Endocrine Flashcards
1
Q
mc pituitary adenoma?
A
prolacitnoma.
2
Q
`prolactin dx?
A
> 150 (symptomatic)
3
Q
sx of prolactinoma?
A
galactorrhea, irregular menses, decreased libido, infertility
4
Q
mgmt prolactinoma?
A
asx and <1 cm, follow with MRI.
if sx or if >1cm, bromocriptine (if pregnant) or cabergoline»_space;> transsphenoid resection if failed mgmt
5
Q
what is deadly about acromegaly?
A
cardiac sx (valve dysfunction, cardiomyopathy).
6
Q
acromegaly GH dx?
A
elevated IGF-1 > 10 in 90%; MRI
7
Q
mgmt acromegaly?
A
transsphenoid resection, XRT, bromocriptine, octreotide, pegvisomant (GH-R antagonist)
8
Q
Sheehan’s syndrome?
A
postpartum lactation issues, amenorrhea, AI, hypothyroid
anterior pit ischemia after peripartum hemorrhage
9
Q
mgmt sheehan’s?
A
steroids, hormone replacement
10
Q
pituitary apoplexy
A
bleeding into pituitary tumor with gland destruction; acute bleeding sx
treat: steroids emergently; hormone replacement
11
Q
craniopharyngioma origin?
A
rathke’s pouch; benign calcified cyst.grows along stalk to suprasellar anterior pituitary
12
Q
mgmt craniopharyngioma?
A
resection (endocrine abnormalities, bitemporal hemianopsia, HA, hydrocephalus, etc.)
13
Q
complication of craniopharyngioma resection
A
DI
14
Q
Nelson’s syndrome?
A
after b/l adrenalectomy; increased CRH (enlarged pituitary).
sx: amenorrhea, bitemporal hemianopia, hyperpigmentation (B-MSH byproduct of ACTH)
15
Q
mgmt Nelson’s
A
steroids.
16
Q
Waterhouse Friderichsen syndrome?
A
adrenal gland hemorrhage after meningococcal sepsis leading to AI.
17
Q
arterial supply to adrenals?
A
superior: inferior phrenic
middle: aorta
inferior: renal.
18
Q
venous drainage from adrenals?
A
left: left renal
right: cava.
19
Q
innervation to the adrenals?
A
cortex: none
medulla: from sympathetic splanchnics.
20
Q
lymphatic drainage from adrenals?
A
subdiaphragmatic and renal LNs.
21
Q
rate of adrenal incidentaloma?
A
1-2% of CTs. 5% are mets.
22
Q
when to check for functionalty of adrenal mass?
A
ASAP, BEFORE IMAGING.
23
Q
concerning adrenal incidentaloma findings
A
> 4 cm
10 HU
internal calcs/hemorrhage
high vascularity
heterogeneous
interval tumor growth
24
Q
functional studies for incidentaloma?
A
urine metanephrines/VMA/catecholamines
urinary hydroxycorticosteroids,
serum K, plasma renin/aldosterone
low dose dexamethasone suppression test
25
indication for adrenalectomy?
1. 4+ cm or ENLARGING 0.5 cm/6 mos
2. functional
3. non-homogenous on CT scan >10 HU
26
how to follow incidentaloma < 4 cm and nonfunctional and homogenous (AKA not going to resect)?
CT scan q3mo x 1 year then yearly.
27
how to access (post or ant) adrenal for resection?
anterior approach. reflect right lobe of liver or reflect spleen & pancreas.
28
common mets to adrenal?
LUNG >>>> breast, melaoma, renal. must biopsy before.
29
isolated mets to adrenal? chemo or surgery.
just resect.
30
salt sugar sex. GFR
MESODERM CORTICAL CELLS
glomerulosa: aldosterone
fasciculata: glucocorticoids
reticularis: androgens/estrogens
31
where do hormones originate from? base.
cholesterol > progesterone > hormones x 3.
32
common hydroxylases?
21 and 11 B-hydroxylase.
33
posterior pituitary gland secretes what 2 things?
ADH and oxytocin alone.
NEUROhypophysis does not contain cell bodies
34
where ADH and oxytocin stimulated (nuclei) in hypothalamus
ADH: supraoptic nuclei
oxytocin: paraventricular nuclei
35
blood supply to anterior pituitary
PORTAL venous system (from neurohypophysis - posterior pitutary)
36
hypothalamus stuff travels where?
TRH, CRH, GnRH, GHRH, DA travel into median eminence and pass through NEUROHHYPOPHYSIS ON WAY TO ADENOHYPOPHYSIS
37
congenital adrenal hyperplasia? 21
21 deficiency: MC. hypotensive man. increased 17-hydrogyproge
early puberty in M, virilization in F. salt wasting (hypoTN).
treat: cortisol + genitoplasty.
38
congenital adrenal hyperplasia? 11
11 deficiency. hypertensive man. increased 11-deoxycortisone, later...
early puberty M, virilization in F. salt saving (causes HTN)
treat: cortisol, genitoplasty.
39
Conn syndrome sx?
hypertension and hypokalemia (weakness, polydipsia, polyuria)
40
primary Conn (dx: renin)
MC from HYPERPLASIA > adenoma, ovarian tumor, carcinoma
41
secondary hyperaldosteronism/Conn?
more common than primary Conn's
etiology: CHF, RAS, liver failure, diuretics, Bartter's (renin-secreting tumor)
renin is HIGH
42
Bartter's syndrome
renin secreting tumor
43
how to dx primary Conn? 2 modalities
1. salt load suppression test (urine aldosterone stays HIGH)
2. AND aldosterone:renin > 25 (renin low)
then.. localize.
44
imaging for adrenal tumor?
CT scan
consider: MRI, NP-59 scintigraphy, venous sampling
45
when to consider adrenal scintigraphy?
when cross sectional is nondiagnostic.
46
NP-59 scintigraphy can show what
adenoma from hyperplasia
47
how to optimize prior to adrenalectomy
BP and K control.
48
adenoma tx
adrenalectomy
49
hyperplasia tx MC: conn
medical therapy first (spironolactone, ACEi, CCBs nifedipine, potassium)
then bilateral resection for refractory hypokalemia
50
what supplement will be required after bilateral adrenal resection?
fludrocortisone.
51
adrenal insufficiency Addison's disease = hypocortisolism
#1 cause?
withdrawal of exogenous steroids
global: TB
developed: autoimmune
52
sx adrenal CRISIS
all loss.... refractory hypotension, fever, lethargy, pain, n/v
53
sx addisons disease
weakness, nausea, anorexia, weight loss, hyperK
54
#2 cause hypocortisolism
autoimmune disease
55
labs for hypocortisolism?
1. decreased AM cortisol? then proceed.
2. ACTH stimulation test - cosyntropin -- cortisol should stay LOW in primary
3. get AM ACTH level: if high, primary adrenal insufficiency; if low/nl , secondary adrenal insufficiency
56
dx hypocortisolism?
cosyntropic stimulation test. give ACTH, cortisol will remain LOW
57
how to tx acute adrenal crisis/insufficiency?
dexamethasone, fluids, tx the hyperkalemia & hypoglycemia
58
how to tx chronic adrenal insufficiency?
steroids
59
hypercortisolism = Cushing's SYNDROME; #1 cause
IATROGENIC > cushing disease > ectopic > adenoma primary
60
dx hypercortisolism?
24 hour urine cortisol and ACTH
ACTH low then primary (adrenal) secreting lesion
ACTH high then secondary (pituitary or ectopic)
61
if ACTH and cortisol is high on 24 hour urine collection?
high dose dexamethasone suppression test
pituitary adenoma will have SUPPRESSED cortisol "Cushing's disease"
ectopic source (small cell lung ca) will not suppress
62
Cushing's *DISEASE
= PITUITARY ADNOMA.
#1 non-iatrogenic cause of Cushing's syndrome 80%
63
#1 cause of noniatrogenic Cushing's syndrome
Cushing's disease - pituitary adenoma
64
dx Cushing's disease
brain MRI
65
treat Cushing's disease
transsphenoidal resection
radiation if too large for resection or if postop high cortisol that responds to HD dexa... there's still some tissue there
66
dx ectopic ACTH secretion (failed high dose suppression test)
CT CAP to localize primary tumor
67
treat ectopic
resect primary and medically suppress if inoperable
68
adrenal cause of hypercortisolism? low ACTH. and high cortisol.
adenoma > hyperplasia
69
treat adrenal hypercortisolism adenoma vs hyperplasia
adenoma: adrenalectomy (use scintigraphy to figure out adenoma vs hyperplasia)
hyperplasia: metyrapone (block cortisol synthesis), aminoglutethimide (inhibit steroid production), bilateral adrenalectomy if all else fails.
70
when to consider bilateral adrenalectomy without adrenal lesion
when cannot find ectopic tumor source
when ectopic tumor source is unresectable (and it's slow growing)
when pituitary adenoma cannot be found
71
what age gets adrenocortical carcinoma?
before 5 YO
after 50 YO
bimodal!
72
F or M get adrenocortical carcinoma?
F
73
are adrenocortical caricinomas functional?
50% are.
74
treat adrenocortical carcinoma?
radical (take kidney) adrenalectomy with debulking
+ mitotane/external beam RT (chemoXRT) if high risk local recurrence (positive margin, invasion, intraop spillage, Ki67 > 10%)
75
role of debulking in adrenocortical carcinoma?
helps with sx. and prolongs survival.
76
how to treat recurrent, residual, or metastatic disease after adrenocortical carcinoma?
mitotane (adrenalytic + XRT
77
5yr survival rate adrenocortical carcinoma?
20%.
78
postop adrenalectomy if negative margins?
CT CAP q 3 mos x 2 years
79
if R1 adrenalectomy,/invasiom/spillage/Ki67 >10%>
postop chemoradiation with mitotane
80
neural crest cell to adrenal medulla catecholamines?
tyrosine >**tyrosine hydroxylase**> dopa > dopamine > NE >**PNMT**> Epi
81
epi is made where exclusively
in the medulla where PNMT is - so excess epi is for sure a pheo in the ADRENAL GLAND. cannot be extra-adrenal
82
VMA vanillylmandelic acid
byproduct of epinephrine to metanpehrine and norepi to normetapnephrine via MAO.
83
pheo origin
slow growing from sympathetic ganglia or ectopic neural crest cells
84
10% rule of pheo
10% malignant, bilateral, kids, familial, extraadrenal
85
pheo laterality
R>L
86
dx pheo?
1. plasma non specific
2. confirm with urine metanephrines (24 hr) and VMA
3. localize CT vs hyperintense T2 MRI vs mIBG
87
adjunct pheo diagnostics?
131Iodinine-MIBG (norepi analgoue) can ID location if CT/MRI cannot help
clonidine suppression will have no effect on the elevated hormones (used as adjunct if all levels are normal)
88
venography in pheo dx?
DO NOT DO. can cause hypertensive crisis.
89
preoperative preparation for pheo removal?
a-blocker first (phenoxybenzamine, prazosin) and volume replacement then B block if tachycrdic or arrhythmias ssen
90
mgmt of pheo?
adrenalectomy (ligate veins first to avoid spilling catecholamines)
91
debulking role in pheo?
helps with sx
92
metyrosine role in pheo?
can give preop or in unresectable.
inhibits tyrosine hydroxylase to decrease synthesis of catecholamines.
93
extraadrenal 10% mostly malignant; locations?
MC: aortic bifurcation = origin IMA = organ Zuckerkandl
other: vertebral bodies, bladder
94
extramedullary tissue rests especially on organ of Zuckerkandl; where is that
inferior aorta near bifurcation
95
falsely elevated VMA
coffee, tea, fruit, vanilla, iodine contrast, labetalol, a/B-blocker
96
pharyngeal arches that make up the thyroid?
1st and 2nd. (* as opposed to pharyngeal POUCHES)
97
byproduct of T3 to T4 conversion?
cAMP
98
superior thyroid aa origin?
1st branch of ECA.
99
inferior thyroid aa origin?
off thyrocervical trunk; supplies both inferior and superior parathyroids.
100
Ima aa?
1%.
arises from innominate or aorta; traverses towards isthmus.
101
venous drainage from thyroid?
superior/middle thyroid: into IJ
inferior: into innominate.
102
innervation around thyroid?
external branch superior laryngeal nerve, recurrent laryngeal nerve.
103
external branch superior laryngeal nerve function?
motor to cricothyroid muscle
INJURY = loss of PROJECTION and voice FATIGUABILITY.
104
where dose superior laryngeal nerve run?
lateral to thyroid lobes. close to superior thyroid aa.
105
MC injured nerve in thyroidectomy?
superior laryngeal nerve.
106
MC injury location SLN?
near superior pole of thyroid during ligation of superior thyroid aa
107
recurrent laryngeal nerve function?
motor to all of larynx except cricothyroid. control vocal cords.
INJURY = HOARSENESS, b/l injury can obstruct airway (need trach)
108
where does recurrent laryngeal nerve run?
posterior to thyroid lobes in TE groove
track with inferior thyroid aa sometimes
L down around aorta
R down under SCA
109
ligament of berry?
posterior medial suspensory ligament of the thyroid close to RLNs.
careful on dissection!
MC injury location of RLN
110
delphian nodes
level VI; frequent first mets of thyroid ca
located in ANTERIOR SUSPENSORY LIGAMENT
111
thyroglobulin role?
stores T3 and T4 in colloid
112
T3 vs T4
T3 is active (tyrosine + iodine)
T4:T3 15:1
T4 to T3 via deiodinases
113
most sensitive indicator for thyroid gland function?
TSH.
114
tubercles of Zuckerkandl?
very lateral; posterior extension of thyroid tissue; rotate medially to find RLNs
leave alone in subtotal because of proximity
115
most common cause of death in thyroid storm?
high output heart failure.
116
mgmt of thyroid storm?
B-blockade, Lugol's solution (KI, slow), cool, oxygen, glucose
117
Wolff Chaikoff effect
high dose iodine via Lugol's inhibiting TSH action on thyroid and inhibits coupling of iodide resulting in less T3
118
thyroid nodule step to dx?
1. US to see nodule (if > 1cm sus features or >1.5cm) q6mo US if smaller
2. FNA and TFTs
3.
119
FNA results for thyroid nodule?
1. follicular cells - lobectomy
2. thyroid cancer - thryoidectomy or lobectomy
3. cyst fluid - drain fluid and send for cytology; resect if recurs/bloody
4. colloid tissue: leave alone = goiter
5. normal tissue but TFTs high - toxic nodule.... MTM and iodine if sx
120
concerning US findings for thyroid nodule
hypoechogenicity
microcalcification
irregular margin
unorganized vascular pattern
lymphatic invasion
TALLER than wider
121
if indeterminant FNA,
get radionuclide study
122
hot nodule on radionuclide sestimibi
MTM and iodine if symptomatic
123
cold nodule on sestimibi?
lobectomy (likely malignant)
124
MC cause of goiter
identifiable is iodine deficiency
MCC In US: low grade stimulation of the thyroid gland
125
primary substernal goiter vessels originate from?
innominate
126
secondary substernal goiter vessels originate from?
superior and inferior thyroid aas.
127
pyramidal lobe thyroid?
10%.
extends from isthmus superiorly.
128
lingual thyroid?
base of tongue in foramen cecum.
treat because can cause dysphagia.... thyroxine suppression, abolish with iodine.
2% malignancy risk
129
thyroglossal duct cyst
MIDLINE between hyoid and thyroid isthmus. develops in pyramidal lobe
moves with swallow.
can be premalignant or infected
130
mgmt thyroglossal duct cyst?
resect with midportion or all of hyoid bone (SISTRUNK PROCEDURE, lateral neck incision)
131
MTM vs PTU
PTU OK in pregnancy 1st tri; otherwise use MTM
both inhibit peroxidase (link iodine and tyrosine together)
132
MTM adverse effects?
cretinism in newborns, aplastic anemia, agranulocytosis.
133
PTU adverse effects?
aplastic anemia, agranulocytosis. hepatotoxicity esp in kids (but overall this precludes use a lot these days except in pregnancy)
134
when to operate on thyroid in pregnancy?
2nd trimester
135
graves' disease Abs
IgG to TSH-R
(long acting thyroid stimulator, thyroid stimulating immunoglobulin).
136
dx Graves?
decreased TSH, inc T3 and T4, TSH-R Ab, diffuse thyroid uptake of 123I
137
mgmt Graves?
thioamides (MTM, PTU), 131Iodine > thyroidectomy
RAI can cause worsening opthalmopathy
138
lugol solution indication
thyroidectomy for hyperthyroidism
to make thyroid decrease vascularity... firmer, easier to resect
also in thyroid storm
139
toxic multinodular goiter demographic?
F, 50+YO
140
etiology toxic multinodular goiter?
low grade chronic TSH stimulation; hyperplastic response
141
pathology toxic multinodular goiter?
colloid
142
mgmt toxic mulitnodular goiter
subtotal or total thyroidectomy >>>>>
if poor surgical candidate, 131Iodide
143
single toxic nodule size to be sx
>3 cm to be sx
144
single toxic nodule dx
thryoid scan shows hot nodule.... 20% of hot eventually end up causing sx
145
single toxic nodule tx
thioamides and 131i ... lobectomy if ineffective
146
Hashimoto's Ab?
IgG and T cells to Tg and TPO
147
Hashimoto goiter etiology
lack of organification of trapped iodide inside the gland
148
Hashimoto humeral vs cell mediated autommune dsease?
BOTH! Tg Abd and microsomal disease!
149
pathology Hashimoto's?
lymphocyte predominance.
150
mgmt Hashimoto's
levothyroxine > partial thyroidectomy.
151
de Quervain's thyroiditis sx
hyperthyroid then hypothyroid, PAINFUL sore throat after URI.
152
de Quervain's dx?
elevated ESR. "subacute granulomatous thyroiditis"
LOW uptake RAI
153
mgmt de Quervains?
steroids, aspirin > lobectomy/thyroidectomy.
154
Riedel's fibrous struma?
wood fibrous components involve strap muscles and carotid sheath
sx: hypothryoid, compressive sx
155
Riedel's fibrous struma dx?
looks like ca, so Bx.
156
mgmt Riedel's
steroids, thyroxine
157
Riedel associations
PSCLEROSINGCHOLANGITIS
FIBROTIC disease
METHYSERGIDE therapy
retroperitoneal FIBROSIS
158
if FNA shows follicular cells?
5-10% malignancy.
159
mgmt follicular adenoma?
lobectomy to provide it is not ca
160
most common thyroid cancer?
papillary thyroid carcinoma 85%
161
spread lymph or heme papillary
thyroid?
lymphatic
162
prognosis based on what for papillary thyroid ca?
local invasion.
163
where does papillary thyroid ca spread (rarely, as it is mostly local invasion)?
LUNG.
164
pathology papillary thyroid carcinoma?
psammoma bodies and orphan annie nuclei.
165
5 yr survival rate papillary thyroid carcinoma?
95%.
166
papillary thyroid ca postop HIGH RISK next steps
after total thyroidectomy, do 131RAI
can do whole body RAI scan 6 mo after to eval for disease
167
HIGH risk papillary ca that will require RAI
tumor 2-4 cm
vascular invasion
anti-Tg Abs
Tg < 5
168
follicular thyroid ca spread heme or lymph?
heme only. BONE common mets 50% at presentation.
169
prognosis of follicular thyroid ca based on?
staging.
170
5 yr survival rate follicular thyroid ca?
70% (95% papillary)
171
mgmt of papillary thyroid ca
lobectomy.
thyroidectomy indication: 4+cm [Fiser says 1+cm], beyond thyroid capsule/mets/clinical node, multicentric lesions, previous radiation
172
mgmt of follicular thyroid ca
lobectomy to diagnose... then THYROIDECTOMY if confirmed
+ MRM for positive nodes (not all)
+ postop RAI (all)
consider just lobectomy if: <4 cm, <45 YO, no distant, no personal/fam hx thyroid ca
173
indications for modified radical neck dissection in the setting of thyroid ca?
extrathyroid disease, medullary, or clinically apparent nodal disease (Hurthle, papillary, follciular)
174
indications for postop 131iodide (after thyroidectomy) - 6 wks postop?
1+cm, extra thyroidal disease. (cannot be after lobectomy)
175
medullary thyroid ca associated syndromes?
MENIIa or IIb (RET protooncogene)
176
pathology of medullary thyroid cancer
amyloid deposition
177
manifestation of medullary thyroid ca?
diarrhea
usually early in MEN2 syndromes
178
etiology of medullary thyroid ca?
parafollicular C cell hyperplasia (calcitonin)
179
calcitonin fx
release by C parafollicular cells
inhibit osteoclast and decreases Ca
increase renal phosphate excretion
180
calcitonin sx?
flushing, diarrhea
181
lymph or heme spread of medullary thyroid ca?
lymphatic - likely to have nodal disease at dx
182
mets from medullary thyroid ca?
lung, liver, bone.
183
when to do prophylactic thyroidectomy in MEN2s?
MEN2a: 6 YO
MEN2b: 2 YO
184
bad prognosis for medullary thryoid ca?
MEN 2b or sporadic type.
185
mgmt medullary thyroid ca?
total thyroidectomy with central neck dissection
+MRND with palpable mass
+ b/l MRND if extrahyroidal disease or both lobes affected.
186
5 yr survival medullary thyroid ca?
50% (vs 70% foll, 95% pap)
187
surveillance of medullary thyroid (high risk recurrence)
serum calcitonin, CEA repeat every** 2-3 mos** until clear
routine US
thyroid replacement (but to maintain EUTHYROID)
RAI is not necessary.
takes mos to hit nadir after initial ectomy
188
hurthle cell carcinoma benign or malignant?
mostly benign (adenoma) in older pts
189
mets from hurthle cell?
bone and lung if malignant.
190
pathology for hurthle cell ca?
Ashkenazi cells
191
mgmt hurthle?
cannot distinguish adenoma vs ca so need LOBECTOMY vs total thyroidectomy
+MRND if clinical nodes.
192
anaplastic thyroid ca demographic?
old long standing goiters.
193
pathology anaplastic thyroid ca?
vesicular appearance of nuclei.
194
5yr survival anaplastic thyroid ca?
0%.
195
mgmt anaplastic thyroid ca?
total thyrdoiectomy (rarely resectable)
+/- palliative chemotx
196
131I not effective for what ca
MTC
anaplastic
Hurthle
197
131I effect on mets?
good for lung and bone mets
198
131I side effects?
sialoadenitis, nv, infertility, BM suppression, PTH dysfxn, leukemia
199
superior vs inferior parathyroid origin?
superior: 4th pharyngeal POUCH ass'd thyroid complex
inferior: 3rd pharyngeal POUCH ass'd thymus
200
superior parathyroid location
lateral to RLNs, posterior/superior to thyroid, above inferior thyroid aa.
ectopic: check in the (retro esoph) TE groove or carotid sheath
201
inferior parathyroid location
more likely ectopic
found in tail of thymus > anterior mediastinum, intrathyroid, near TE groove
202
blood supply to parathyroids
inferior thyroid artery from thyrocervical trunk
203
4 PTH resected but still high PTH ... where to look for supernumerary?
just do thymus
204
dx primary hyperparatyroidism?
high PTH
high Ca
low urinary Ca <100
low phos
CL:phos ratio > 33
increase renal cAMP
loss bicarb in urine
205
dx next step to localize PTH adenoma?
SESTAMIBI + US / CTA venous if reoperative/complex case
206
acid base disturbance in primary hyperPTH
hyperchloremic metabolic acidosis.
207
indication for parathyroidectomy
symptomatic
asx with Ca>13, decrease Cr clearance, kidney stones, UCa > 600, osteoporosis, <50YO, poor access
208
how to confirm you got the PTH adenoma out?
50% drop in PTH from pre-incision value to 10 min after resection
209
mgmt pth adenoma
resect.
210
mgmt pth hyperplasia
resect 3.5 glands or total and autoimplant.
211
mgmt pth carcinoma
radical parathyroidectomy (with ipsilateral thyroid lobe)
212
Ca level in parathyroid carcinoma?
very very high > 14
213
PTH ca mgmt
en bloc resection + ipsilateral thyroid possibly + neck dissection if LN involvement suspected
214
PTH ca mgmt if recurrent/metastatic
chemoXRT NOT effective.. so palliative or Ca bisphos/calcimims
215
pregnancy PTH hyperparathryoidism
resect in 2nd timester
216
lesion in primary hyperparathyroidism (adenoma vs?)
single adenoma 80%
multiple adenoma 4%
diffuse hyperplasia 15%
carcinoma 1-2% -- usually VERY high
217
MEN association with primary hyperparathryoidism?
MEN I>>> and IIa; diffuse 4 gland hyperplasia. treatment is 3.5 or 4 gland
218
what presents first in MEN I
hyperPTH - Hyper Ca
so, resect 4 and autoimplant first before anything else
219
utility of sestamibi scan?
best for ectopic glands. use if cannot find gland (close and scan)
220
bone hunger vs aparathyroidism causing hypocalcemia postop parathyroidecotmy
bone hunger: normal PTH, decrease bicarb, increase UcAMP
aparathyroi: decreased PTH, normal bicarb and UcAMP
221
mgmt normocalcemic primary hyperparathyroidism nPHPT
surgery if symptomatic
222
secondary hyperparathyroidism cause
ESRD; chronically lost Ca (lost with HD); cause increase PTH; low Ca***
223
mgmt secondary hyperPTH?
Ca supplement, Vit D, low phos diet, phos binders (sevelamer), cinacalcet (mimic Ca, inhibits PTH), surgery...
224
surgical indication (total with auto; or subtotal) in secondary hyperPTH
if bone pain, fx, pruritus
225
tertiary hyperparathyroidism cause
ESRD s/p txp. autoPTH high
226
mgmt tertiary hyperPTH?
subtotal 3.5 or total with auto
227
familial hypercalcemic hypocalciuria lab abnormalities?
increased serum Ca, low urine Ca, normal PTH
due to defect in PTH-R in DCT (can't resorb Ca)
Diagnosis <100 mg/24 hr urine calcium with high serum Ca
228
mgmt FHH
nothing; no surgery.
229
pseudohypoparathyroisim issue?
PTH-R in DCT defect (like FHH); does not respond to PTH (normal PTHN levels)
230
5 yr survival parathyroid ca?
50%.
231
mets commonly from PTH to what?
lung.
232
multiple endocrine neoplasia syndromes AD vs AR?
AD.
233
MEN from what* cells
APUD = GI endocrine cells
234
MENI menin
PPP parathyroid hyperplasia (urinary first), PNET (gastrinoma >), pituitary adenoma (prolactinoma)
235
MENIIa ret
PMP parathyroid hyperplasia, medullary thyroid (first, main cause of death), pheo
236
MENIIb ret
MMP medullary, mucosal, marfan's habitus, pheo
237
mgmt hypercalcemic crisis?
fluids=NS and lasix.
238
mgmt PTHrP medical mgmt (poor surigcal candidate for SCC lung)?
judicious fluids and IV pamidronate (ca binder bisphos)
239
TIRADS
TIRADS 1. benign NTD
2. not suspicious NTD
3. mildly suspicious FNA if 2.5cm+, follow if 1.5cm+
4. moderately FNA if 1.5cm +, follow if 1cm+
5. highly FNA if 1cm, follow if 0.5cm+
240
Bethesda guidelines thyroid FNA
1. nondx; repeat FNA
2. benign; clinical/US f/u until 2x negative
3. atypia of undetermined signif; repeat FNA, molecular testing, lobectomy
4. follicular neoplasm or suspicious for; molecular testing, lobectomy
5. suspicous for malignancy; lboectomy or near total thryoidectomy
6. malignancy diagnosed; lobectomy or near total thyroidectomy.
241
myxedema coma
intubate, NS (hypoNa), glucose (hypogly), iv thyroxine
242
intraop BP control in pheo resection
nitroprusside >>> phentolamine, nicardipine, labetalol, esmolol
243
what does a recurrent laryngeal nerve injury look like on DL
adducted cord.
244
mgmt for thyroid lymphoma (rapidly growing)
B cell lymphoma
R-CHOP
rituximab, cyclophosphamide, doxorubicin, oncovin (vincristine), prednisone
radiation if compressive sx
245
papillary ca staging
I and II < 55
III and IV > 55
II has mets
246
recurrent parathyroid ca mgmt
radioresistant;
no role for chemo
so, reexplore/resect.
247
postop diet after aldosterinoma resection?
HIGH salt to prevent rebound hyperK
248
timing of thyroidectomy preg graves
4-8 wks after ptu or mtm
249
stress dose steroids if taking< 5 mg pred a day
jsut take PO dose on AM
250
stress dose if 5-20 mg/day for > 3 weeks
take AM PO dose if minor surgery (inginalhernia)
take AM + 50 hydrocort wit 25 q8 if moderate (revascul)
take AM + 100 hydrocort with 25q8 if major cardiac/thor/abd
BTK sasy: minor IV hydo 25-50 day of then normal dosing
major IV hydro 50-75 for 1-2 days then normal
251
stress dose if >20 mg regardless fo type of surgery
neesd stress dosing steroids
252
insulin periop
continue reduced dose SC inulin if short proceudre
IV insulin gtt for long omplex
hold oral antihyperglycemics
253
arterial supply thyroid
superior (ECA) thyroid
inferior (thyrocervical STAT) thyroid
IMA (innominate)
254
venous drainage thyroid
superior (IJ)
inferior (innominate)
255
embryology thyroid
pharyngeal pouches (ENDODERM)
C cells (4th and 5th branchial pouches)
256
RAI doesn’t work for what thyroid ca
MTC
257
myelolipoma adrenal
benign... CT adrenal to show fat... adrenalectomy if >7cm or symptomatic
258
arteria lusoria
aberrant R SCA off the descending aorta distal to L SCA; MC congenital arch anomaly... ass'd with R non-recurrent laryngeal nerve
259
potency of steroids
hydrocortisone < prednisone < methylpred < dexamethasone
260
incretin signaling pathway
GLP 1
261
survival prognosis for adrenal carcinoma
adequacy of resection - get it all!!!
not just LNs
262
adrenal insufficiency - what to avoid for RSI
etomidate (inhibitors steroid synthesis)
263
contraindications for RAI
current preg, and avoid for 6-12 mos
current breastfeed
severe thyrotoxicosis
severe Graves
264
paraneoplastic syndromes
PTHrP - squamous cell cancers
ADH and ACTH - small cell lung cancer
265
postoperative (after lobectomy even) subclinical hypothyroidism
asx
TSH elevated
fT4 normal
start on levothyroxine instead of observing
266
syndromes associated with pheo
MEN2's, NF1, Sturge Weber, TS
267
paraganglioma?
extra-adrenal pheo
268
ganglioneuroma?
benign.
asx.
neural crest tumor in medulla or sympathetic chain
tx: just resect
269
thyroxine side effect; long term
osteoporosis
270
