Endocrine 2 Flashcards
DM1
Autoimmune Pancreatic beta cells destroyed (Islets of Langerhans) No insulin produced Glucose ^^^
DM2
Excess adipose tissue
Relative insulin deficiency
Glucose ^
Prediabetes
Not meeting DM2 criteria
Likely to develop DM2 in next few years
Require lifestyle interventions
Fasting glucose 6.1-6.9
HbA1c 42-47
DM2 risk factors
Age ^
Family history
Non-white
Sedentary lifestyle
Obesity
Stress
GDM
PCOS
HTN
Dyslipidaemia
CVD
DM clinical features
Polydipsia
Polyuria
Weight loss
Fatigue
Visual disturbances
Abdo pain
N/V
Recurrent infections
- Candidal
- Skin
- UTI
Polydipsia/polyuria pathophysiology
Glycosuria
Water follows by osmosis
= Dehydration
DM investigations
Random plasma glucose > 11
Fasting plasma glucose > 6.9
OGTT - 75g glucose - Wait 2 hours - Positive > 11
HbA1c > 48
Urine dip - Ketones +++
DM1 management
Insulin
- SC pump
- 0.2-0.4 units/kg/day
- BM self-monitoring
- Pre-meal insulin correction dose
DM2 management - Lifestyle
Lifestyle changes (HbA1c 48-53)
- Weight loss 5-10%
- Physical activity
- Reduce alcohol intake - Risk of hypo
- Smoking cessation
Diet - Reduce sugar consumption
- High fibre
- Low GI foods
- Low-fat dairy produts
- Reduced saturated fats and TFAs
DM sick day rules
Increase frequency of BM monitoring Increase fluid intake - 3L / 24 hours Maintain carbohydrate intake - Sugary drinks if necessary Access to a mobile phone Continue medication - Except metformin
DM indications for admission
Inability to tolerate oral fluids Persistent diarrhoea Significant ketosis - Despite additional insulin BM > 20 - Despite additional insulin Lack of support at home
DM2 management
- HbA1c 48-53 - Diet and exercise
- Metformin
- If HbA1c > 58 add…
- Gliptin
- Sulfonylurea
- Pioglitazone
- SGLT-2 inhibitor - Gliflozin - If HbA1c > 58 - Add another
- If HbA1c > 58 and BMI > 35
- Add GLP-1 mimetic
DM drugs MoA
Metformin - CI if eGFR < 30
- Increases insulin sensitivity
- Decreases hepatic gluconeogenesis
Sulfonylurea - Gliclazide
- Risk of hypoglycaemia
- Stimulates pancreatic B cells to produce insulin
Pioglitazone
- Promote adipogenesis and FFA uptake
- Weight gain
Gliptins
- Increases incretin
- Inhibits glucagon secretion
- Risk of pancreatitis
SGLT-2 inhibitors - Inhibits renal reabsorption of glucose
DM complications
Microvascular
- Neuropathy
- Retinopathy
- Neuropathy
Macrovascular
- CVD
- CHF
- Stroke
Infection
DKA
Non-ketotic hyperosmolar state
DKA pathophysiology
Insulin deficiency + Glucagon ^
Triglycerides and AAs metabolised for energy
Increased serum glycerol and FFA
Glucagon converts FFA to ketones
Hyperglycaemia causes osmotic diuresis
Marked urinary loss of water and electrolytes
DKA clinical features
N/V
Abdo pain
Altered consciousness
Dehydration
Hyperventilation - Kussmaul breathing
Ketone breath - Pear drops
Sx of DM
DKA investigations
VBG
- Hyperkalaemia
- Hypokalaemia = Severe DKA
- Metabolic acidosis
- Serum osmolality ^^^
pH < 7.3
Serum ketones > 3
BM > 11
Bicarb < 15
DKA management
Fluid replacement
- 500ml bolus over 10-15 minutes
- 1L over 1 hour
Correct hypokalaemia - SandoK
Insulin - FR infusion
When glucose < 14 - Give 10% Dextrose
Safe rate of glucose reduction - 4-6 mmol/hr
DKA complications
Arrhythmias - Hypo/hyperkalaemia
VTE
ARDS
Gastric stasis
AKI
Cerebral oedema
Hyperosmolar hyperglycaemic state pathophysiology
Hyperglycaemia Osmotic diuresis - Electrolyte abnormalities - Severe dehydration - Raised serum osmolality - Hyperviscosity
Typically elderly DM2 patients
Develops over many days
Hyperosmolar hyperglycaemic state clinical features
Dehydration
Hypotension
Tachycardia
Fatigue
Lethargy
Weakness
Altered consciousness
N/V
Headaches
Papilloedema
Hyperosmolar hyperglycaemic state diagnosis criteria and management
- Hypovolaemia
- Hyperglycaemia > 30 ± Ketonaemia/acidosis
- Serum osmolality > 320
Management
- Fluid replacement
- Correct electrolyte abnormalities
- Normalise blood glucose
Thyroid storm precipitating events
MIST
Media - Contrast - Acute iodine load
Infection
Surgery
Trauma
Thyroid storm clinical features
Fever > 38.5
Tachycardia
Hypertension
HF
Confusion and agitation
N/V
Abnormal LFTs
Jaundice
Thyroid storm management
Symptomatic - Paracetamol
BBs - IV propranolol
Carbimazole
Dex - Blocks conversion of T3 to T4
Myxoedema coma
Symptoms and management
Confusion
Hypothermia
Management
- IV thyroxine
- IV Fluid replacement
- IV corticosteroids
- Correct electrolyte imbalance
- Rewarming?
Thyroid cancers
Presentation - Thyroid nodule in a woman aged 30-50
Papillary carcinoma - 70%
- Young females
- Excellent prognosis
Follicular adenoma - 20%
- Solitary thyroid nodule
Medullary carcinoma - 5%
- Secrete calcitonin
- 20% familial genetics
Anaplastic carcinoma - 1%
- Pressure symptoms
- Elderly females
- Chemo ineffective
Lymphoma - Associated with Hashimoto’s
Thyroid nodule investigations
TSH - Normal
USS + FNB
Laryngoscopy - Paralysed vocal cord?
CT staging
Serum calcitonin - Medullary carcinoma
Thyroid cancer management
Total thyroidectomy
Radioiodine ablation
TSH suppression - Levothyroxine
Screen for recurrence - Yearly thyroglobulin levels
Hypoadrenalism
Primary
- TB
- Metastases
- Meningococcal septicaemia
- HIV
- Antiphospholipid syndrome
Secondary - Pituitary disorders
- Tumours
- Irradiation
- Infiltration
Pituitary adenoma risk factors
MEN-1
Familial isolated pituitary tumours - FIPA
Carney complex - CNC
Pituitary adenoma clinical features
Headaches
Bitemporal hemianopia
Central adiposity
Reduced muscle mass
Hypogonadism
- Gynaecomastia
- Amenorrhoea
- Infertility
- Loss of libido
- ED
Hypothyroidism
Fatigue
Osteopenia
Adrenal insufficiency
- Anorexia
- N/V
- Weakness
Pituitary adenoma investigations
Prolactin ^
IGF-1 - Low with GH deficiency
Sex hormones - LH, FSH, testosterone, oestrogen
Morning cortisol
ACTH
ACTH stimulation test
Insulin tolerance test
U&E - Hyponatraemia
FBC - Anaemia
CT/MRI
Pituitary adenoma management
Pituitary apoplexy
- Hydrocortisone
- Levothyroxine
- Trans-sphenoidal resection
Adenoma
- Observation
- Hormone replacement
- Radiotherapy
- Dopamine agonist - Bromocriptine / Cabergoline
- Somatostatin analogue - Octreotide
PTH physiology and vit D synthesis
PTH released in response to low Ca
- Increased bone resorption by OCs - More Ca released
- Increased Ca reabsorption in kidneys
- Increased vit D synthesis in kidney
- Increased calcium and phosphate absorption from gut
25-hydroxyvitamin D
Converted to 1,25-dihydroxyvitamin D
Absorbed in gut
HyperPTH aetiology
Primary - Solitary adenoma
Secondary - Hyperplasia
Risk factors
- Female
- Age > 50
- Family history
- MEN
- Li treatment
HyperPTH clinical features
= Hypercalcaemia
Bones - Osteoporosis, osteopenia, pain Stones - Renal Moans - Depression and anxiety Groans - Abdominal pain and myalgia Thrones - Constipation
Sleep disturbances
Fatigue
Cognitive changes
Paraesthesia
HyperPTH investigations
Calcium profile
- Calcium ^ (Low in 2)
- Phosphate ^ (Low in 2)
- PTH ^
- ALP ^
Tech-99 scan
ECG - Short QT
Skeletal survey - Pepper pot skull
Knee XR - Chondrocalcinosis
HyperPTH management
Parathyroidectomy
+ Vit D supplementation - Ergocalciferol
+ Alendronic acid
+ Cinacalcet
HypoPTH aetiology
Thyroid/parathyroid surgery
Malnutrition
Malabsorption
Diarrhoea
Chronic alcoholism
Hypomagnesaemia
AD conditions - CASR and GATA3
HypoPTH clinical features
Secondary to hypocalcaemia
Tetany - Muscle twitches, spasms, cramps
Perioral paraesthesia
Trosseau’s sign - Carpal spasm on inflation of BP cuff
Chvostek’s sign - Tapping parotid causes facial muscles to twitch
Depression Cognitive changes Anxiety Dry hair and brittle nails Cataracts
HypoPTH investigations and management
Calcium profile
- Ca - LOW
- PTH - LOW
- Phosphate ^
- Vit D - LOW
Albumin
- Low albumin will falsely lower serum calcium
- Ionised calcium accurately reflects physiological calcium
Magnesium - LOW
ECG - Prolonged QT
Management
- Calcium carbonate
- Calcitriol
Hypernatraemia aetiology
Dehydration
Osmotic diuresis
DI
Infancy
Old age
Renal concentrating deficit
Iatrogenic
- IV saline
- Lithium
- Mannitol
Hypernatraemia clinical features
CNS manifestations
- Lethargy/weakness
- Irritability
- IC haemorrhage
- Seizures
- Stupor
- Coma
Weight loss - Hypovolaemia
Hypo/tachy
Decreased JVP
Dry mucous membranes
Hypernatraemia investigations and management
Serum sodium
Urine osmolality
- Low - DI
- High - Volume depletion
Serum osmolality - High
Management - Treat cause
- Fluid replacement
- DI - Desmopressin / Thiazide diuretic
Carcinoid syndrome aetiology
Metastases in the liver
Serotonin released into systemic circulation
Risk factors - MEN-1
Carcinoid syndrome clinical features
Flushing
Palpitations
Diarrhoea
Abdo cramps
Signs of RHF
Cardiac murmurs
Hepatomegaly
Carcinoid syndrome investigations and management
Serum chromogranin A/B ^^^
Urinary 5-hydroxyindoleacetic acid ^^^
Creatinine ^^^
LFTs
Management - Somatostatin analogue - Octreotide
Multiple endocrine neoplasia
MEN-1 - 3Ps - Parathyroid - Pituitary - Pancreas \+ Adrenal \+ Thyroid
MEN-2a - 2Ps - RET oncogene
- Medullary thyroid cancer
- Parathyroid
- Phaeochromocytoma
MEN-2b - 1P - RET oncogene
- Phaeochromocytoma
- Marfanoid body habitus
- Neuromas
Phaeochromocytoma
Catecholamine secreting tumour
Associated with
- MEN-2
- Neurofibromatosis
- Von-Hippel Lindau syndrome
10% rule
- Familial in 10%
- Bilateral in 10%
- Malignant in 10%
- Extra-adrenal in 10% - Organ of Zuckerlandl
Phaeochromocytoma clinical features
HTN - 90%
- Headaches
- Palpitations
- Diaphoresis
Hypertensive retinopathy Pallor DM Orthostatic hypotension Cafe au lait spots
Phaeochromocytoma investigations
24-hour urine collection
- Catecholamines
- Metanephrines
- Normetanephrines
- Creatinine
MRI - Adrenal medulla
Genetic testing
Phaeochromocytoma management
AB - Phenoxybenzamine
BB - Propranolol
+ Surgical excision
