Endo Flashcards
T1DM blood glucose targets
5-7 mmol/l on waking and
4-7 mmol/l before meals at other times of the day
recommend testing at least 4 times a day, including before each meal and before bed
MEtformin in T1?
NICE recommend considering adding metformin if the BMI >= 25 kg/m²
What is De Quarvain’s thyroiditis? Treatment/ management?
Subacute thyroiditis (also known as De Quervain’s thyroiditis and subacute granulomatous thyroiditis) is thought to occur following viral infection and typically presents with hyperthyroidism.
There are typically 4 phases; phase 1 (lasts 3-6 weeks): hyperthyroidism, painful goitre, raised ESR phase 2 (1-3 weeks): euthyroid phase 3 (weeks - months): hypothyroidism phase 4: thyroid structure and function goes back to normal
Investigations
globally reduced uptake on iodine-131 scan
Management
usually self-limiting - most patients do not require treatment
thyroid pain may respond to aspirin or other NSAIDs
in more severe cases steroids are used, particularly if hypothyroidism develops
Hypopit causes
Hypothalamus Kallmann syndrome Rare genetic, failure to start or complete puberty - anosmia or hyposmia - GnRH deficiency Infection Meningitis Tumour Inflammation Pituitary stalk Mass lesion e.g. craniopharyngioma Meningioma Carotid artery aneurysm Trauma Surgery Pituitary Autoimmune hypophysitis Irradiation Tumour Ischaemia DIC Snake bite in India assoc with kidney failure Sheehan's syndrome - necrosis after postpartum haemorrhage Pituitary apoplexy
Hypopit features GH
Central obesity Atyherosclerosis Dry wrinkly skin Osteoposois Hypoglycaemia Decreased strength Tiredness Decreased CO
hypopit features LH/FSH
Decreased muscle bulk Hypogonadism Less hair Less ejaculate Small testes Decreased libido Low mood Tiredness Female Low libido Amen/oligomenorrhea Dyspareunia Decreased breast tissue atrophy Osteoporosis
hypopit features not GH and LF/FSH
Corticotroph Addisons without pigmentation Prolactin None usually, decreased breast milk production Thiotrophs Hypothyroidism If tumour May secrete one of the hormones Mass effect - bitemporal hemi and mass effect
Hypopit diagnosis
Static (one may be high)
TSH - t4
GH - insluin like growth factor (IGH-1) better marker though (GHRH)
Cortisol
LH/FSH - testosterone/ oestradiol (GnRH)
Prolactin - may be high due to loss of dopamine
U&E - cortisol, Na low from dilution
Low Hb from thyroid normochromic normocytic
Dynamic
ITT - Give insulin - release cortisol, glucose should be induced below2.2 and patient should be symptomatic when cortisol and GH are measured
Short Synacthen - Should supress ACTH and increase glucose?
Arginine and growth hormone-releasing test - should stimulate growth hormone
Hypopit treatment
Endo referral - treatment of underlying cause Replacement Gonadotrophs Male Testogel IM injection (buccal monoadhesive tablets) Female OCP contains enough for maintainence Patch or oral Testoesterone - may help Gonadotrop therapy to induce fertility in both Glucocorticoids Hydrocortisone 15mg oral Thyrotrophs Thyroxine Somatotrophs Growth hormone - somatotrophin better as less fat gain/ muscle loss Lactotrophs
Pit adenomas classification
Chromophobe (no colour on staining) - 70%, very common e.g. microadenomas (<1cm) which are common. Most likely to be ‘non functioning’ i.e. no hormones secreted so revealed by mass effect or hypopit. Some can secrete
Acidophil 15% Rarer local pressure effect. PRL or GH
Basocphil 15% Rarer local pressure effect. ACHT
** 99% of functioning secrete ACTH, PRL, GH. 30% are non functioning
Pit adenomas symptoms
Hypopituitarism Cushings/ Acromegaly/ Prolactinoma Mass effect Headache Visual disturbance Bitemporalhemianopia - optic chiasm CN III,IV, VI (all muscles of eye) - If infiltrated into cavernous sinus Hypothalmic disturbance Sleep control Temperature control Diabetes Insipidous (rarely pit cause)
Pit adenoma diangosis
Static TSH Cortisol LH/FSH GH/ IGF-1 Prolactin ADH Dynamic Water suppression test - Stage 1 - no drink for 8 hours, measure weight and urine osmolality Stage 2 - Give Desmopressin (like ADH) if nephrogenic there will be no response (if nephrogenic give hydrochlorothiazide or amiloride) Short acting Synacthen test OGTT Imaging MRI - look at mass effect
Pit adenoma treatment
Hormone replacement Treat Cushings, Acromegal If prolactinoma Dopamine - cabergoline Other Transphenoidal resection Transfrontal resection if adenoma is supra-stela extension (stellar=saddle) Radiotherapy (stereotactic) - if recurrent
Complications of pit adenoma
Post op recurrence - need monitoring.
Post op hormone deficiency
Pituitary apopexy
Bleeding in large adenoma, can be life threatening due to sudden hypopituitarism. - headache, menigism, similar to subachacnoid
Urgent steroids and fluid balance and surgery
Hyperthyroidism causes
Autoimmune - Grave's disease Toxic multinodular goitre Second most common Elderly caused by iodine deficiency (Surgery if compressive e.g. dysphagia or dyspnoea) (radioactive iodine give Toxic adenoma Solitary nodule (Hot on isiotope scan - malig is white) Exogenous Levothyroxine, idoine exess e.g. food contam or contrast medium Ectopic thyroid tissue NSAIDs Post viral (painful goitre) Postpartum TB Amiodarone, lithium (hypo more common)
Symptoms of hyperthyroid
General Heat intolerance Agitation Sleep disturbance Weight loss Hair loss Osteoporosis Tremor GI Diarrhoea Increased appetite (some may get paradoxical weight gain) Sweats Cardiac Palpations GU Oligomen/ infert Psych Psychosis Chorea Labile emotions Opthalmology Eye discomfort Grittiness Tears Photophobia Diploria Less acuity/ colour (more likely if less protrusion as more compression)
Signs of hyperthyroidism
Tachycardia HBP Arrythmia Anaemia Lig lad/ retraction Goitre/ nodules/ bruit Graves Pretibial myxoedema - swelling above lateral malleoli Exomphalmos Thyroid acropachy - clubbing, periosteal reaction in limb bones, painful finger and toe swelling
Complications of hyperthy
AF HF Osteoporosis Thyroid storm Opthalmology Gynacomastia
Diagnosis of hyperthyroidism
Blood Haem FBC - normocytic anamia In graves can get neutropenia Bio chem Immunology TPO - anti thyroid peroxidase (more hashimoto) Antithyroglobulin antibody TSH receptor antibody (more graves) Special T4/T3 (normal or high) TSH (low) Imagine Isotope scan - for cause - nuclear scintigraphy
Treatment hyper
Rapid contorl of symptoms with propanolol
Carbimazole
Titration with T4 levels
Blockade - high dose and then Thyroxine
Risk of agranularcytosis e.g. temp, sore throat/ mouth ulcers
Radioactive iodine
Most become hypothyroid
Surgical resection - total thyroidectomy
Raised TSH and normal T4
subclinical hypothyroidism or treated
If everything low thyroid
sick euthyroid
Use of isotope scan in thyroid
Ionie and tachnetiu, pertechnetate
Detect goitre, ectopic thyroid tissue or thyroid mets
Isotope scan - malignant parts tend to have no ‘hot’ nodules
Use of US thyroid
Cystic from malignant/ benign nodules - can do with fine needle aspiration
US not enough, also need fNAC and hemithyroidectomy
