperparathyroidism
Chronic renal failure
Vitamin D deficiency
Malabsorption syndromes
List the presenting symptoms of primary hyperparathyroidism
Signs of hypercalcaemia:
-Polyuria
-Renal calculi
-Constipation
-Depression/anxiety
-Fatigue
-Memory loss
-Paraesthesia