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Endocrine / adrenal Flashcards

1
Q

Briefly describe the anatomy of the adrenal gland

A

Nebenniere

Cortex 3 zones
Z. Glomerulosa- mineralcorticoids
Z. Fasiculata - glucocorticoids
Z. Reticularis - sex steroids

Medulla
Produces adrenaline and Noradrenaline

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2
Q

Which specific cells does the medulla of the adrenal gland contain?

And what is their function?

A

Chromaffin cells

Release Adrenalin and noradrenalin

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3
Q

All corticoids are produced from?

A

Cholesterol

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4
Q

Name the actions of cortisol

A

Gluconeogenesis ( anabolic)
Lipolysis, protein breakdown (catabolic )
CNS altered perception
Immunosuppressive
Anti-inflammatory
Vasoconstriction , maintains blood volume

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5
Q

Name the actions of adrenaline and noradrenaline

A 
Increased heart rate and contractility 
Increase respiratory rate and promotes bronchodilation
Gluconeogenesis
Lipolysis 
Alertness 
Sweating 
Pupil dilation
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6
Q

What is Addison?

A

Primary adrenal sufficiency

  • lack of mineralcorticoids
    Glucocorticoids, Sex steroids
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7
Q

Name the commonest cause of addisons ? What are other causes?

A

Autoimmune adrenalitis

CMV 
TB
HIV
Waterhouse Friedrichsen ( adrenal haemorrhage ) 
Tumour 
Congenital adrenal hyperplasia
21-alpha hydroxylase deficiency
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8
Q

How to differentiate between primary and secondary adrenal insufficiency ?

Name a cause for secondary adrenal insufficiency

A

In primary, all corticoids are low in secondary mineralcorticoid secretion remains intact
High ACTH in primary , low ACTH in secondary

In Secondary adrenal insufficiency there is lack of ACTH secretion resulting from hypopituritarism ( tumour , irradiation )
Or eg sudden withdrawal from prolonged corticoid therapy

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9
Q

Addisons presents with lots of unspecific features . Name some and the most common signs .

A 
Postural hypotension 
Hyperpigmentation ( palmar creases )
Weight loss 
Wasting 
Lethargy 
Depressed mood 
Unexplained abdominal pain, nausea , vomiting

Hyponatraemia
Hyperkalaemia
Hypoglycaemia

Loss of libido
Hair loss ( axillary and Pubic hair )
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10
Q

What causes skin hyperpigmentation in addisons ?

A

High ACTH levels

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11
Q

What tests could you perform to diagnose addisons ?

A

ACTH stimulation test
- give synacthen , failure to increase cortisol

Measure ACTH - high - screen for autoantibodies

Single cortisol measurement unreliable as varies during day

Electrolyte disturbances
Low Na
High K
Low glucose

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12
Q

What other conditions can Addison be associated with ?

A

Diabetes mellitus 1
Hashimoto
Pernicious anaemia

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13
Q

Treatment of addisons

A

Steroid replacement
Hydrocortisone 15-25mg

Replace mineralcorticoids
Eg fludricortisone

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14
Q

What can trigger an adrenal crisis and how does it present?

A

Triggered by stress , sepsis , sudden stop of cortison

Fever, vomiting, diarrhoea 
Abdominal pain
Hypoglycaemia 
Hyperkalaemia 
Huponatraemia 
Metabolic acidosis 
Shock

-> give IV or IM hydrocortisone

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15
Q

What is Conn Syndrome ?

A

Primary hyperaldosteronism

Leading to excess aldosterone due to overproduction

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16
Q

Name two conditions that can cause conn syndrome

A

Idiopathic adrenal hyperplasia

Aldosteronoma (aldosteroneproducing adenoma )

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17
Q

What are the clinical signs of Conn’s?

A

Hypertension
Hypokalaemia
Metabolic alkalosis
Diabetes insipidus

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18
Q

A young patient presents with treatment resistant hypertension . His blood tests reveal hypokalaemia . What is a possible diagnosis ?

A

Conns syndrome

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19
Q

Which investigations would you perform in a patient with conns sydrome ?

A

Plasma aldosterone concentration to plasma renin activity (PAC:PRA) Ratio ( >20 ng/dl)

Oral Saline or Saline Infusion test would both slow normal suppression of RAAS

CT

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20
Q

Why is there no Oedema and only

Mild hypernatraemia in conns syndrome ?

A

Aldosterone escape

Volume expansion causes ADH secretion which leads to compensatory diuresis

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21
Q

Treatment of conns

A

Spironolactone ( SE gynaecomastia, loss of libido )

Surgery if only one adrenal gland affected

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22
Q

What is a phaeochromozytoma and what is it associated with ?

What’s the most
Common location?

A

Catecholamine secreting tumour from chromaffin cells , most commonly adrenal medulla (10% sympathetic ganglion )

Neurofirbomatosis 1
Von hippel Landau disease
Multiple endocrine neoplasia 2

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23
Q

How may a patient with phaeochromocytoma present with?

A 
Hypertension 
Hyperglycaemia 
Throbbing headache 
Palpitations 
Tachycardia 
Sweating
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24
Q

Name 2 tests performed in patients with phaeochromocytoma .

A

Metanephrine in Plasma

24h urine test for metanephrine and catecholamines / vanillymandelic acid

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25
Q

How would you manage a patient with phaeochromocytoma ?

A

Selective alpha blocker
Labetalol

Fluid replacement
Surgical removal

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26
Q

What is Cushing syndrome?

What are it’s causes ?

A

Increased levels of cortisol

Exogenous: prolonged glucocortico steroid

Endogenous
Primary : ACTH independent : adrenal adenoma

Secondary : ACTH dependant
Increased ACTH production from pituitary gland = cushings disease
Or ACTH from ectopic production e.g paraneoplastic syndrome

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27
Q

Name the features of Cushing’s syndrome

A

Skin:
Bruising , thinning , striae, delayed wound healing, flushed face , hirsutism , acne

Neuropsychological 
Lethargy 
Depression 
Sleep disturbance 
Psychosis

Muskulosceletal
Muscle wasting , weakness
Osteoporosis

Endocrine / metabolic 
Hyperglycaemia , Diabetes 
Central obesity 
Moon face 
Buffalo hump

Increased risk of infection

Hypertension
Amenorrhea

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28
Q

How to investigate a patient with signs of high cortisol levels ?

A

Dexamethasone suppression test

24 h cortisol urine

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29
Q

How would you differentiate the causes of high cholesterol regarding their location on the pituitary - adrenal axis ?

A

ACTH measurement
If low - adrenal tumour
If high - cushings disease or ectopic

Dexamethasone high dose
In ectopic no change in cortisol levels

CRH stimulation
If in pituitary - cortisol rises
If ectopic - no change

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30
Q

Give the features of ACTH, cortisol and CRH in Pituitary Tumor
Adrenal
Tumour
Ectopic cortisol production

A

Pituitary Tumor

  • high cortisol
  • high ACTH

Adrenal Tumour

  • low ACTH
  • high Cortisol
  • low CRH

Ectopic
Doesn’t respond
High Cortisol
High ACTH from ectopic source possible

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31
Q

What electrolyte changes would you find in Cushing’s syndrome?

A

Hypernatraemia

Hypokalaemia

Metabolic acidosis

Hyperglycaemia

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32
Q

How to treat an exogenous Cushing syndrome , how an endogenous ?

A

Exo: reduce dose ! Don’t just withdraw -> adrenal crisis

Endo
Surgery + replacement
Or
Cortisol suppression 
Fluconazole 
Mitotane
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33
Q

Name the 2 commonest cause of hypercalacaemia .

A

Primary hyperparathyroidism

Malignancy

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34
Q

What is SIADH

What does it result in?

A

Syndrome of inappropriate ADH secretion

  • excessive ADH secretion resulting in hyponatraemia ( due to water retention )

There is no hypovolaemia and no oedema

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35
Q

What findings would you expect in SIADH?

A

Hyponatraemia - plasma hypoosmolality

Concentrated urine - hyper osmolality

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36
Q

What das ADH do?

A

Inserts aqua poring causing water reabsorption

In response to hypotension or hyperosmolality in plasma

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37
Q

Define Hyponatraemia

What are symptoms ?

A 
< 135 mmol/l 
Asymptomatic 
Nausea vomiting = mild
Confusion ( neuro signs ) = moderate 
Seizures , coma = severe
38
Q

What are the causes of hyponatraemia ?

A 
Hypovolaemic
Urine sodium >20 
- diuretics 
- Diabetes mellitus ( osmotic diuresis )
- Addison's disease 
Urine sodium <20
-Vomiting 
-Diarrhoea 
-Fistula , Burns

Hypervolaemic
Nephrotic syndrome
Cardiac failure
renal failure

Euvolaemic
SIAD
Stress
Hypothyroidism

39
Q

What is the danger of sodium replacement in hyponatraemia ?

A

If too quickly

Central pontine myelinolysis

40
Q

Define hypernatraemia .

What is it always associated with?

A

> 145 mmol/l

Water loss

41
Q

Causes of hypernatraemia

A 
Hypovolaemic ( low sodium but greater water loss )
Diuretics
Sweating 
Burns
Diarrhoea
Fistula

Euvolaemic ( normal Saline but water loss )
Diabetes insipidus

Hypervolaemic ( increased total sodium )
Overuse of IV saline fluids

42
Q

How to correct hypernatraemia ?

A 
Hypovolaemic give Saline 
Euvolaemic give glucose 5%
Hypervolaemic give diuretics 
Not too quickly otherwise 
Cerebral oedema
43
Q

Define hypercalcaemia and name it’s 2 most common causes .

What’s the initial management ?

A

> 2.6 mmol/L

Primary hyperparathyroidism

Malignancy

Rehydration with saline

44
Q

How are calcium levels in the body regulated ?

A

Low calcium stimulates PTH ( from parathyroid gland ) which
Promotes ca reabsorbtion from kidney ( and phosphate excretion ) increased vitamin D production ( 1-alpha hydroxylase -> calcitriol )
And release from Ca from bones ( activation of osteoclasts )

45
Q

Define hypocalcaemia

And give 4 causes

A

< 2.0 mmol/L

VIt D deficiency 
Chronic renal failure 
Hypoparathyroidism 
Hyperphosphataemia 
Loop Diuretics  
Multiple transfusions
46
Q

What are symptoms of hypocalcaemia?

A 
Muscle spasm 
Tetany 
Carpopedal sign
Trousseu's sign ( spasm after inflation BP cuff )
Totsage de Point arrhythmia 
Abdominal cramps
Seizures
47
Q

Name the two most common causes for hypocalcaemia . How to differentiate between them ?

A

Hypoparathyroidism
(Low PTH)

Vitamin D deficiency - malabsorption , CKD

( high PTH )

48
Q

What causes Hypoparathyroidism ?

A

Post Op
Autoimmune
Congenital - Di-George -syndrome

Destruction by metastasis etc

49
Q

How do acute and chronic hypoparathyroidism present ?

A 
Acute : Signs of Hypocalcaemia 
Muscle spasm 
Tetany 
Carpopedal spasm 
Trousseu's sign 
Seizures 
Chvostek's sign

Chronic :
Extrapyramidal signs
Increased bone mineral density
Cataract

50
Q

In hypoparathyroidism , which blood results would you expect ?

A

Hypocalcaemia
Low PTH
Hyperphosphatameia

51
Q

Name the 3 types

Of hyperparathyroidism and it’s causes.

A

Primary
Adenoma of parathyroid gland

Secondary 
CKD
Malnutrition
Vit D deficiency 
Cholestasis

Tertiary
Longstanding secondary HPTH in CKD

52
Q

What is the main feature of primary hyperparathyroidism and it’s symptoms ?

A

Hypercalcaemia

Kidney stones
Bone pain
Abdominal pain 
Paeudohout 
Salt-and-pepper- skull 
Psychiatric disorders
53
Q

What happens in secondary hyperparathyroidism ?

A

Conditions lead to Hypocalcaemia resulting in excessive PTH production

Can lead to risk of fractures

54
Q

How to treat primary hyperparathyroidism ?

A

Surgery

Calcimimetics

55
Q

What is Paget’s disease ?

A

A disease of the bone with increased and uncontrolled bone turnover ( disease of osteoclasts )

56
Q

Which classical features are seen in Paget’s disease ?

A

Deformities
Bossy Skull
Bowing of tibia

Diffuse , increased bone density
Bone pain
Fractures - osteoporosis circumscripta

57
Q

How to treat Paget’s?

A

Bisphosphonate
Oral risedronate
IV zoledronate

58
Q

How to differentiate between primary and secondary hypothyroidism ?

A

Primary
TSh high, T3, 4 low

Secondary
TSH low, t3,t4 low

59
Q

What are possible causes of a goitre ?

A

Diffuse:
Graves , hashimoto , subacute viral, physiological

Nodular
Multinodular
Adenoma
Carcinoma

60
Q

Name 6 causes of hypothyroidism

A

Atrophic ( antithyroid antibodies causing atrophy and fibrosis but no goitre)

Hashimoto (goitre)

Postpartum thyroiditis (lymphocytic )
Iodine deficiency
Drug induced : amiodarine, Lithium
Post thyroidectomy and radioiodine treatment

61
Q

What effect does amiodarone have on thyroid hormones ?

A

Decrease conversation of T4 to T3

62
Q

Name 7 symptoms of hypothyroidism

A 
Lethargy 
Depression, low mood
Cold intolerance 
Constipation 
Bradycardia 
Loss of libido 
Impaired Menstruation
Weight gain 
Hair loss 
Hyporeflexia
63
Q

How would you investigate a patient with suspected thyroid disease?

A 
USS
Autoantibodies
Biopsy
Scintigraphy
Isotope scan in hyperthyroidism (hot and cold nodules )
64
Q

How to treat hypothyroidism ?

Side effects ?

A

Levothyroxine
0-100mcg , review after 3 months or when change or dose than yearly control

S/E
Hyperthyroidism
Reduced bone mineral density
AF

65
Q

What are rare complications of untreated hypothyroidism ?

A

Myoedemcoma
Hypothermia
Hypoventilation
Loss of consciousness

66
Q

How to differentiate between primary and secondary hyperthyroidism ?

A

Primary
High T3,T4, low TSH
Secondary high T3,T4, high TSH

67
Q

What are causes of hyperthyroidism?

A

Exogenous- l-thyroxin , iod, contrast media

Graves

Toxic multinodular goitre
Single toxic goitre 
Viral thyroiditis (de Quervain)
Drug induced : amiodarone 
Post Parfum thyroiditis
TSH pituitary adenoma 
Hashitoxicosis
Ectopic thyroid tissue (thyroid cancer ovarian teratoma) 
Marine Leihart syndrome
68
Q

Explain Graves’ disease and give its typical presentation.

A 
IgG antibodies stimulation TSH receptor , causing excess production and diffuse gland enlargement
Goitre
Exophthalmos + opthalmoplegia
Thyroid acropathy 
Pretibial myxoedema
69
Q

Give 7 symptoms of hyperthyroidism

A 
Weight loss 
Diarrhoea
Hyperreflexia 
Hair loss
Palpitations 
Tachycardia 
Tremor 
Anxiety 
Osteoporosis 
Sleep disturbance 
Sweating 
Moist warm skin
70
Q

What’s the treatment of hyperthyroidism ?

Give each S/E

A

Carbimazole
Thyroid antagonism
Block and replace or reduce by titration
20-40mg

S/E
Agranulocytosis
Infection, sore throats
Teratogenicity in pregnancy

PTU: propylthiouracil
S/E liver failure , expensive , used in pregnancy

Surgery
S/E laryngeal nerve palsy, parathyroid gland damage

Radioactive iodine
Takes 6-12 weeks - keep away from baby this time due to radiation

B-blocker like propanolol

71
Q

What’s a complication of hyperthyroidism?

A

Thyrotoxic crisis

Tachycardia , sweating, distress , delirium, mause vomiting

72
Q

Define hyperkalaemia

And give it’s causes

A

K > 5.0 mmol/L

Metabolic acidosis
Haemolysis
Massive blood transfusion
Excess K therapy

Renal failure
Ace inhibitors
Addisons
Amiloride & spironolactone ( k sparring diuretics )

73
Q

Symptoms and signs of hyperkalaemia

A

Fast irregular pulse , palpitations , tachycardia , light headed , chest pain

Asymptomatic

ECG changes 
Tall rented p waves 
Broad QRS
Small
P Waves 
Leading to Ventricular fibrillation and systole
74
Q

Treatment of hyperkalaemia

A 
Non urgent
Calcium resonium - oral 
Emergency 
1. Calcium chloride / gluconate 
2. IV Insulin+Glucose
3. Salbutamol 
4. Dialysis
75
Q

Define hypokalaemia

What are the causes ?

A

< 3.5

Prolonged fasting 
Insulin , salbutamol 
Diuretics : loop and thiazides 
Conns
Cushing's
Steroid use
Vomiting
Diarrhoea
76
Q

Symptoms and ECG changes of hypokalaemia ?

A

Weakness , lethargy, hypotonia, hyporeflexia, cramps, constipation

Flat T waves
U waves
Tachyarrhythmia eg torsade de pointes

77
Q

Explain the hypothalamus - pituitary axis .

A

Hypothalamus stimulates anterior pituitary via different hormones to release :
Growth hormone
ACTH -> cortisol, aldosterone and sex steroid release from adrenal gland
TSH - thyroid gland
FSH and LH - ovaries , cycle and oestrogen / Progesteron production
Prolactin - mammary glands milk production

Hypothalamus also stimulates posterior pituitary via nerves to release oxytocin and ADH

78
Q

What is Kallmans syndrome?

A

Isolated gonadotropin releasing hormone deficiency
+ ansomnia
+ colour blindness
Results in low fsh and lh

79
Q

What type of tumours are pituitary tumours ?

Between which types can you differentiate ?

A

Mostly benign adenomas

Chromophobe

  • nom secretory
  • prolactinomaa
  • ACTH release leading to Cushing’s
  • GH release leading to acromegaly

Acidophils
- can Release GH and Prolactin

Basophils
Only release ACTH
Don’t show local compression signs

80
Q

What are local compression signs of a pituitary adenoma ?

A

Headache
Bitemporal heminopia
CN palsy 3,4,6

81
Q

What is a craniopharyngioma?

A

A tumour in rathkes pouch ( btw pituitary and 3rs ventricle )
It’s the most common intracranial tumour in childhood
Presents with growth failure
Rare

82
Q

What is pituitary apoplexy?

A

Rapid pituitary enlargement due to bleed in tumour ,

Presents with rapid acute onset of neurolog. Signs

83
Q

What hormone levels would you suspect in hyperprolactaemia ?

A

High prolactin
Low FSH, LH
Low testosterone and oestrogen

84
Q

Causes of hyperprolactaemia

Including physiological causes

A

Prolactinoma
Craniopharyngioma
Pituitary adenomas compressing pituitary stalk

Dopamine antagonist- metoclopramid
Haloperidol
MDMA
Oestrogen

Physiological
Pregnancy
Breast feeding
Post orgasm
Stress
85
Q

Symptoms

Of hyperprolactaemia ?

A

Female
Infertility
Amenorrhea
Galactorrhea

Men
Erectile dysfunction  
Hair loss 
Galactorrhea
Both : loss of libido, osteoporosis
86
Q

Which test would you perform in a young female presenting with hyperprolactaemia ?

A

Pregnancy test

87
Q

How to treat a prolactinoma?

A

Bromocriptine

=dopamine agonist

88
Q

What is Sheehan syndrome ?

A

Hypopituitarism

After childbirth causes by post partum haemorrhage ( hypovolaemic shock ) -> ischaemia of anterior pituitary

89
Q

What is Acromegaly and what is it caused by?

A

Excess growth hormone and insulin like growth factor 1 due to pituitary adenoma

90
Q

How does acromegaly / gigantism present in adults and children?

A 
Children = gigantism 
Longitudinal growth -> 
Tall stature 
Long hand , feet fingers, toes 
Coarsening of face 
Adults = acromegaly 
Epiphyseal plate closed no change in stature 
Big hand and feet , enlarged nose , jaw 
Teeth spacing 
Painful joints
Cardiomyopathy

+ effects of tumour
Bitemporal hemianopia
Headache
CN palsy

91
Q

How to investigate a patient that complains of an increase in shoe , ring and glove size ?

A

Acromegaly
Measure IGF1
If high perform oral glucose tolerance test with GH
If growth hormone not suppressed - indicative for acromegaly

92
Q

A patient was diagnosed with acromegaly , what’s the treatment ?

A

Transphenoidal adenomectomy

GI (7 decks)

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