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Phase 2a > Endocrine > Flashcards

Endocrine Flashcards

1
Q

What are the 3 main types of hyperparathyroidism?

A

1) Primary
2) Secondary
3) Tertiary

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2
Q

What are the 6 main causes of hypercalcaemia?

A

1) Hyperparathyroidism (1 +3)
2) Malignancy (ectopic PTH-like protein production)
3) Drugs (Thiazides, vit D analogues, Li)
4) XS calcium intake (crohn’s disease, dietary)
5) Familial hypocalciuric hypercalcaemia
6) Long-term immobility

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3
Q

What is the most common cause of hypercalcaemia?

A

Primary hyperparathyroidism.

80% adenoma, 20% glandular hyperplasia, <0.5% carcinoma

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4
Q

What is the pathophysiology of secondary hyperparathyroidism?

A

hypocalcaemic parathyroid stimulation –> hyperplasia –> increased PTH secretion
Can be caused by CKD or Vitamin D deficiency

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5
Q

What is tertiary hyperparathyroidism?

A

Prolonged secondary hyperparathyroidism leading to hyperplasia and an autonomous PTH function

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6
Q

Primary hyperparathyroidism diagnosis + treatment?

A

High PTH
High Ca2+
Low PO43-
High ALP

No underlying pathology
Identify with: PT ultrasound, CT/MRI
-Hyperparathyroidectomy 
-If contraindicated --> take CINACALCET
-Avoid thiazides, XS vit D and calcium
-Exercise
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7
Q

Secondary hyperparathyroidism diagnosis + treatment?

A

High PTH
Low Ca2+
High PO43-
High ALP

Treat underlying pathology

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8
Q

Tertiary hyperparathyroidism diagnosis + treatment?

A

High PTH
High Ca2+
High PO43-
High ALP

Treat prolonged underlying pathology
If not possible –> surgery

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9
Q

What are the main clinical presentations of hyperparathyroidism?

A

Bones, stones, abdominal groans, psychiatric moans, cardiac tones

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10
Q

Malignant hypercalcaemia diagnosis and treatment?

A

Low PTH
Low albumin
High ALP
B2 microglobulin

Identify with:

  • radioisotope screening
  • CT/MRI

Chemo + radiotherapy, surgery

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11
Q

What additional tests can be done in hyperparathyroidism?

A

TSH levels to exclude hyperthyroidism
DXA bone density scan
24hr urinary Ca2+ (familial hypocalciuric hypercalcaemia)

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12
Q

What 4 things would you do if patient has SEVERE ACUTE HYPERCALCAEMIA?

A
  1. IV 0.9% saline: prevent renal calculi
  2. Bisphosphonates (e.g. IV pamivonate): prevent bone resorption
  3. Check serum U&E daily and calcium 48hrs after initial treatment
  4. Give GC (e.g. prednisolone) if e.g. sarcoidosis, myeloma, vit D excess
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13
Q

Why might hypoalbuminaemia cause hypocalcaemia despite no change in free calcium levels?

A

Because some calcium is albumin bound.

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14
Q

In what group of people is hypocalcaemia most common?

A

Hospitalised patients

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15
Q

What percentage of intensive care patients have hypocalcaemia?

A

Up to 88%

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16
Q

Give an aetiological factor of hypocalcaemia.

A

1) CKD
2) Vitamin D deficiency
3) Hypoparathyroidism (primary and secondary)
4) Pseudoparathyroidism
5) Drugs e.g. Calcitonin, bisphosphonates
6) Pancreatitis or osteomalacia

17
Q

How does CKD cause hypocalcaemia?

A

1) Less activation of calcidiol to calcitriol via 1-a-hydroxylase
2) Less gut Ca2+ absorption

18
Q

What are the 2 forms of primary hypothyroidism and how do they cause hypocalcaemia?

A

1) Congenital AI DiGeorge syndrome
2) Idiopathic: AI parathyroid Ab’s
- Less PTH –> less Ca2+

19
Q

What can cause secondary hypoparathyroidism?

A
  • Radiation
  • Parathyroidectomy/ Thyroidectomy
  • Hypomagnesaemia
20
Q

Why are PTH levels raised in pseudohypoparathyroidism?

A

Due to the failure of target organ PTH stimulation, there is no increase in serum Ca2+, so no negative feedback mechanisms are activated to inhibit PTH production.
PTH is continually secreted in an attempt to increase serum Ca2+. (Similar to beta cells insulin secretion in early DMT2)

21
Q

What are the similarities and differences in pseudohypoparathyroidism and pseudopseudohypoparathyroidism?

A

Similarities:

  • Skeletal defects e.g. shorter 4th and 5th metacarpals
  • Subcutaneous calcification
  • Short
  • Intellectual impairment

Differences:

  • Pseudo: High PTH and PO43-, Low Ca2+
  • All are normal in pseudopseudoparathyroidism
22
Q

How might bisphosphonates cause hypocalcaemia?

A

Inhibit osteoclast activity so prevent bone resorption.

23
Q

What is significant about the phosphate levels in pancreatitis and osteomalacia?

A

They are normal or low, despite the low Ca2+.

24
Q

What are some clinical presentations of hypocalcaemia?

A

1) Spasms - carpopedal (Trousseau’s sign)
2) Paraoral paraesthesia
3) Anxiety/irritation/irrational
4) Seizures
5) Muscle (smooth) contraction (wheeze)
6) Orientational impairment + confusion
7) Dermatitis/diarrhoea
8) Impetigo Herpetiformis (in pregnancy)
9) Chvodeck’s sign/ cataracts/ cardiomyopathy

25
Q

What is a positive trousseau’s sign?

A

A carpopedal spasm when the sphygmomanometer cuff is inflated above systolic BP.

26
Q

What is a positive Chvodeck’s sign?

A

When the facial nerve (CN VII) is tapped near the parotid, the IPSILATERAL facial muscles twitch.

27
Q

What 2 signs are seen in severe hypocalcaemia?

A

Prolonged QT interval

Papilloedema (^ ICP = optic disc swelling)

28
Q

How is alkalosis e.g. caused by HYPERVENTILATION, a differential dignosis of hypocalcaemia?

A

Because albumin becomes more negatively charged and so it binds to more free Ca2+. This means levels of bioavailable Ca2+ is decreased.

29
Q

How are magnesium or potassium deficiencies differential diagnoses of hypocalcaemia?

A

Magnesium is required for PTH production.

Mg is also required to transport Ca2+ and K+ into and out of cells.

30
Q

How do you check for renal impairment as a cause of hypocalcaemia?

A
  • Serum urea
  • Serum creatinine
  • eGFR
31
Q

What are PTH, Ca2+, PO43- and AI Ab serum levels in idiopathic primary hypoparathyroidism?

A

PTH: low
Ca2+: low
PO43-: high
AI Ab: present

32
Q

What are PTH, Ca2+, PO43- and AI Ab serum levels in secondary hypoparathyroidism?

A

PTH: low
Ca2+: low
PO43-: high
AI Ab: absent

33
Q

How do you treat a patient with acute severe hypocalcaemia?

A

IV CALCIUM GLUCONATE

over 30 minutes, monitor ECG

34
Q

How do you treat a patient with vitamin D deficiency that does not have hypoparathyroidism?

A 
ORAL CHOLECALCIFEROL (vitamin D3)
ORAL ADCAL (vitamin D + Ca2+)
35
Q

How do you treat a patient with vitamin D deficiency that does have hypoparathyroidism?

A

ORAL CALCITRIOL

CALCIUM SUPPLEMENTS

Phase 2a (5 decks)

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