Endocrine disease (medicine) II Flashcards by Soph 1

What are endocrine gland?

ductless glands that usually release a product into the bloodstream for transport to body targets

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What are hormones?

Hormones are chemical signals produced by an
endocrine gland that
act at some distance from the gland

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What are targets?

Targets are organs, tissues or cells capable of responding to the hormone due to the presence of a receptor that binds the hormone

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What is the largest endocrine gland?

Thyroid gland

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What does the thyroid gland produce?

Produces hormones
– thyroxine (T4) and tri-iodothyronine (T3)
regulate basal metabolic rate
– calcitonin which has a role in regulating blood calcium levels

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Why is the thyroid gland a unique endocrine gland?

It stores large amounts of inactive hormone within extracellular follicles

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Surface anatomy of the thyroid gland?

Clasps anterior and lateral
surface of pharynx, larynx, oesophagus
and trachea “like a shield”
• Parathyroid glands usually lie
between posterior border of thyroid gland
and its sheath (usually 2 on each side of the thyroid)
• Internal jugular vein and common carotid artery lie
postero-lateral to thyroid

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What to measure regarding thyroid issues?

Free Thyroxine (T4)
Free Triiodothyronine (T3)
Thyroid Stimulating Hormone(TSH)

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Causes of hypothyroidism?

Primary failure of thyroid gland = decreased T3 and T4, Increased TSH
Goitre present

2ndry to hypothalamic or pituitary failure = low T3 and T4, low TSH and/or decreased TRH
No goitre

Dietary iodine deficiency = low T3 and T4, increased TSH, goitre present

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Clinical features of hypothyroidism relating to the thyroid gland’s hormones?

weight gain
 lethargy
 increased sleep
 constipation
 cold intolerance
 dry skin
 hair loss
 menorrhagia
 deafness
 muscle weakness
 facial puffiness
 periorbital oedema
 bradycardia
 hoarseness
 delayed reflexes

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Causes of hypothyroidism?

Primary
 Dyshormonogenesis
 Iodine Deficiency
 Autoimmunity
 Post Radioactive Iodine
 Post Thyroidectomy
 Iodine Excess

2ndry and tertiary:
 Pituitary Tumours
 Pituitary Granulomas
 Empty Sella
 Isolated TRH deficiency
 Hypothalamic disorders

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Indications for thyroid screening?

Congenital hypothyroidism
Tx of hyperthyroidism
Neck irradiation
Pituitary surgery/irradiation

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Investigations and management of thyroid issues?

Thyroid function tests, thyroid antibodies

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Dental complications in hypothyroidism?

Delayed eruption
 Enamel hypoplasia
 Macroglossia (large tongue)
 Micrognathia (undersized jaw)
 Thick lips
 Dysgeusia (disruption of taste)

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Causes of hyperthyroidism relating to the hormones?

Abnormal thyroid stimulating immunoglobulin
(eg. Grave’s disease) = High T3 and T4, low TSH, goitre present

2ndry to excess hypothalamic or pituitary secretion = increased T3 and T4, TSH and/or TRH, goitre present

Hypersecreting thyroid tumour = increased T3 and T4, low TSH, no goitre

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Causes of hyperthyroidism?

 Autoimmune thyroid
disease
o Graves Disease
o Postpartum thyroiditis
 Toxic nodular goitre
 Toxic adenoma

Rare:

Amiodarone induced
hCG hyperthyroidism

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Clinical features of hyperthyroidism?

 Weight loss
 Heat intolerance
 Anxiety, irritability
 Increased sweating
 Increased appetite
 Palpitations
 Loose bowels
 Goitre
 Tremor
 Warm moist skin
 Tachycardia
 Eye signs
 Thyroid bruit
 Muscle weakness
 Atrial fibrillation

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Diagnosis of graves disease - clinical features?

 Diffuse goitre
 Eye signs
 Pretibial myxoedema
 Vitiligo and features of
other autoimmune
disease
 FH of autoimmune
thyroid disease

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Graves disease investigations

 TSH receptor Abs
 TPO Abs
 Thyroglobulin Abs
 Thyroid Radioisotope
scan

Tx of graves disease?

 Medical
Drug side effects e.g. nausea, vomiting,
leucopenia leading to agranulocytosis,
aplastic anaemia, drug fever, cholestatic
jaundice
 Surgical
 Radioactive iodine

Dental complications of hyperthyroidism?

 Accelerated dental eruption
 Maxillary or mandibular osteoporosis
 Increased susceptibility to caries
 Periodontal disease
 Increased sensitivity to epinephrine which may
result in arrhythmias or palpitations
 Surgery, oral infection and stress may
precipitate thyroid crises

Why refer someone regarding their thyroid nodules?

 New onset
 Increase in size
 Onset of pain
 Associated speech disturbance
 Lymphadenopathy
 Patient / Doctor concern

Pituitary dysfunction investigations?

How do pituitary dysfunctions present?

Hormonal tests
• If hormonal tests
abnormal or tumour
mass effects perform
MRI pituitary

Present as tumour mass effects, hormone excess and hormone deficiency

Causes of hypopituitarism?

 Pituitary tumours
 Radiotherapy
 Trauma
 Infarction
 Infiltration e.g. sarcoidosis, haemochromatosis
 Infection e.g. tuberculosis, syphilis
 Sheehan’s syndrome (post partum pituitary
necrosis)

What is acromegaly?

Excessive GH secretion with high IGF-1 levels

Clinical features of acromegaly?

``` Head related:  Coarse facial features  Enlargement of supraorbital ridges  Separation of teeth  Prognathism (class III skeletal)  Macroglossia ``` ``` Other features:  Headaches  Spade-like hands  Joint pains  Excess sweating  Hypertension  Impaired glucose tolerance ```

Investigations of acromegaly?

IGF1, dynamic tests, MRI pituitary

Tx of acromegaly?

``` Surgical resection – TSS, TFS - biochemical control  Somatostatin analogues  Pegvisomant reduces IGF-1 to levels > 90%  Radiotherapy in unsuccessful surgery ```

Dental complications of acromegaly?

```  Jaw Malocclusion  Difficulty in speech due to macroglossia  Teeth mobility  Missing teeth  Teeth separation  Thickening of alveolar processes  Enlarged posterior roots  In 50% upper airways obstruction caused by pharyngeal hypertrophy and macroglossia with obstructive sleep apnoea. ```

Presentation of local mass effects?

Headaches, visual field defects, cranial nerve palsy and temporal lobe epilepsy

What does a lack of GH result in?

Short Abnormal body composition Poor QoL Rx: GH

Lack of LH/FSH results in?

Hypogonadism Reduced sperm count Infertility Menstruation Rx: testosterone (males), progesterone and oestradiol in females

Lack of TSH results in?

Hypothyroidism | Rx: levothyroxine

Lack of ACTH results in?

Adrenal failure Reduced pigment Rx: hydrocortisone

Lack of ADH results in?

Diabetes insipidus Decreased water absorption in kidney = polyuria, polydipsia Rx: DDAVP

Adrenal disorders - what causes excess glucocorticoids (cushing's syndrome)?

Pituitary tumor 70-80% Adrenal tumor 10-20% Ectopic ACTH tumor 10% Iatrogenic

Clinical features of cushing's syndrome? (excessive cortisol - adrenal gland)

``` Weight gain Moon face Acne Bruising Osteopenia Glucose intolerance Hyperpigmentation ```

Investigations of cushing's syndrome?

``` Hormonal tests (dynamic suppression tests, measuring cortisol, ACTH) Radiological if hormonal tests abnormal = MRI pituitary, CT adrenals, CT chest ```

Tx of cushing's?

Surgery Drugs Consider radiotherapy for pituitary disease if surgery fails

Causes of adrenal insufficiency?

``` Primary:  Autoimmune  Tuberculosis  Fungal infections  Adrenal hemorrhage  Congenital adrenal hypoplasia  Sarcoidosis  Amyloidosis  Metastatic neoplasia ``` ``` 2ndry: After exogenous glucocorticoids  After treatment of Cushing’s  Hypothalamic or pituitary tumours ```

Clinical features of adrenal insufficiency?

Weakness Skin and mucous membrane pigmentation (darker gingival margin) Loss of weight, emaciation, anorexia, vomiting, diarrhea Hypotension Salt craving Hypoglycemic episodes

Investigations of adrenal insufficiency?

Hormonal tests - dynamic stimulation tests measuring cortisol, ACTH, adrenal antibodies Radiological if abnormal hormonal tests: - MRI pituitary - CT or MRI adrenals

Tx of adrenal insufficiency?

Hydrocortisone replacement tx

Glucocorticoid cover for dental procedures?

```  On treatment therapy e.g asthma, rheumatoid arthritis ◦ Prednisolone > 7.5mg ◦ Hydrocortisone > 30mg ◦ Dexamethasone > 0.75mg  On replacement therapy ◦ Addison’s e.g. Hydrocortisone 20/10mg ◦ ACTH deficiency 10/5/5mg ``` Simple Procedures: double dose one hour before surgery, double dose oral medication for 24 hours Major Procedures/GA: hydrocortisone 100mg im at induction and double dose oral medication for 24 hours

Endocrine causes of hypertension?

* Primary aldosteronism * Phaeochromocytoma * Acromegaly * Cushing’s syndrome * Hypothyroidism * Hyperthyroidism

How to manage hyperthyroidism, Phaeochromocytoma, Cushing’s?

Hyperthyroidism – render euthyroid • Phaeochromocytoma – treat before any surgery • Cushing’s – avoid infections and pathological fractures; steroid cover Refer to endocrinologist