Endocrine Flashcards
Symptoms of adrenal mass?
recent weight changes, virilization, hair growth, decreased libido, irregular menses, mood changes, new onset hypertension or hyperkalemia
Adrenal mass workup
serum cortisol, BMP, 24 hour urine collection with aldosterone, renin, DHEAs, plasma metanephrines/normetanephrines
Periop Mgmt for pheo
Rule out MEN2/hyperPTH
Refer to PCP/genetic counselor
A-blocker (phenoxybenzamine or prazosin), the betablock if still hypertensive. Hydrate for weeks up to surgery, when BP controlled with orthostatic hypoTN then ready for OR
Post: glucose monitoring due to rebound hyperinsulinemia
Aldosterone secreting mass management
Find which is functional with adrenal vein sampling
If bilateral functional tumors, medical management with aldosterone receptor antagonist (spironolactone)
History for hyperparathyroid?
Osteoporosis/pathologic fx, renal stone, body aches, diarrhea
Ask about thiazides, lithium, ca/vit D supplements
Rule out familial hypocalciuric hypercalcemia
Indication to operate on primary hyperparathyroid?
<50 yo, pathologic fx, ca >1 above upper limit of normal, tscore<2.5 (check distal 3rd of radius), 24 urine calcium >400 mg, Crcl <60, renal stones
Given calcium and calcitriol. Obtain serum Ca 6 month postop
Workup/management for medullary thyroid
Path: Congo red on amyloid stain w apple-green birefringence
Screen for genetic mutation (RET), Pheo, hyperPTH. If positive for genetic refer family
Metastatic workup w panCT
Perform total thyroid w central neck dissection. Lateral if positive node in lateral neck
Gastrinoma workup/Mgmt
Gastrin level after holding PPI, confirm with secretin stimulation test
Check for Menin mutation
Ct panc protocol for localization. Gastrinoma triangle: cystic duct, duo, pancreas
EUS or octreotide scan if CT doesnt show location
Tumor in panc body: distal panc
Panc head <2 cm: enucleation
IN panc head > 2 cm: Whipple
Intraop US if unable to find tumor
Do EGD and turn off light and look for dark spot in wall against light
Duodenotomy and feel for tumor in the wall
Annual gastrin level. If elevated, check secretin stimulation test and get repeat CT chest/abdomen/pelvis
Secretin stimulation test
Stop PPI therapy
Get baseline gastrin level then give 2 u/kg of secretin
Check gastrin q5 minutes 30 minutes.
If gastrin increases by >200 above baseline then +gastrinoma
In the absence of gastrinoma, secretin would cause serum gastrin levels to decrease.
Management/workup of Insulinoma
Whipple’s triad: glucose <50 when fasting, symptoms of hypoglycemia, resolution w dextrose
Check for exogenous use (low c-peptide w high insulin, serum sulfonylurea level)
Confirm w food diary or hospitalization w fasting for 72 hours
Attempt imaging w CT then MRI. Then EUS or cath-directed hepatic vein sampling.
Intraoperative ultrasound or palpating for masses with blind enterotomy in duodenum.
If metastatic lesion, >90% debulking can be of benefit + chemo
5-FU, streptoszosin, doxorubicin
What are signs of benign adrenal mass on imaging?
<4 cm, smooth, <10 HU, >60% washout on 15 minute delay phase, simple cyst, myelolipoma
How do you manage hypercalcemic crisis
NS boluses, loop diuretics, bisphosphonates or cinacalcet
Thyroid nodule
Thyroid panel
If hypothyroid -> Thyroperoxidase Ab (hashimoto)
If hyperthyroid -> TSH Receptor Ab (Graves’s disease)
If Dx of Graves unclear, radionucleotide scan shows diffuse thyroid uptake
- RAdioactive ablation if young unless pregnancy planned
- Antithyroid drugs if high surgical risk
- Thyroidectomy if large symptomatic goiter or cancer suspected or if pregnancy planned in next 6 months.
If baseline HR>90, start Betablocker
If solid hypervascular mass, FNA
- Papillary or Follicular cells: hemiothyroidectomy
- Follicular lesion of undertermined significance: Repeat vs hemithyroid
If papillary or follicular cancer > 4cm or high grade -> total thyroid w radioactive ablation
Surveil with annual thyroglobulin levels
Thyroid storm
Beta blocker, Methimazole vs PTU, steroids, tylenol, cooling blanket, vent support, IVF
