ENDO Flashcards
Commonest cause of acromegaly
Benign growth hormone secreting pituitary adenoma
DDx acromegaly
Cushings
Hypothyroidism
Signs of active disease
Headache
Visual field defect
Sweating
HTN
Hyperglycaemia
Associated conditions
Diabetes mellitus
Complications to look for A-M
Acanthosis nigricans
BP raised
CTS
DM
Enlarged organs
Field defect (BTH)
Goitre, GI malignancy
HF, Hirsute, hypopituitarism
IGF 1 raised
Joint arthropathy
Kyphosis
Lactation
Myopathy (proximal)
Investigations to diagnose acromegaly
Serum IGF-1
Non suppression of GH after OGTT
MRI pituitary fossa
Ix for complications of acromegaly
CXR (cardiomegaly/ heart failure)
ECG (ischaemia, DM and HTN)
Echo
Pituitary function testing (LH/FSH, TSH, ACTH, PRL)
Visual perimetry
OSA (polysomnography)
Colonoscopy
Anterior pituitary hormones
LH/FSH
Prolactin
TSH
ACTH
GH
MSH
What syndrome could acromegaly be assocaited with?
MEN 1
Outline the MEN syndromes
MEN 1: Pituitary, parathyroid, pancreatic
MEN2a: parathyroid, phaeo, MTC
MEN 2b: Mucosal neuromas, Marfanoid, MTC, phaeo
Examination of hands in acromegaly
Sweating
Pulse
Coarse, spade like hands
CTS release scar
Sensation over lateral 3.5 fingers
Tinel’s and Phalen’s
Wasting of thenar eminance
Weakness of opposition and thumb abduction
Possible findings on cardiovascular examination of a patient with Acromegaly
Irregularly irregular HR, HTN, Displaced apex beat, S3, bibasal crackles
Why may prolactin be raised in acromegaly?
1/3 of patients will have pituitary adenoma that secretes both PRL and GH
Bedside tests acromegaly
BP
Urine dip
CBG
Fundoscopy (hypertensive or diabetic retinopathy)
ECG
REVIEW OLD PHOTOGRAPHS
Blood tests in acromegaly
Serum IGF1
OGTT and GH measurement
TFTs (differential of hypothyroidism)
BM and hba1c
BONE PROFILE FOR CALCIUM!!!
BNP
Management of acromegaly
Non-pharmacological
MDT: Endocrinologist, specialist nurses, support groups and psychologist, PT/OT
DVLA if driving impairment from vision
dietary and lifestyle advice to minimise CVS risk factors
Medical
Somatostatin analogues: octreotide
Dopamine agonists - cabergoline
GH receptor antagonist - pegvisomant
Surgical - 1st line Transsphenoidal hypophysectomy
Radiotherapy if non surgical candidate
Complications of transsphenoidal surgery
Diabetes insipidus
Meningitis
Panhypopituitarism
What test used to monitor response to treatment in acromegaly?
IGF-1
Macroglossia DDx
Downs syndrome
acromegaly
Hypothyroidism
Amyloidosis
Acanthosis nigricans ddx
DM
Obesity
CUshing’s
Acromegaly
Ethnicity
Malignancy
How can the causes of cushing;s syndrome be classified?
ACTH dependent
ACTH independent
ACTH dependent causes
ACTH-secreting pituitary adenoma (cushing’s disease)
Ectopic ACTH secretion e.g. small cell lung cancer
ACTH independent
Iatrogenic (RA, asthma. COPD)
Adrenocortical adenomas or carcinomas
what is cushing’s syndrome
A collection of signs and symptoms secondary to excess glucocorticoid
When would a cushing’s pateint also exhibit hyperpigmentation?
Only when there is excess ACTH
Neurological signs in Cushing’s
proximal myopathy
bitemporal hemianopia
Cushing’s DDx
Hypothyroidism
Acromegaly
Pseudo-Cushing’s
Cushing’s investigations to confirm diagnosis
24hr urinary cortisol collection
Low dose dexamethasone suppression test
Investigations to localise lesion in cushings
ACTH level
High: ectopic ACTH secreting tumour or pituitary adenoma
Low: adrenal adenoma/carcinoma
MRI pituitary fossae
Adrenal CT +/- whole body CT
Bilateral inferior petrosal sinus vein sampling - lateralise pituitary adenoma and confirm if pituitary or adrenal cause
High dose-dex suppression
Cortisol will fall in ACTH dependent Cushing’s disease but not in ectopic ACTH secretion or adrenal adenoma/carcinoma
Bedside tests in Cushing’s
Obs (BP)
BM
Urine dip for glucose
ECG: IHD
VBG: hypokalaemic metabolic alkalosis
Bloods: FBC, UE, LFT, Hba1c, lipids
CXR: underlying lung lesion
Fundoscopy (Cataracts)
Cushing’s management
MDT
Non-pharm: patient education, lifestyle support to minimise CVS risks, psychologists, endocrinologist
Medical:
Anti-glucocorticoids e.g. metyrapone
Surgical (1st line): transsphenoidal hypophysectomy
adrenalectomy
pituitary irradiation
scars to look for in patient with previous cushing’s syndrome
bilateral adrenalectomy scars
complication of bilateral adrenalectomy
nelson’s
what is nelson’s?
Bilateral adrenalectomy for cushing’s causing massive production of ACTH (And MSH) due to lack of -ve feedback -> hyperpigmentation and pituitary overgrowth (pronouncedBTH)
Define osteoporosis
DEXA scan -> bone densite > 2.5 standard deviations below from the mean value of a healthy young individual (T-score)
Inherited causes of proximal myopathy
Myotonic dystrophy
Muscular dystrophy
Endocrine causes of proximal myopathy
Cushings
Hyperparathyroidism
Thyrotoxicosis
Diabetic amyotrophy
Inflammatory causes of proximal myopathy
Polymyositis
Rheumatoid arthritis
Metabolic causes of proximal myopathy
Osteomalacia
Malignancy causes of proximal myopathy
Paraneoplastic
LEMS
Drug causes of proximal myopathy
Alcohol
Statins
Steroids
