Endo Flashcards
What is Abetalipoproteinemia?
Features?
Abetalipoproteinemia is rare autosomal recessive disorder
Features: Failure to thrive Steatorrhoea Retinitis pigmentosa Cerebellar signs Absent deep tendon reflexes Acanthocytosis Hypocholesterolaemia
What is acromegaly?
Features?
Complications?
Excess growth hormone
Features: Coarse facial features Large tongue Prognathism Excessive sweating Features of pituitary tumour Galactorrhoea
Complications: HTN Diabetes Cardiomyopathy Colorectal Cancer
Investigation of Acromegaly?
Serum IGF-1 with serial GH measurements
OGTT to confirm diagnosis oif IGF-1 raised
Pituitary MRI - may show pituitary tumour
NOTE: no suppression of GH in OGTT
Management of Acromegaly?
Trans-sphenoidal Surgery (1st line)
Somatostatin Analogue:
- Octreotide (1st Line drug)
Dopamine Agonists:
- Bromocriptine
GH Receptor Antagonist:
- Pegvisomant (S/C administration)
What is addison’s disease?
What does it result in?
Features?
Autoimmune destruction of adrenal glands
Reduced cortisol and aldosterone
Features: Lethargy Weakness N&V Hyperpigmentation Hypotension Hypoglycaemia Hyponatramia and Hyperkalaemia
Name causes of hypoadrenalism?
Primary:
- TB
- Metastases
- Meningococcal Septicaemia (Waterhouse-Friderichsen)
- HIV
- Antiphospholipid
- Addison’s disease
Secondary:
- Pituitary
Exogenous Glucocorticoid Therapy
Investigation of addison’s disease?
Short Synacthen test
- Plasma cortisol before and 30 mins after giving
9 am Cortisol
>500 - unlikely
<100 - abnormal
100-500 - ACTH stimulation test needed
Management of addison’s disease?
Hydrocortisone
Fludrocortisone
Also:
Patient education
MedicAlert Bracelet
Double glucocorticoid in illness
Addisonian crisis: Causes and Management
Causes:
- Sepsis or surgery causing acute exacerbation of chronic insufficiency
- Adrenal haemorrhage
- Steroid withdrawal
Management:
- Hydrocortisone 100mg IM or IV
- 1L Normal saline
- 6 hourly hydrocortisone until stable
- Oral replacement after 24 hours. Reduce to maintenance over 3-4 days
What is androgen insensitivity syndrome?
Features?
Diagnosis?
Management?
X-Linked recessive
End organ resistance to testosterone
Genotypical male children (46XY) have female phenotype
Features:
- Primary amennorhea
- Undescended tests -> groin swelling
- Breast development may occur
Diagnosis:
- Karyotype
Mangaement:
- Counselling
- Bilateral orchidectomy
- Oestrogen
What is autoimmune polyendocrinopathy syndrome?
Which is the most common type?
APS Type 1 = Multiple Endocrine Deficiency Autoimmune Candidiasis (MEDAC): 2 of
- Chronic mucocutaneous candidiasis
- Addison’s disease
- Primary hypoparathyroidism
APS Type 2 (most common) = Schmidt’s Syndrome: Addisons plus 1 of
- Addisons
- T1DM
- Autoimmune Thyroid disease
NOTE: Both can also get vitiligo
What are the features of Bartter’s syndrome?
Polyuria Polydipsia Hypokalaemia Normotension Weakness
What is Canakinumab?
monoclonal antibody targeting interleukin-1β.
What is carbimazole used for?
Adverse features?
Management of thyrotoxicosis
Adverse features:
- Agranulocytosis
- Crosses placenta - may be used in low doses in pregnancy
Mechanism:
- Blocks thyroid peroxidase from coupling and iodinating tyrosine residues on thyroglobulin
What serotypes of HPV cause cervical cancer?
Other risk factors?
16
18
33
Smoking HIV Early intercourse Many partners High parity Low socioeconomic status COC
What is congenital adrenal hyperplasia?
What are the main types?
Autosomal recessive disorders
High ACTH due to low cortisol levels. This stimulates adrenal androgens that may virilize female infant
21-hydroxylase deficiency (90%)
11-beta hydroxylase deficiency (5%)
17-hydroxylase deficiency (very rare)
Features of congenital adrenal hyperplasia for each type?
21-hydroxylase deficiency features
virilisation of female genitalia
precocious puberty in males
60-70% of patients have a salt-losing crisis at 1-3 wks of age
11-beta hydroxylase deficiency features virilisation of female genitalia precocious puberty in males hypertension hypokalaemia
17-hydroxylase deficiency features
non-virilising in females
inter-sex in boys
hypertension
Features of congenital hypothyroidism?
Prolonged neonatal jaundice Delayed mental and physical milestone Short stature Puffy face Macroglossia Hypotonia
Side effects of glucocorticoid therapy?
endocrine: impaired glucose regulation, increased appetite/weight gain, hirsutism, hyperlipidaemia
Cushing’s syndrome: moon face, buffalo hump, striae
musculoskeletal: osteoporosis, proximal myopathy, avascular necrosis of the femoral head
immunosuppression: increased susceptibility to severe infection, reactivation of tuberculosis
psychiatric: insomnia, mania, depression, psychosis
gastrointestinal: peptic ulceration, acute pancreatitis
ophthalmic: glaucoma, cataracts
suppression of growth in children
intracranial hypertension
neutrophilia
Side effects of mineralocorticoid therapy?
Fluid retention
HTN
Causes of cushing’s syndrome?
ACTH Dependent:
- Cushings disease (80%) - pituitary secreting ACTH tumour
- Ectopic ACTH
ACTH Independent:
- Steroids
- Adrenal adenoma
- Adrenal carcinoma
- Carney Complex (syndrome including cardiac myxoma)
- Micronodular adrenal dysplasia
What is pseudo-cushings?
Who is it commonly seen in?
Mimics cushings
Alcohol excess
Severe depression
False positive dexamethasone suppression test or 24 hour urinary free cortisol
Insulin stress test may differentiate
Investigation in Cushing’s syndrome?
Confirmation and localisation test/
Confirm Cushing’s Syndrome:
- Overnight dexamethasone suppression test
- 24 hr free urinary cortisol
Localisation:
- 9am Cortisol and midnight plasma ACTH. If ACTH suppressed, then non-ACTH dependent cause is likely
- Low and high dose dexamethasone tests
Results:
- Not suppressed by low dose (Secondary cause)
- Suppressed by high, but not low (Cushing’s disease)
- Not suppressed by either (ectopic ACTH)
If can’t differentiate between pituitary and ectopic ACTH:
- Petrosal sinus sampling
Causes of delayed puberty?
Differentiate by stature
Short Stature:
- Turner’s Syndrome
- Prader-Willi Syndrome
- Noonan’s Syndrome
Normal Stature:
- PCOS
- Androgen insensitivity
- Kallmann’s Syndrome
- Klinefelter’s Syndrome
Diagnosis of T2DM?
Symptomatic:
- Fasting glucose >= 7.0
- Random Glucose >= 11.1
Asymptomatic:
- As above on two separate occasions
Normal glucose levels?
Glucose and HbA1c
<= 6.0 glucose <= 41 HbA1c (5.9%)
Prediabetes?
Glucose and HbA1c
6.0-7.0 glucose
41-48 HbA1c
NOTE: HbA1c < 48 does not exclude diabetes
Diabetes?
Glucose and HbA1c
>= 7.0 glucose >= 48 HbA1c (6.5%)
What is impaired fasting glucose?
A fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l implies impaired fasting glucose (IFG)
What is impaired glucose tolerance?
Impaired glucose tolerance (IGT) is defined as fasting plasma glucose less than 7.0 mmol/l and OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l
Examples of GLP-1 mimetics?
What are their criteria for use?
What is the criteria to continue?
Increase insulin secretion. Inhibit glucagon secretion
Result in weight loss
Exanatide
Liraglutide
Uses if:
BMI >35 and problems with weight
BMI <35 and insulin use unacceptable
Criteria for continued use:
- 11mmol/mol reduction HbA1c (1%)
- 3% weight loss after 6 months
What are DPP-4 inhibitors?
Give examples
Oral
No weight gain
No hypoglycaemia
Vildagliptin
Sitagliptin
Management of T1DM
Target HbA1c
Frequency of self monitoring?
Blood glucose target?
=<48 (6.5%)
Self monitoring:
QDS
More often if pregnancy, sport or ill
Blood Glucose target?
5-7mmol/l on waking
4-7 mmol/l other times
When should Metformin be added to T1DM management?
If BMI >25
T1DM insulin of choice?
Basal-bolus with rapid acting insulin analogue before meals
Management of T2DM?
Target HbA1c?
When should second agent be added?
Target 48 (6.5%) (lifestyle + metformin) Target 53 (7.0%) (drugs which cause hypoglycaemia i.e. sulfonylurea)
Second agent when 58 (7.5%)
Dietary advice (high fibre, low glycaemic index, low-fat dairy, oily fish).
Aim weight loss 5-10% if overweight
Management of T2DM?
What are the four oral antidiabetic drugs?
Metformin Gliptin Sulfonylurea Pioglitazone (SGLT-2 inhibitor)
Always begin with metformin unless this cannot be tolerated
- If not able to get under 7.5% and on dual therapy, add third agent
- If still not controlled –> insulin
OR if BMI >35: (Metformin, Sulphonylurea, GLP1-mimetic)
Cannot tolerate Metformin:
- Sulfonylurea/Gliptin/Pioglitazone
Target BP in diabetes? First line anti-hypertensive?
<140/80
<130/80 if end organ damage
ACEi first line
Management of T2 diabetes in Ramadan?
Long acting carbs at sunrise
Metformin (1/3 before, 2/3 after)
Sulfonylurea (switch to once daily after sunset)
Moderate risk in diabetic feet?
Deformity
Neuropathy
Non-critical limb ischaemia
Management of DKA?
Criteria for DKA?
Criteria:
glucose > 11 mmol/l or known diabetes mellitus
pH < 7.3
bicarbonate < 15 mmol/l
ketones > 3 mmol/l or urine ketones ++ on dipstick
Management:
- Fluids (1L 1hr, 1L 2hr, 1L 2hr, 1L 4hr, 1L 4hr, 1L 6hr)
- Insulin 0.1 unit/kg/hr
- Once BG <15, add 5% dextrose
- Correct hypokalaemia
- Continue long acting insulin
What to do for DKA and K
>5.5
3.5-5-5
<3.5
> 5.5 - Nil
3.5-5.5 - 40mmol K
<3.5 - senior review
Management of diabetic neuropathy?
Amitryptyline, Duloxetine, Gabapentin or Pregabalin
Tramadol as rescue therapy
Topical capsaicin for localised neuropathic pain
Management of diabetic gastroparesis?
Metoclopramide
Domperidone
Erythromycin
List five disorders of sex development?
What is their pathogenesis?
1) Androgen insensitivity syndrome (46XY)
- defect in androgen recentor leading to end organ resistance
- Rudimentary vagina and testes. No uterus
2) 5-alpha reductase deficiency (46XY)
- inability to convert testosterone to dihydrotestosterone
- Ambiguous genitalia. Hypospadius. Virilization at puberty
3) Male pseudohermaphroditism (46XY)
- Testes but external genitalia female
- CAIS
4) Female pseudohermaphroditism (46XX)
- Ovaries but external genitalia male
- CAH
5) True hermaphroditism (46XX or 47XXY)
- Both ovarian and testicular tissue present
Features of Klinefelters? LH and Testosterone
Features?
LH - high
Testosterone - Low
Primary Hypogonadism
Taller than average Lack of secondary sexual characteristics Small, firm testes Infertile Gynaecomastia
Features of Kallman’s?
LH and Testosterone.
Features?
Management for fertility treatment?
LH - low
Testosterone - low
Hypogonadotrophic hypogonadism
Lack of smell
Delayed puberty
Cryptorchidism
Females:
- HCG
- FSH
- IVF
Androgen insensitivity syndrome? LH and Testosterone.
Features?
LH - high
Testosterone - normal/high
Primary amenorrhoea
Undescended testes - groin swelling
Breast development
Testosterone secreting tumour? LH and Testosterone.
Features?
LH - low
Testosterone - high
Rules of Diabetics with DVLA
Key points
Rules of insulin
No severe hypoglycaemic event in last 12 months
Full hypoglycaemic awarenesss
Adequate control by regular monitoring
Understand risks
Insulin - can drive car if hypoglycaemic aware. No more than one event needing help in last 12 months
Annual review needed
Management of endometrial cancer?
Investigation?
Investigation:
- PMB - 2WW
- Trans-vaginal USS
- Hysteroscopy with endometrial biopsy
MAnagement:
- Local disease - Total abdominal hysterectomy
- High risk - as above with radiotherapy
What is familial benign hypocalciuric hypercalcaemia?
Rare autosomal dominant
Asymptomatic hypercalcaemia
PTH often not suppressed
Decreased sensitivity to increase in extracellular calcium
Familial hypercholesterolaemia:
Autosomal dominant
Simon Broome Criteria for diagnosis
Management:
- Specialist lipid clinic
- High dose statins
- Screen relatives
Features of gitelman’s syndrome?
Normotension Hypokalaemia Hypocalcuria Hypomagnesaemia Metabolic alkalosis
Features of glucagonoma?
Investigation?
Management?
Tumours in pancreas
Diabetes mellitus
VTE
Necrolytic migratory erythema
Serum glucagon >1000pg/ml
Management:
- Resection
- Octerotide
Features of Graves disease?
Thyrotoxicosis Age 30-50 Women Exophthalmos Ophthalmoplegia Pretibial myxoedema Thyroid acropachy TSH antibody 90% anti-TPO antibody 55%
Management of Graves?
Titration - Carbimazole 40mg and reduced for 12-18 months to achieve euthyroid
Block and replace - Carbimazole 40mg. Add thyroxine when euthyroid
Radioiodine
- Contraindication - pregnancy, age <16, thyroid eye disease
Causes of gynaecomastia?
Drug causes?
Physiological Kallmanns/ Klinefelters Testicular Failure Liver disease Testicular Cancer Ectopic tumour Hyperthyroidism Haemodialysis
Drugs: Spironolactone Cimetidine Digoxin Cannabis Finasteride Gonadorelin analogue Oestrogen
Features of Hashimoto’s thyroiditis?
Autoimmune
Hypothyroid (although may be transient thyrotoxicosis)
Hypothyroid
Firm goitre, non-tender
Anti-TPO
Anti-Tg antibodies
What is hungry bone syndrome?
After parathyroidectomy
If hyperparathyroidism long standing:
- Constant osteoclast stimulation (hypercalcamemia, lytic lesions)
- Hormone falls rapidly and rapid re-mineralisation occurs
Can be painful
Can result in systemic hypocalcaemia
Causes of hypercalcaemia?
- Primary hyperparathyroidism
- Malignancy
Other:
- Sarcoid
- Vit D excess
- Acromegaly
- Thyrotoxicosis
- Milk-alkali syndrome
- Thiazides, Calcium containing antacids
- Dehydration
- Addison’s disease
- Paget’s disease
Management of hypercalcaemia?
Normal saline (3-4L per day)
Bisphosphanates (take 2-3 days to work)
Calcitonin (quicker effect)
Steroids if sarcoidosis
Hyperemesis Gravidarum
Referral criteria to hospital
Triad of features?
Management?
Complications?
Referral Criteria:
- Unable to keep down liquids
- Continue N&V with ketonuria and or weight loss
- Confirmed or suspected comorbidity
Triad:
- 5% weight loss
- Dehydration
- Electrolyte imbalance
Management:
- Antihistamines / cyclizine
- Ondansetron and metocroplramide
- IV hydration
Complications:
- Wernicke’s encephalopathy
- Mallory-Weiss Tear
- Central pontine myelinolysis
- ATN
- Small foetus, pre-term
Causes of hyperkalaemia?
AKI ACEi, ARB, Spironolactone, Ciclosporin, Heparin Metabolic acidosis Addison's Rhabdomyolysis Massive blood transfusion
Management of hyperlipidaemia?
Who are there specific guidelines for?
Who may tests undestimate in?
When should you consider familial cause?
Primary Prevention:
- 10 yr risk >10% or T1DM or GFR <60)
- Atorvastatin 20mg
Secondary prevention:
- IHD, PVD, CVD
- Atorvastatin 80mg
Specific guidelines?
- T1DM
- eGFR <60
- Familial
May underestimate in:
- HIV
- Mental health
- Antipsychotics, corticosteroids, immunosuppressants
- Autoimmune disorders
Consider it being familial if total cholesterol >7.5
Lipid management in T1DM
Consider statin 20mg if T1DM and:
- age 40+
- diabetes for 10+ years
- nephropathy
- other CVD risk factors
Lipid management in CKD
Atorvastatin 20mg
Increase dose if greater than 40% reduction in non-HDL not achieved and eGFR > 30mmol
What is the maximal rate of correction of sodium in hypernatraemia?
0.5mmol/hr
What is hyperosmolar hyperglycaemic state?
What is the serum osmolarity?
Triad of features?
Hyperglycaemia –> osmotic diuresis, severe dehydration, electrolyte deficiency
Serum osmolarity >320mosmol/kg
Features:
- Hypovolaemia
- Glucose >30 mmol with no significant ketones
- Osmolarity >320
Management of HHS?
Monitoring?
- Fluid replacement (gradual)
- aim positive balance 3-6L by 12 hours - Normalise osmolality
- Normalise glucose
Monitoring:
- Plot osmolarity (2Na+glucose+urea) and glucose hourly
- Aim rate glucose fall 4-6mmol/hr
- Fall sodium <10mmol/24hr
- Target glucose 10-15mmol/L
Causes of hypocalcaemia?
Management?
Vit D deficiency CKD Hypoparathyroid Pseudohypoparathyroidism Rhabdomyolosis Magnesium deficiency Massive blood transfusion Acute pancreatits
Management:
- IV replacement
- 10ml of 10% solution over 10 minutes
- Calcium gluconate
- ECG monitoring
Features of testosterone deficiency?
Loss of libido Erectile dysfunction Lethargy Decreased muscle mass and strength Reduced facial hair growth IGT
Causes of hypokalaemia
Separate by alkalosis and acidosis
Alkalosis
- Vomiting
- thiazide and loop diuretics
- cushing’s
- conns
Acidosis
- Diarrhoea
- Renal tubular acidosis
- Acetazolamide
- Partially treated DKA
ALSO: Magnesium deficiency
Causes of hypokalaemia
Separate by HTN and not HTN
HTN
- Cushing
- Conn
- Liddle
- 11-beta hydroxylase deficiency
Without HTN
- Diuretics
- GI loss
- Renal tubular acidosis
- Barter’s Syndrome
- Gitelman
What is hypokalaemic periodic paralysis?
Rare autosomal dominant
Paralysis
Often at night
May be precipitated by carbohydrate meals
Rx: Lifelong supplementation
Causes of hyponatraemia separated by:
Urinary Sodium
High - Hypovolaemic/Euvolaemic
Low - Sodium Depletion/Water Excess
Urinary sodium > 20 mmol/l
Sodium depletion, renal loss (patient often hypovolaemic)
- Diuretics: thiazides, loop diuretics
- Addison’s disease
- Diuretic stage of renal failure
Patient often euvolaemic
- SIADH (urine osmolality > 500 mmol/kg)
- hypothyroidism
Urinary sodium < 20 mmol/l
Sodium depletion, extra-renal loss
- diarrhoea, vomiting, sweating
- burns, adenoma of rectum
Water excess (patient often hypervolaemic and oedematous)
- secondary hyperaldosteronism: heart failure, liver cirrhosis
- nephrotic syndrome
- IV dextrose
- psychogenic polydipsia
Management of hyponatraemia?
Who should be fluid restricted?
Who should have vasopressin used?
Acute - <48hrs
Chronic - >48hrs
Fluid Restrict
- Oedematous States (i.e. HF)
- SIADH
- Renal Failure
- Psychogenic polydipsia
Vasopressin:
- Hypovolaemic hyponatraemia
What is primary hypoparathyroidism?
Biochemistry and treatment
Primary Hypoparathyroidism
- Reduced PTH
- Low calcium, high phosphate
- Treat with alfacalcidol
Symptoms of hypoparathyrodism?
Tetany
Perioral paraesthesia
Trosseau’s sign (Spasm with inflating BP cuff)
Chvostek’s sign (tap parotid causes face muscles to twitch)
Prolong QT
What is pseudohypoparathyroidism?
Investigation?
Target cells insensitive to PTH
- Low IQ
- Short Stature
- Short 4/5th metacarpals
- Low calcium, high phosphate, high PTH
Invfusion of PTH followed by urinary phosphate measurement helps differentiate between Type 1 (cell receptor defect complete) and Type 2 (intact cell receptor)
What is pseudopseudohypoparathyroidism?
Similar phenotype to pseudohypoparathyroidism but normal biochemistry
Target cells insensitive to PTH
- Low IQ
- Short Stature
- Short 4/5th metacarpals
Causes of hypophosphataemia?
Alcohol excess Acute liver failure DKA Refeeding Primary hyperparathyroidism Osteomalacia
Consequences: RBC Haemolysis WBC and Plt dysfunction Muscle Weakness and Rhabdomyolysis CNS dysfunction
Features of hypopituitarism?
Biochemistry
Low peak GH in response to insulin induced hypoglycaemia
Low ACTH - tired, postural hypotension
Low Gonadotrophics - amenorrhoea
Low TSH - constipated
Causes of hypothyroidism?
Name 7
Hashimoto’s thyroiditis
Subacute Thyroiditis (de Quervain’s)
Riedel Thyroiditis
Post Thyroidectomy
Drugs (lithium, amiodarone, carbimazole etc.)
Dietary iodine deficiency
Secondary (pituitary failure)
Management of hypothyroidism?
What is target TSH?
What happens in pregnancy?
Start with 50-100mcg
If elderly/severe cardiac disease/severe hypothyroid - start with 25mcg
Slowly titrate every 8-12 weeks
Repeat TFTs 4 weeks after change made
Aim for TSH 0.5-2.5
Pregnancy:
Increase by 25-50mcg
What reduces the absorption of levothyroxine?
Iron
Calcium Carbonate
These should be given at least 4 hours apart
What is an insulinoma?
Investigation?
Management? - If not fit, then what?
Neuroendocrine tumour
From Pancreatic Islets of Langerhans cells
- 10% multiple
- 10% malignant
- 50% will have MEN1
Features:
- Hypoglycaemia early in morning or before meal
- Rapid weight gain
- High insulin
- High C-Peptide
Investigation:
- Supervised, prolonged fasting (up to 72 hours)
- CT pancreas
Management:
- Surgery
- Diazoxide and somatostatin if not fit for surgery
What is Kallmann’s syndrome?
Hypogonadotrophic Hypogonadism
- Low FSH
- Low LH
- Low testosterone
- Delayed puberty
- Hypogonadism, cryptorchidism
- Anosmia
What is Klinefelter’s syndrome?
47 XXY
Taller than average Lack of secondary sexual characteristics Small, firm testes Infertile Gynaecomastia Elevated gonadotrophin levels Low Testosterone
What is Liddle’s syndrome?
Management?
HTN
Hypokaleamia
Alkalosis
Autosomal dominant
Amiloride
Triamterene
What is MODY?
Features?
Maturity onset diabetes of young
T2DM age <25 years
Autosomal dominant
Family history of early onset diabetes
Ketosis NOT a feature
Very sensitive to sulfonylurea
MODY 3 gene defect?
Increased risk of???
HNF-1 alpha gene
Risk of HCC
MODY 2 gene defect?
Glucokinase gene
MODY 5 gene defect?
Features? (2)
HNF-1 beta gene
Liver and renal cysts
MEN 1 - features and gene
Parathyroid (95%)
Pituitary (70%)
Pancreas (50%)
Also adrenal and thyroid
MEN1 gene
MEN 2a - features and gene
Medullary Thyroid (70%)
Parathyroid (60%)
Phaeochromocytoma
RET Oncogene
MEN 2b - features and gene
Medullary Thyroid
Phaeochromocytoma
Marfinoid Body Habitus
Neuromas
What is a neuroblastoma?
Where does it arise?
Features?
Investigation?
Tumour from neural crest tissue of adrenal medulla and sympathetic nervous system
Age 20 months
Abdominal mass Pallow, weight loss Bone pain, limp Hepatomegaly Paraplegia Proptosis
Investigation
- Raised VMA and HVA
- Calcification on AXR
- Biopsy
What is normoglycaemic ketoacidosis often seen with?q
SGLT-2 inhibitors
Management of obesity?
Conservative - diet, exercise
Medical (only after at least 3 months of dietary and lifestyle)
- orlistat
- If BMI >28 with risk factors
- If BMI >30
- Use less than one year. Aim continued loss of 5% weight at 3 months
Surgical
- failure of non-surgical measure
- BMI >40 or BMI >35 and significant disease
- Commits to long term follow up
Features of phaeochromocytoma?
Investigation?
Management?
10% bilateral
10% malignant
10% extra-adrenal
HTN Headache Palpitaiton Sweating Anxiety
Investigation:
24hr urinary metanephrines
Surgery
Stabilise with alpha blocker then beta-blocker
What is a pituitary adenoma?
How can they be classified?
What are the most common types?
Investigation?
Benign tumour of pituitary
Microadenoma <1cm
Macroadenoma >1cm
Hormonal Status - secretory/functioning or non-secretory
Prolactinoma -> non-functioning ->GH secreting -> ACTH secreting
Investigation:
Pituitary Blood Profile (GH, prolactin, ACTH, FH, LSH, TFT)
Formal visual field testing
MRI with contrast
Treatment of prolactinoma?
Bromocriptine, Cabergoline (dopamine agonist)
Surgery (transsphenoidal)
What are the features of PCOS?
Investigation?
Subfertility infertility Menstrual disturbance Hisuitism Acne Obesity Acanthosis Nigricans Insulin resistance
Investigation:
- Pelvic USS
- LH, FSH (raised LH:FSH ratio)
- IGT
- Testosterone
Management of PCOS?
General
Hirsuitism and Acne
Infertility
General
- weight reduction
- COC if needs contraception
Hirsuitism/Acne
- COC or co-cyprindiol
- Topical eflornithine
- Spironolactone, flutamide, finasteride (secondary care)
Infertility
- Weight reduction
- Clomifene
- Metformin
Stages of post-partum thyroiditis?
What antibody is present?
Management?
- Thyrotoxicosis
- Hypothyroid
- Normal TFT
anti-thyroid peroxidase (90%)
Symptoms 2 weeks post partum
Management:
- Propranolol for symptoms
- Thyroxine when hypothyroid
Screening of gestational diabetes in pregnancy?
Diagnostic thresholds?
Management?
OGTT at booking
OGTT at 24-28 weeks
Threshold:
Fasting Glucose =>5.6
2-hr glucose =>7.8
Management:
Diet
If not meeting target in 1-2 weeks - metformin
Add insulin if this is still not met
NOTE: If fasting glucose => 7 start insulin first
If fasting glucose 6-6.9 with macrosomia, hydramnios give insulin
Glibenclamide can be given if don’t tolerate metformin
Risk factors for gestational diabetes?
BMI >30 Macrosomic Baby >4.5kg Previous GD 1st Degree relative with diabetes South Asian, Black Caribbean, Middle Eastern
Management of pre-existing diabetes in pregnancy?
Weight loss if BMI >27
Only continue metformin. Start insulin
Folic acid 5mg/day until 12 weeks
Aspirin 75mg from 12 weeks
Anomaly scan at 20 weeks
What happens to thyroxine-binding globulin in pregnancy?
Increase levels of TBG
Thus increase in total thyroxine
Does not affect free levels
Management of thyrotoxicosis in pregnancy?
What is target free thyroxine levels?
Propylthiouracil in first trimester
Carbiazole in second and third trimester
Aim to keep in upper 1/3 of normal reference range
What is primary hyperaldosteronism?
Features?
Investigation?
Management?
Adrenal Adenoma
Bilateral idiopathic adrenal hyperplasia (70%)
HTN
Hypokalaemia
Alkalosis
Aldosterone:Renin ratio (should be high)
CT Abdomen
Adrenal Vein sampling (this is to determine which side is secreting)
Surgery (adrenal adenoma)
Spironolactone (Bilateral Hyperplasia)
What is primary hyperparathyroidism?
Causes?
Features?
Investigations?
Solitary adenoma (80%)
Hyperplasia (15%)
Multiple adenoma (4%)
Carcinoma (1%)
Polyuria, polydipsia Peptic ulceration Constipation Bone pain Renal stones Depression HTN
Raised Ca, Low PO
PTH raised or inappropriatly normal
MIBI
Management:
Total parathyroidectomy
Cinacalcet if unsuitable for surgery
Management of primary hypertriglyceridaemia?
Fibrates
Management of galactorrhoea?
Dopamine Agonists (i.e. bromocriptine)
Causes of raised prolactin?
Features?
Features of excess prolactin
men: impotence, loss of libido, galactorrhoea
women: amenorrhoea, galactorrhoea
Causes of raised prolactin prolactinoma *pregnancy oestrogens physiological: stress, exercise, sleep acromegaly: 1/3 of patients polycystic ovarian syndrome *primary hypothyroidism (due to thyrotrophin releasing hormone (TRH) stimulating prolactin release)
*Drug causes of raised prolactin metoclopramide, domperidone phenothiazines haloperidol very rare: SSRIs, opioids
Indications for radioiodine therapy?
Contraindications?
Differentiated thyroid cancer
Toxic multinodular goitre
Graves disease refractory to medical management
Radiation exposure
Contraindications:
Pregnancy
Breastfeeding
Active Thyroid Eye Disease
What is Renal Tubular Acidosis 1?
Distal - inability to secrete H+
Hypokalaemia
Nephrocalcinosis
Renal stones
Causes: RA SLE Sjogren Analgesic nephropathy Amphotericin B toxicity
What is Renal Tubular Acidosis 2?
Proximal - reduced HCO3 reabsorption
Hypokalaemia
Osteomalacia
Causes: Fanconi Syndrome Wilsons disease Cystinosis Acetazolamide
What is Renal Tubular Acidosis 4?
Reduced aldosterone leading to reduced proximal tubular ammonium secretion
Hyperkalaemia
Causes:
Hypoaldosteronism
Diabetes
What is Riedel’s Thyroiditis?
Hypothyroidism
Dense fibrous tissue replace normal thyroid parenchyma
Hard, fixed, painless goitre
Associated retroperitoneal fibrosis
Adverse effects of SGLT-2 inhibitors?
Urinary and genital infection
Normoglycaemic ketoacidosis
Incease risk of lower limb amputation
Causes of SIAHD?
Use a sieve
Management?
Malignancy: Small Cell Lung, Pancreas, prostate
Neuro: Stroke, SAH, SDH, Meningitis, Encephalitis, Abscess
Infection: TB, Pneumonia
Drugs: Sulfonylurea, SSRI, TCA, Carbamazepine, Vincristine, Cyclophosphamide
Other: PEEP, prophyria
Management:
Fluid restriction
Demeclocycline
ADH receptor antagonists
What is subacute (de quervain’s) thyroiditis?
Phases?
Investigation?
Management?
Follow viral infection
Sx of hyperthyroidism
Phases:
- Hyperthyorid (painful goitre, raised ESR)
- Euthyorid
- Hypothyroid
- Return to normal
Investigation:
Reduced uptake of I131
Management:
Self limiting
NSAID for pain
Steroids if severe
What is subclinical hyperthyroidism?
Causes?
Risks?
Management?
Normal serum T4 and T3
TSH below normal range
Causes:
Multinodular goitre
Excessive thyroxine
Risks:
AF
Osteoporosis
Dementia
Management:
Often self limit. Observe
If persistent, can use anti-thyroid agent as a trial
What is subclinical hypothyroiidism?
Significance?
Mangement?
TSH raised
T3, T4 normal
Significance:
Risk progressing to hypothyroid 2-5% per year
Management: TSH 4-10 - <65 with sx --> trial levothyroxine - Older, watch and wait - Asymptomatic - observe and repeat
TSH >10
- Treat even if asymptomatic if <70
- Older, watch and wait
Mechanism of action of Thiazolidinediones?
PPAR-gamma receptor agonist
Thyroid Cancer: Which are most common?
Papillary (70%) Follicular (20%) Medullary (5%) Anaplastic (1%) Lymphoma (rare) - associated with hashimoto's
Monitoring of papillary and follicular thyroid cancer?
TBG
Monitoring of medullary thyroid cancer?
Calcitonin
Features of thyroid eye disease?
Exophthalmos
Conjunctival oedma
Optic Disc swelling Ophthalmoplegia
Inability to close eyes
Management: Stop smoking Topical lubricants Steroids Radiotherapy Surgery
Who with thyroid eye disease should be referred?
Unexplained deterioration in vision Aware of change in intensity or quality of colour vision One eye pop out Corneal opacity Cornea visible when eyelids closed Disc swelling
Management of thyroid storm?
Paracetamol IV Propranolol Propylthiouracil/Methimazole Lugol's iodine Dexamethasone (blocks conversion of T4 to T3)
Causes of thyrotoxicosis?
Graves Toxic nodular goitre Acute phase of subacute thyroiditis Acute phase of Hashimotos thyroiditis Amiodarone therapy
Investigation and management of toxic multinodular goitre?
Nuclear scintigraphy - patchy uptake
Treatment:
Radioiodine
What is waterhouse-friderichsen syndrome?
Please give some example causes?
Adrenal gland failure secondary to previous adrenal haemorrhage caused by severe bacterial infection
Neisseria meningitidis: most common cause Haemophilus influenzae Pseudomonas aeruginosa Escherichia coli Streptococcus pneumoniae
Why should patients with diabetes have increased frequency of retinal screening whilst pregnant?
Increased risk of retinopathy
How long should avoid becoming pregnant after radioiodine treatment?
6 months
What should you do if normal T4 but suppressed TSH?
Measure T3
Could be T3 thyrotoxicosis
What should be measured if pregnant and known graves?
TSH antibody titre
They may cross the placenta and cause foetal issues
Features of fanconi syndrome?
Type 2 Renal Tubular Acidosis
Polyuria
Polydipsia
Osteomalacia
Causes of high anion gap metabolic acidosis?
Ketoacidosis
Uraemia
Lactate
Toxins (salicylates, ethylene glycol, methanol)
Causes of normal anion gap metabolic acidosis?
Addison’s disease
Bicarbonate loss (GI or renal)
Chloride excess
Drugs
Management of patient with addison’s and vomiting?
IM hydrocortisone if at home
If systemically unwell, admit for IV fluids and IV steroids
What is beer potomania?
Cause of hyponatraemia which occurs due to low dietary intake of solutes
Urine osmolarity <100
(i.e. appropriate ADH suppression)
Which T2DM medication is linked to pancreatitis?
Sitagliptin
What should you do with aspirin in acute thyrotoxicosis? Why?
Stop aspirin as it can worsen the storm by displacing T4 from TBG
What condition can CT contrast provoke?
The iodine in CT contrast can precipitate thyrotoxicosis or thyroid storm
