endocrine and metabolic Flashcards
discuss obesity
one of the most common preventable diseases
1/3 of adults (US) and 17% of adolecents.
100bili to us economy.
500mili adults worldwide.
genetic, psyc, endocrine issues lead to obesity
leptin- resisted in obese people.
FTO gene also inc risk
classified as a BMI of over 30
hip to waste or waste circumferance is possibly better.
discuss the endocrine secretions of adipose tissue
secrete adipokines + free fatty acids
these cause systemic inflammation
causing insulin resistance, which increaces obesity.
lean individuals secrete anti inflam stuff
obese secrete pro inflam- TNF etc etc.
can also peripherally aromatise leading to increaced levels of oestrogen- linked to breast cancer.
management of obesity
should include dietary modification,
behaviour interventions
medications
and if needed surgical intervention.
medications- orlistat, semaglutide, phentermine, naltrexone.
Surgial indications- greater than 40bmi or 35 with severe comorbid stuff
should be compliant with post surgical lifestyle changes,
common procedures- roux en y
gastric banding
sleeve gastrectomy
hypothyrodism types and causes (primary)
primary(more common)- atrophic- T cell mediated autoreactive cytotoxicity of follicular cells. - blockage of TSH receptors.
congenital- ?iodine deficiency in pregnant mothers.
autoimmune- hashimotos- autoantibodies to the enzyme thyroid peroxidase- unable to convert iodine to iodide - meanint T3/4 cant be made.
iodine deficiency- common in the alps, hiamallayas, south america and central africa. - goitres normally presant.
radioiodine for hyperthyroidism treatment- doesnt recover after being blasted.
types of secondary hypothyroidism
space occupying pituitary tuour- insufficient TSH produced.
myxoedema coma- long standing untreated hypo- precipitated by something- get hypotheramia, hyponatraemia, glycaemia, tension, bradycardia
thyroiditis- inflammation from a virus causes it to be leaky- get high T3 then low T3 as it runs out.
signs and symptoms of hypothyroidism
S+S: fatigue, cold inolerance, weight gain, brady, constipation, puffy eyes, dry skin, brittle hair, loss of eyebrows, depression.
Ix: Thyroid function tests- TSH- if high + low T4 level- primary hypothrdoidism
High TSH + normal T4- subclinical hypo or sick euthyroid syndrome
Normal/ low TSH + Low T4- 2’ hypothryoidism.
Rx:
oral T4 levothyroixine 1.6mcg/kg.
risk factors for hypothyroidism
iodine deficiency, female, middle age, family history, autoimmune disorder, prev thyroid treatment, turner/ down syndrome, head + neck radiotherapy, amiodarone use, lithium use.
what is thyrotoxicosis - list the top 3 causes. what is the pathophysiology of its damage causing element.
the state of elevated thyroid levelvs in the body. - from any cause
common causes- Graves
Toxic multinodular goiter
toxic adenoma
incidence peaks 20-50 years.
patho:
increaced metabolic activity due to T3/4. upregulation of alpha receptors –> inc sympathetic activity. inc HR + contractility. dec systemic vascular resistance. —> chronic activation of RAAS –> heart faliure.
risk factors and investigation of thyrotoxicosis/ hyperthyroidism
RF: female
other autoimmune diseases
family history
smoking
low idoine intake
history:
wt loss, heat intolerance, palpitations, tremour, anxiety, alopecia + fatigue.
Ix:
TSH if low–> T3/4 should be measured. (overt hyperthyroidism) if T3/4 are high.
subclinical if T3/4 are normal but low TSH.
repeat after 3 months.
if suspecting graves- check for TSH receptor antibodies.
imaging:
ultrasound with doppler
radioiodine uptake (general in graves, hot spots in TMNH)
management of thyrotoxicosis / hyperthyroidism
urgent refferal to endocrinologist if: pituitary or hypothalamic disorder is suspected.
consider a B blocker –> tacy, anxiety, palpitations.
carbimazole 1st/ propylthiouracil 2nd - decrease synth by out competing TPO.
OR
radioactive iodine treatment- damage thyroid- replace with T4
1st line for graves + TMNH
Or surgery- for recurrent/ if goitre massive/ not tolerating other treatment.
discuss thyroid storm
an acute- life threatening condition.
precipitated by- illness, sugery to thyroid, abrutly stopping meds- something has to start it.
more common in graves, TMNG
related to the relative increace in levels rather than absolute levels.
S+S: intense inc in metabolic requirements, inc HR, this can induce heart faliure + arrythmias.
additionally- seziures, delerium coma.
evaluation of thyroid storm + management
if Fever
tacy
CNS manifestation
CHF signs (edema, cardiogenic shock)
some GI symptoms
with confirmed or suspected hyper thyroid can start treatment
Rx:
supportive- fluids, warming/ cooling,
beta blockers for tacy,
reduc thyroid levels- inhib synth, recycling or stop release.
prognosis: most patient improve with treatment, but can be fatal
clinical summary of thyroid cancer
most commonly presents as a asymptomatic nodule detected by palpation
RF: 30s-40s
female
family history
head+neck radiation
many types of thyroid cancer, associated with BRAF or RAS Or TP53.
Ix: TSH level- usually normal.
ultrasound
fine-needle aspiration.
Rx:
surgery is generally therapy of choice. +/- chaemo.
discuss thyroid eye disease
most commonly caused by graves, less commonly hasmimotos.
lid retraction, lag, erythema, exophthalmos, corneal ulceration.
16/100 000 women.
ciggie smoking inc x7.7
autoantibodies bind to myocites, these can turn into adipocites and become inflamed + fibrosed. - causes enlargement which compresses veins/ nerves. - causing proptosis.—> leading to ulceration and damage.
diagnosed clinically. MRI to image.
Rx:
regulate thyroid levels, lubricate eye.
steroids if severe.
new drug- teptotumumab-trbw - binds to igf-1b.
classification system for graves eye disease
NOSPECS
no symptoms
only signs (lid retraction)
soft tissue involvement (oedema)
proptosis
extraocular
corneal involvement
sight loss.
