Endo Flashcards
Secondary causes of DM
Drugs: steroids, ART, antipsychotics, thiazides
Pancreatic: CF, chronic pancreatitis, pancreatic cancer
Endo: phaeo, Cushings, acromegaly, thyrotox
Other: glycogen storage diseases, PCOS
Metabolic syndrome
Central obesity and two of: increased triglycerides decreased HDL HTN Hyperglycemia (DM, IGT, IFG)
Diabetes lifestyle management
DELAAYS
Diet - increased complex carbs and soluble fibre, reduced fat and sodium
Exercise
Lipids - statins
ABP - reduce sodium and EtOH and keep BP <130/80 with ACEi doing this best (B-b masks hypos and thiazide increases glucose)
Aspirin - for all > 50 or under 50 and have CV RF
Yearly / 6 monthly follow-up
smoking cessation
Diabetes management
- DELAAYS
- Metformin (C/I: GFR<30, tissue hypoxia (sepsis/MI as lactate increases), morning before GA and contrast)
- Metformin + sulfonylurea (gliclazide taken with breakfast)
- can add insulin OR sitagliptin/exenatide if obese or employment/social issues with insulin
Insulin regimes
BD Biphasic Regime
BD insulin mixture 30min before breakfast and dinner
Rapid-acting: e.g. actrapid
Intermediate- / long-acting: e.g. insulatard
T2 or T1 DM with regular lifestyle: children, older pts.
Assoc, with fasting hyperglycaemia
Basal-Bolus Regime Bedtime long-acting (e.g. glargine) + short acting before each meal (e.g. lispro) Adjust dose according to meal size ~50% of insulin given as long-acting T1DM allowing flexible lifestyle Best outcome
OD Long-Acting Before Bed
Initial regime when switching from tablets in T2DM
Diabetic retinopathy
Background Retinopathy
Dots: microaneurysms
Blot haemorrhages
Hard exudates: yellow lipid patches
Pre-proliferative Retinopathy
Cotton-wool spots (retinal infarcts)
Venous beading
Haemorrhages
Proliferative Retinopathy
New vessels
Pre-retinal or vitreous haemorrhage
Maculopathy
↓ acuity may be only sign
Hard exudates w/i one disc width of macula
Diabetic neuropathy
Peripheral Neuropathy:
Includes absent ankle jerk which is treated paracetamol/ amitriptyline/ gabapentin/ baclofen
Mononeuritis multiplex:
e.g. CN3/6 palsies
Femoral Amyotrophy:
Painful asymmetric weakness and wasting of quads with loss of knee jerks
Dx: nerve conduction and electromyography
Autonomic Neuropathy
Postural hypotension – Rx: fludrocortisone
Gastroparesis → early satiety, GORD, bloating
Diarrhoea: Rx c¯ codeine phosphate
Urinary retention
ED
Causes of hypos
EXPLAIN Exogenous drugs (insulin or sulphonyl) Pituitary insufficiency Liver failure Addison’s Islet cell tumours (insulinomas) Immune (insulin receptor Abs: Hodgkin’s) Non-pancreatic neoplasms: e.g. fibrosarcomas
Cause from Ix for hypo
Look at ketones, C-peptide and insulin
Hyperinsulinaemic hypoglycaemia
Drugs: ↑ C-pep = sulfonylurea; normal C-pep = insulin
Insulinoma (MEN1)
↓ insulin, no ketones
Non-pancreatic neoplasms
Insulin receptor Abs
↓ insulin, ↑ ketones
Alcohol binge with no food
Pituitary insufficiency
Addison’s
Hypo Mx
Alert and Orientated: Oral Carb
Rapid acting: lucozade
Long acting: toast, sandwich
Drowsy / confused but swallow intact: Buccal Carb
Hypostop / Glucogel
Consider IV access
Unconscious or Concerned re Swallow: IV dextrose
100ml 20% glucose (50ml 50% dextrose: not used)
Deteriorating / refractory / insulin-induced / no access:
1mg glucagon IM/SC
Won’t work in drunks + short duration of effect (20min)
Insulin release may → rebound hypoglycaemia
Thyroid storm Rx
- Fluid resuscitation + NGT
- Bloods: TFTs + cultures if infection suspected
- Propranolol PO/IV
- Digoxin may be needed
- Carbimazole then Lugol’s Iodine 4h later to inhibit thyroid
- Hydrocortisone
- Rx cause
Causes of hypothyroidism
Primary:
- Atrophic thyroiditis: most common in UK; antibodies but no goitre, associated with pernicious anaemia, vitiligo
- hashimoto’s thyroiditis: TPO +ve with goitre
- Iodine deficiency
- Post de quervain’s thyroiditis
Post-surgical
Secondary to hypopituitarism
Myxoedema coma features
Looks hypothyroid Hypothermia Hypoglycaemia Heart failure: bradycardia and ↓BP Coma and seizures
Myxoedema coma Mx
Bloods: TFTs, FBC, U+E, glucose, cortisol
Correct any hypoglycaemia
T3/T4 IV slowly (may ppt. myocardial ischaemia)
Hydrocortisone 100mg IV
Rx hypothermia and heart failure
Plummer’s vs multinodular goitre
Multinodular goitre evolves from simple goitre caused by iron deficiency or autoimmune; it usually is euthyroid or subclinical hyperthyroidism
Plummer’s is a toxic multinodular goitre where one of the nodules becomes toxic, so can cause thyrotox and will show uneven uptake on hot nodule
Graves Ab
anti-TSH (T2 hypersensitivity)
Hashimoto’s thyroiditis Ab
anti-TPO, anti-Tg (T2 and T4 hypersensitivity)
de Quervain’s Ag
usually caused by Coxsackie virus; shows reduced iodine uptake
Subacute lymphocytic thyroid disease
Diffuse painless goitre
May occur post-partum
Thyrotoxicosis → hypo→eu
Riedel’s thyoiditis
Hard fixed thyroid mass
Mass effects only (dysphagia, obstruction etc)
Assoc. with retroperitoneal fibrosis
Follicular adenoma
Single thyroid nodule ± thyrotoxicosis (majority are cold); treat with hemi-thyroidectomy
thyroid cyst
Solitary thyroid nodule
Asympto or pressure symptoms
Can → localised pain due to cyst bleed
Rx: aspiration or excision
Thyroid cancer
Papillary is most common, mainly affects 20-40y.o., which spreads to jugulodigastric lymph node or lung
Follicular (bones or lung mets) and papillary stem from follicular cells and have Tg as tumour marker
Medullary associated with MEN2, so must do phaeo screen pre-op. Stem from parafollicular C-cells and use CEA snd calcitonin as tumour markers
Anasplastic are undifferentiated follicular cells that are sen in elderly (>60) and have rapid aggressive growth
Risk factors for malignancy in thyroid nodules
Solitary Solid Younger Male Cold (non-functional) Risk factor: e.g. radiation exposure
Complications of thyroid surgery (usually a collar incision)
Early
Reactionary haemorrhage → haematoma (<1%)
Laryngeal oedema
Recurrent laryngeal nerve palsy (0.5%) (Right RLN more common - oblique ascent)
Hypoparathyroidism (2.5%) → ↓ Ca2+ → Chvostek’s and Trousseau’s
Thyroid storm - Rx: propranolol, antithyroid drugs, Lugol’s
Late:
Hypothyroidism
Recurrent hyperthyroidism
Keloid scar
Ix and Rx for primary hyperparathyroidism
↑Ca2+ + ↑ or inappropriately normal PTH, ↑ALP, ↓PO4
ECG: ↓QTc → bradycardia → 1st degree block
X-ray: osteitis fibrosa cystica → phalangeal erosions
DEXA: osteoporosis
Treat hypercalcaemia with: ↑ fluid intake
Avoid dietary Ca2+ and thiazides (↑ serum Ca)
Can remove adenoma but risk of hypoparathyroidism and recurrent laryngeal nerve palsy
Hypoparathyroidism Causes
Autoimmune
Congenital: DiGeorge (CATCH22)
Iatrogenic: Surgery; radiation
Rx: ca supplements and calcitriol
Pseudohypoparathyroidism
Failure of target organ response to PTH
Symptoms of hypocalcaemia
Short 4th and 5th metacarpals, short stature
Ix: ↓Ca, ↑PTH
Rx: Ca supplements + calcitriol
ACTH independent causes (low ACTH)
Iatrogenic steroids: commonest cause Adrenal adenoma / Ca: carcinoma often → virilisation Adrenal nodular hyperplasia Carney complex: LAME Syndrome McCune-Albright
ACTH dependent causes (high ACTH)
Cushing’s disease:
Bilat adrenal hyperplasia from ACTH-secreting
pituitary tumour (basophilic microadenoma)
Cortisol suppression occurs with high-dose dex
Ectopic-ACTH: excise tumour and give metyrapone
SCLC
Carcinoid tumour
Skin pigmentation, metabolic alkalosis, wt. loss,
hyperglycaemia
No suppression with any dose of dex
Nelson’s syndrome
Rapid enlargement of a pituitary adenoma following
bilateral adrenelectomy for Cushing’s syndrome
Not typically performed nowadays
Presentation:
Mass effects: bitemporal hemianopia
Hyperpigmentation
Primary hyperaldosteronism causes; Ix; Rx
High BP and hypokalaemia
Bilateral adrenal hyperplasia Adrenocortical adenoma (Conn's)
Aldosterone:renin ratio elevated; adrenal CT/MRI needed
Conn’s: laparoscopic adrenelectomy
Hyperplasia: spironolactone
Secondary hyperaldosteronism
Due to ↑ renin from ↓ renal perfusion
Causes RAS Diuretics CCF Hepatic failure Nephrotic syndrome
Ix
Aldosterone:renin ratio: normal
Bartter’s syndrome
Autosommal recesive
Blockage of NaCl reabsorption in loop of Henle (as if
taking frusemide)
Congenital salt wasting → RAS activation →
hypokalaemia and metabolic alkalosis + hyponatraemia
Normal BP
Secondary Adrenal insufficiency
Causes
Chronic steroid use → suppression of HPA axis
Pituitary apoplexy / Sheehan’s
Pituitary microadenoma
Features
Normal mineralocorticoid production
No pigmentation (ACTH ↓)
Phaeo
Rule of 10s
10% malignant
10% extra-adrenal (found by aortic bifurcation)
10% bilateral
10% part of hereditary syndromes: MEN2a and 2b; Neurofibrimatosis; Von Hippel-Lindau: RCC + cerebellar signs
Ix: Plasma + urine metadrenaline Also vanillylmandelic acid Abdo CT/MRI MIBG (mete-iodobenzylguanidine) scan
Hypertensive crisis Rx
Phentolamine 2-5mg IV (α-blocker) then labetalol 50mg IV
Repeat to safe BP (e.g. 110 diastolic)
Phenoxybenzaime 10mg/d PO when BP controlled
Elective surgery after 4-6wks to allow full α-blockade
and volume expansion
MEN1
Pituitary adenoma: prolactin or GH
Parathyroid adenoma / hyperplasia
Pancreatic tumours: gastrinoma or insulinoma
MEN2
Thyroid medullary carcinoma
Adrenal phaeochromocytoma
A) Hyperthyroidism
B) Marfanoid habitus
Carney Complex/LAME Syndrome
LAMES
Lentigenes - spotty skin pigmentation (Peutz Jehgers is DDx)
Atrial Myxoma
Endocrine tumours (pituitary, adrenal hyperplasia)
Schwannomas
Peutz-Jeghers
Mucocutaneous freckles on lips, oral mucosa and palms /
soles
GI hamartomas: obstruction, bleeds
Pancreatic endocrine tumours
↑ risk of cancer: CRC, pancreas, liver, lungs, breast
Von Hippel-Lindau
Renal cysts Bilateral renal cell carcinoma Haemangioblastomas - Often in cerebellum → cerebellar signs Phaeochromocytoma Pancreatic endocrine tumours
Neurofibrimatosis
Dermal neurofibromas Café-au-lait spots Lisch nodules Axillary freckling Phaeochromocytoma
Autoimmune polyendocrine syndrome
Type 1: AR - Addison’s, candidiasis, hypoparathyroidism
Type 2 (schmidt’s syndrome): polygenic - Addison’s, thyroid disease, T1DM
Craniopharyngeoma
Originates from Rathke’s pouch
Commonest childhood intracranial tumour → growth failure
Calcification seen on CT/MRI
DI causes
Cranial Idiopathic: 50% Congenital: DIDMOAD Tumours Trauma Vascular: haemorrhage (Sheehan’s syn.) Infection: meningoencephalitis Infiltration: sarcoidosis
Nephrogenic Congenital Metabolic: ↓K, ↑Ca Drugs: Li, demecleocycline, vaptans Post-obstructive uropathy
Waterhouse-Friedrichsen syndrome
Adrenal failure with haemorrhage from N meningitidis
