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endocrine pathology Flashcards

1
Q

What is the main cause of acromegaly?

A

Increased secretion of GH from a pituitary adenoma (99%)

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2
Q

What is the male:female ratio of acromegaly and what is the UK incidence?

A

M:F

3 per million people/year

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3
Q

What are the symptoms of acromegaly?

A

low libido, headaches, pins and needles in extremities, joint pain, shoes no longer fit

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4
Q

What are the signs of acromegaly?

A

widely spaced teeth, macroglossia, prominent supraorbital ridge, massive growth of hands, feet and jaw

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5
Q

What are the complications of acromegaly?

A

impaired glucose tolerance and DM
Hypertension
Left ventricular hypertrophy
Increased risk of IHD, stroke and colon cancer

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6
Q

What are the diagnostic tests used to confirm acromegaly?

A

Oral glucose test - high glucose suppresses GH secretion. If the lowest GH recording is still above 1 microgram/litre = acromegaly

MRI scan of pituitary fossa
Look at old photos of patient
Visual fields and acuity examinations

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7
Q

What is the treatment for acromegaly?

A

Prevent tumour compression by excising the lesion
Reduce GH and IGF-1 by 1st line treatment = trans-sphenoidal surgery
somatostatin analogues = octreotide
GH antagonists = Pegvisomant

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8
Q

What is Cushing’s disease and syndrome

A 
Increased glucocorticoid (cortisol) levels in the blood. 
chief cause = long term steroid use
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9
Q

What is Cushing’s disease caused by

A

Bilateral adrenal hyperplasia from an ACTH-secreting pituitary adenoma

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10
Q

What are the other causes of Cushing’s syndrome?

A

Ectopic ACTH production - small lung cancers and carcinoid tumours. Leads to pigmentation, weight loss, hyperglycaemia and hypokalemic metabolic alkalosis. Dexamethasone fails to suppress cortisol.

ACTH-independent causes (decreased ACTH due to negative feedback). Iatrogenic, adrenal adenoma. dexamethasone won’t suppress cortisol.

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11
Q

What are the symptoms of Cushing’s syndrome?

A

mood change, muscle weakness, weight gain, acne

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12
Q

What are the signs of Cushing’s syndrome?

A

Central obesity, moon face, buffalo hump, purple abdominal striae, osteoporosis

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13
Q

What are the diagnostic tests used to confirm Cushing’s disease and syndrome?

A

Measure free cortisol in 24hr urine test
overnight dexamethasone suppression test - dexamethasone suppresses ACTH production. if Cushing’s syndrome, there is no suppression
Check ACTH plasma levels - low=adrenal adenoma/carcinoma. high=Cushing’s disease –> inject dexamethasone to confirm
MRI scan of pituitary gland
CT scan of adrenal glands.

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14
Q

What is the treatment of Cushing’s disease and syndrome?

A

Treatment depends on cause
Iatrogenic = stop medications if possible
Cushing’s disease = surgical excision of pituitary tumour
Adrenal steroid inhibitors = metyrapone
Adrenal carcinoma –> radiotherapy

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15
Q

What is Conn’s syndrome and hyperaldosteronism?

pathophysiology

A

Excess production of aldosterone independent of the RAAS
Decreased potassium, increased sodium, increased BP
Aldosterone binds to receptors on the DCT of the nephron:
- stimulates sodium/potassium pumps on principle cells = more sodium in blood and more potassium in urine
- stimulates ATPase pump in alpha-intercalated cells = acidifies urine

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16
Q

What are the causes of primary hyperaldosteronism?

A

Conn’s syndrome = aldosterone-producing adenoma

Bilateral adrenocortical hyperplasia

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17
Q

What is the cause of secondary hyperaldosteronism?

A

Excess aldosterone production in response to high levels of renin

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18
Q

What are the symptoms of hyperaldosteronism?

A

Hypokalaemic signs - constipation, heart rhythm changes, muscle weakness, cramps
Headaches

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19
Q

What are the signs of hyperaldosteronism?

A

Hypertension
Hypernatremia
Metabolic alkalosis

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20
Q

What are the diagnostic tests used to confirm hyperaldosteronism?

A

U&E tests

Measure renin and aldosterone levels:

  • low renin + high aldosterone = primary cause
  • high renin + high aldosterone = secondary cause
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21
Q

How is hyperaldosteronism treated?

A

Conn’s syndrome = laparoscopic adrenalectomy, give spironolactone pre-operatively - potassium sparing diuretic. competitively binds to aldosterone receptors on principle cells and alpha intercalated cells of the DCT.

adrenal carcinoma = surgery

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22
Q

What is the epidemiology of Addison’s disease?

A

rare - 0.8/100,000

destruction of the adrenal cortex leads to cortisol and mineralocorticoid deficiency

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23
Q

what are the causes of Addison’s disease?

A

80% = autoimmune
TB, adrenal metastases, lymphoma, opportunistic infections in HIV

primary adrenal insufficiency = Addison’s disease
secondary adrenal insufficiency cause = iatrogenic - long term steroid use

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24
Q

What are the signs and symptoms of Addison’s disease?

A

lean, tanned, tired, anorexia, weakness, dizziness, nausea/vomiting
pigmented palmar creases and buccal mucosa
postural hypotension

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25
What is the differential diagnosis of Addison's disease?
viral infection or anorexia nervosa (potassium levels are decreased in anorexia but increased in Addison's disease)
26
Diagnostic tests and results in Addion's disease
decreased sodium and increased potassium levels - due to decreased mineralocorticoid decreased glucose levels - due to decreased cortisol Short ACTH stimulation test 21-hydroxylase adrenal autoantibodies are positive in autoimmune disease
27
What is the treatment of Addison's disease?
replace steroids - hydrocortisone | mineralocorticoids to correct postural hypotension - fludrocortisone
28
What do beta cells produce?
insulin - decreases blood glucose levels
29
what do alpha cells produce?
glucagon - increases blood glucose levels
30
3 microvascular problems of hyperglycaemia?
retinopathy, neuropathy, nephropathy
31
3 macrovascular problems of hyperglycaemia
stoke, heart disease, limb ischaemia
32
WHO criteria - diagnosis of DM
symptoms of hyperglycemia = polyuria, polydipsia, unexplained weight loss, visual blurring raised venous glucose - fasting>7, random>11 HbA1c>48mmol/l (6.5%)
33
Clinical presentations of DM
acute presentation = young person with short history of thirst, polyuria and unexplained weight loss subacute presentation = older patients with same symptoms but less marked over time retinopathy type 1 DM = presenting with thirt, polyuria, weight loss type 2 DM = complications generally seen
34
Type 1 DM cause
autoimmune destruction of beta cells by CD4 and CD8 T-lymphocytes usually adolescent onset patient must be given insulin prone to ketoacidosis and weight loss
35
Treatment of T1DM
insulin, patient education
36
Type 2 DM cause
strongly related to obesity and insulin resistance - initially the pancreas compensates for insulin resistance by increasing insulin secretion (hypertrophy and hyperplasia) - eventually beta cells suffer secretory exhaustion (atrophy) - insulin levels fall High prevalence in Asians, elderly and men onset is usually >40 years stronger genetic influence than type 1 - twin studies
37
What are the other causes of DM?
drugs, pancreatic issues, Cushing's disease, acromegaly, pregnancy
38
3 risk factors for type 2 DM
pregnancy, central adiposity, asian background, overweight/obese, >40 years of age, family history
39
Diagnostic tests for DM
fasting blood glucose = >7mmol/l | random blood glucose = >11mmol/l
40
Treatment of type 2 DM
first line = exercise and healthy diet metformin - increases insulin sensitivity sulfonylurea - increases insulin secretion = gliclazide
41
What are the complications of diabetes?
- infection at injection sites - MI, stroke - give statins - neuropathy - use an ACE inhibitor - diabetic retinopathy - cataracts - diabetic foot - BM of capillaries thickens --> hypoxia
42
What is the diagnostic test for hypoglycemia?
>3mmol/l
43
What are the symptoms of hypoglycaemia?
Autonomic - sweating, anxiety, palpitations | Neuroglycaemic - confusion, drowsiness, seizures
44
Causes of hypoglycaemia
insulin or SU treatment in diabetics Non-diabetes = EXPLAIN acronym - exogenous drugs, liver disease, addison's disease
45
Who are typically at risk of a hyperosmolar hyperglycaemic state?
type 2 diabetics | >30mmol/l
46
Treatment of hyperosmolar hyperglycaemic state
rehydrate slowly with IV saline | replace potassium when urine starts to flow
47
What happens in diabetic ketoacidosis?
there is high plasma glucose but a lack of insulin causes a starvation-like state
48
Signs and symptoms of diabetic ketoacidosis
gradual drowsiness, vomiting and dehydration | pear drop smell on breath
49
What can cause diabetic ketoacidosis?
infection, surgery, MI, wrong inslulin dose
50
What are the diagnostic tests for diabetic ketoacidosis?
acidaemia (pH<7.3) hyperglycaemia ketonemia ECG, chest X-ray urine dipstick
51
What is present in severe DKA?
pH<7.1 | blood ketones >6mmol/l
52
Complications of DKA
cerebral oedema, hypokalemia, thromboembolism
53
Treatment of DKA
give fluids, insulin IV infusion, potassium replacement
54
What is hyperkalemia?
plasma potassium >6.5mmol/l | causes myocardial hyperexcitability --> ventricular fibrillation and cardiac arrest
55
Causes of hyperkalemia?
insulin deficiency, potassium sparring diuretics, Addison's disease, ACEi
56
Signs and symptoms of hyperkalemia
chest pain, weakness, small P waves on ECG, light headedness
57
Treatment of hyperkalemia
non-urgent - treat underlying cause - polystyrene sulfonate resin - prevents K+ absorption in gut Urgent treatment - IV calcium gluconate - prevents damage to heart - IV actrapid (insulin) - drives K+ into cells
58
What is hypokalemia?
K+<2.5mmol/l
59
Causes of hypokalemia
diuretics, vomiting, diarrhoea, Cushing's, Conn's syndrome
60
Signs and symptoms of hypokalemia
muscle weakness, hypotonia, hyporeflexia, cramps constipation, small inverted T waves on ECG
61
Treatment of hypokalemia
mild hypokalemia = oral potassium supplement | severe hypokalemia = IV potassium
62
What is hyperthyroidism/thyrotoxicosis?
Excess thyroid hormone
63
Causes of hyperthyroidism
``` Graves' disease Toxic adenoma Toxic multinodular goitre Ectopic thyroid issue Exogenous - iodine excess ``` Secondary cause = TSH-secreting adenoma in anterior pituitary gland
64
Symtoms of hyperthyroidism
Diarrhoea, weight loss, increased appetite, overactivity, tremor
65
Signs of hyperthyroidism
fast/irregular pulse, warm skin, fine tremor, palmar erythema, thin hair, eyes wide open
66
Diagnostic tests in hyperthyroidism
- Measure blood levels of TSH, T3 and T4 - check for thyroid autoantibodies - isotope scan
67
Treatment of hyperthyroidism
Drugs - Beta blockers - propranolol - treats immediate symptoms - Anti-thyroid medication - carbimazole - blocks thyroid hormone production and release Radioiodine Thyroidectomy
68
Complications of hyperthyroidism
Heart failure, angina, AF, osteoporosis
69
What is the cause of Graves' disease?
Autoimmune condition. Circulating IgG autoantibodies bind to and activate G-protein-coupled thyrotropin receptors This causes smooth thyroid enlargement and increased hormone production
70
Epidemiology of Graves' disease
0.5% prevalence F:M = 9:1 Typical age = 40-60 years
71
Graves' disease triggers
stress, infection, pregnancy | associated with other autoimmune conditions=vitiligo, T1DM, Addison's disease
72
Graves' specific signs
proptosis (bulging of eyeballs), pretibial myxoedema, thyroid acropachy
73
Treatment of Graves' disease
propanol to relieve symptoms | carbimazole and thyroxine for 12-18 months
74
What is hypothyroidism?
lack of thyroid hormone
75
Epidemiology of hypothyroidism
4/1000/year F:M = 6:1 women approximately 40-60 years
76
Causes of hypothyroidism
- primary atrophic hypothyroidism - common. Diffuse lymphatic infiltration of the thyroid gland --> atrophy, no goitre - Hashimoto's thyroiditis - autoimmune inflammation of the thyroid. Anti-TPO antibodies and antithyroglobulin antibodies. commoner in older women. - iodine deficiency - post-thyroidectomy/radioiodine treatment - drug induced - lithium inhibits thyroid hormone - subacute thyroiditis - temporary hypothyroidism after hyperthyroidism phase
77
what is secondary hypothyroidism?
when the pituitary gland doesn't produce enough TSH
78
What is hypothyroidism associated with?
T1DM, pernicious anaemia, Addison's
79
Symptoms of hypothyroidism
tiredness, lethargy, cold intolerance, weight gain, constipation, weakness
80
Signs of hypothyroidism
puffy face, dry thin hair, bradycardic, cold hands, defeated demeanour
81
Diagnostic tests for hypothyroidism
- TSH, T3 and T4 plasma levels - cholesterol/triglyceride raised - macrocytosis
82
Treatment of hypothyroidism
Replace thyroid hormone - oral levothyroxine (T4)
83
What does the parathyroid gland secrete?
Parathyroid hormone in response to low plasma calcium. secreted by chief cells.
84
What are the effects of parathyroid hormone?
- increased osteoclast activity - more calcium and phosphate - increased calcium reabsorption in kidneys - decreased phosphate reabsorption in kidneys - increases active 1,25-dihydroxyvitamin D production Overall effect = increases calcium, decreases phosphate
85
Causes of primary hyperparathyroidism
solitary adenoma - 80% | hyperplasia - 20%
86
Presentation of primary hyperparathyroidism
increased calcium - renal stones, abdominal pain, constipation, weakness, Asymptomatic PTH effects - pain, fractures, osteoporosis Raised BP
87
Tests for primary hyperparathyroidism
raised calcium, raised PTH, phosphate decreased (unless renal failure) DEXA for osteoporosis
88
Treatment of primary hyperparathyroidism
increase fluid intake to prevent stones | excision of adenoma
89
What is secondary hyperparathyroidism?
High PTH, low/normal calcium
90
Secondary hyperparathyroidism causes
Vit D deficiency | chronic renal failure
91
Treatment of secondary hyperparathyroidism
Treat underlying cause Phosphate binders Vitamin D supplements Cinacalcet - reduces PTH production
92
When does tertiary hyperparathyroidism occur?
occurs after secondary hyperparathyroidism --> hyperplasia of parathyroid gland. It is seen in chronic renal failure
93
What are the levels of calcium and PTH in tertiary hyperparathyroidism?
High calcium | Massively raised PTH
94
Treatment of hyperparathyroidism
Parathyroidectomy
95
What is primary hypoparathyroidism?
PTH decreased due to parathyroid gland failure.
96
Causes of hypoparathyroidism
autoimmune or congenital
97
Tests for primary hypoparathyroidism
low calcium, low/normal phosphate
98
Signs of primary hypoparathyroidism
hypocalcemic signs - cramps, spasms, seizures, slow heartbeat, numbness/tingling of hands, feet and lips
99
Treatment of primary hypoparathyroidism
calcium supplements | calcitriol - vitamin D analogue
100
Secondary hypoparathyroidism
Radiation, surgery, hypomagnesaemia

Hamzah's endocrine pathology (3 decks)

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