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ENDOCRINE - Pituitary conditions Flashcards

1
Q

What is prolactin under tonic inhibition by?

A

Dopamine

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2
Q

What hormones are produced by the posterior pituitary?

A

ADH

Oxytocin

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3
Q

What is a pituitary adenoma?

A

Benign tumour of glandular tissue

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4
Q

Which syndrome are pituitary adenomas associated with

A

MEN I/IIa

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5
Q

Def microadenoma

A

<1cm

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6
Q

Def macroadenoma

A

> 1cm

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7
Q

What is the difference between functioning and non-functioning pituitary adenomas?

A

Functioning - secretory

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8
Q

PS: non-functioning pituitary adenoma (5)

A 
Bitemporal hemianopia 
Ocular palsies 
Hypopituitarism 
Signs raised ICP e.g. headache
Hypothalamic compression Sx
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9
Q

E.g.s of hypothalamic compression Sx (3)

A

Altered appetite
Thirst
Sleep/wake cycle

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10
Q

PS: functioning pituitary adenoma

A

Acromegaly
Hyperprolactinaemia
Cushings

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11
Q

Which hormones are rarely secreted from pituitary adenomas?

A

TSH
FSH
LH

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12
Q

PS hyperprolactinaemia (5)

A 
Galactorrhoea 
Oligo/amenorrhoea 
Decreased libido 
Subfertility in M/ ereticle dysfunction 
Arrested puberty - younger pt
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13
Q

LT consequence hyperprolactinaemia

A

Osteoporosis

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14
Q

Causes hyperprolactinaemia

A

Prolactinoma
Breast stimulation/stress
Dx induced
Idiopathic

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15
Q

How is prolactinoma diagnosed?

A

Pituitary MRI

Following raised serum prolactin

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16
Q

Tx hyperprolactinaemia

A

DA agonists - ropinirole/bromocriptine

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17
Q

SE Ropinirole/bromocriptine (4)

A

N+V
Dizzy
Syncope
Fibrosis

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18
Q

What must be monitored on Ropinirole/bromocriptine

A

Echo due to fibrosis

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19
Q

XS GH in children –>

A

Gigantism

If prior to epiphyseal plate closure

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20
Q

XS GH in adults –>

A

Acromegaly

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21
Q

What is acromegaly almost always due to?

A

Pituitary tumour

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22
Q

Rarer causes acromegaly

A

Paraneoplastic - non- pituitary tumours

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23
Q

diagnosis acromegaly (2)

A

Raised IGF-1

GTT - normally suppresses GH secretion. Acromegaly - [ ] = 2mcg/ml at 2hrs

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24
Q

What does IGF-1 represent

A

GH levels over 24hrs

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25
Q

Sx acromegaly (9)

A 
Change in appearance 
Increased hand/foot size 
Tired
XS sweating 
Loss libido 
Sx DM
Headaches
Visual deterioration 
Sx hypopituitarism
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26
Q

Signs acromegaly (9)

A 
Protruding mandible 
Prominent supraorbital ridge 
Interdental separation 
Large tongues 
Spade-llike hands/feet 
Tight rings 
VF defects 
HTN
Hypopituitarism
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27
Q

Mx acromegaly

A

Somatostatin analogues to shrink tumour

Transphenoidal surgery

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28
Q

What is Cushing’s syndrome due to

A

Increased levels of glucocorticoid

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29
Q

Most common cause Cushings syndrome

A

Exogenous administration of steroids

Or XS endogenous secretions ACTH

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30
Q

ACTH dependent causes Cushings (2)

A

Cushings disease

Ectopic ACTH - non-pituitary ACTH secreting tumour

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31
Q

ACTH independent causes Cushings (2)

A

XS adrenal cortisol production - e.g. b.c adrenal tumour

Steroids

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32
Q

What is Cushings disease

A

Increased ACTH from the pituitary gland

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33
Q

Sx Cushings (= MOON FACE)

A 
Menstrual changes 
Obesity (central) + striae 
Osteoporosis 
Neurosis/depression 
Facial plethora 
Altered mm (proximal myopathy) 
Calor skin 
Elevated BP (HTN)
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34
Q

What electrolyte disturbance may occur in Cushings (+ why)

A

Hypokalaemia

B/c of mineralcorticoid activity of cortisol

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35
Q

Diagnosis Cushings (3 tests)

A

1) Confirm raised cortisol w/ overnight dexamethasone suppression test
2) DDx ACTH indepedent + dependent causes - 9am + midnight plasma ACTH ((+ cortisol) levels
3) Which type of ACTH dependent is it? Low + high dose dexamethasone suppression test

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36
Q

Details of Overnight dexamethasone suppression test

A

Out pt
1mg PO dexamethasone given at night
Serum cortisol checked before + at 8am
Norm: -ve feedback –> cortisol levels decrease
Cushings: failure to suppress cortisol secretion

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37
Q

Details of 9am and midnight plasma ACTH (+cortisol) levels

A

If ACTH depressed/undetecable = adrenal cause likely

If ACTH is detectable = either pituitary or ectopic source

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38
Q

Details of low + high dose dexamethasone suppression test

A

Dexamethasone 2mg/6hr PO for 2d
Measure plasma + urinary cortisol 0 +48hrs
Complete/partial suppression = Cushings disease
No suppression = ectopic source

39
Q

Mx Cushings disease

A

Transphenoidal surgery

40
Q

Def hypopituritism

A

Defective production of all pituitary hormones

41
Q

PS hypopituritism

A 
Fatigue
Myaglia 
HoTN 
Diabetes insipidis 
Hypothyroidism
42
Q

Pituitary causes of hypopituirism (3)

A

Obliteration - 1’/mets tumour
Surgical removal/irradiation
Ischaemic necrosis b/c HoTN shock

43
Q

hypothalamic causes of hypopituiritism (4)

A

1’ brain tumour = cranipharyngoma
Infarction
Sarcoid
Infection

44
Q

Diagnosis hypopituritism

A

Pituitary hormones all low
Effector gland hormones = low
Low response to suppression tests
Imaging (to localise the pathology)

45
Q

What is posterior pituitary disease usually a result of

A

Damage to hypothalamus (tumour invasion/infarction)

46
Q

Failure of ADH prod –>

A

Diabetes insipidis

47
Q

XS ADH production –>

48
Q

What is a pheochromocytoma

A

Catecholamine secreting tumour arising from sympathetic paraganglion cells (chromaffin cells)

49
Q

What familial conditions are 10% of pheochromocytoma associated with?

A

Men 2a/b
NFM
Von Hippel-Lindau syndrome

50
Q

PS pheochromocytoma

A 
Severe HTN unresponsive to medical Sx 
Sweating / heat intolerance 
Visual disturbances/headaches 
Seizures 
Palpitation
Chest tightness
Dyspnoea 
Postural hotn 
Abdo pain 
N+ C
51
Q

What makes pt with pheochromocytoma Sx worse?

A

Stress
Exercise
Drugs

52
Q

Which drugs must NOT be given alone to pt w/ pheochromocytoma

A

B-blockers

due to LF HTN episodes

53
Q

Diagnosispheochromocytoma

A

3x24h urine - raised free metadrenaline + normadrenaline

CT/MRI - locate tumour

54
Q

Mx pheochromocytoma (3)

A

Alpha block - phenoxybenzamine
B blockers once alpha established
Surgical excision

55
Q

What is Addisons

A

Primary adrenal insufficiency due to destruction of adrenal cortex

56
Q

How does Addisons differ from HPA disease?

A

HPA spares mineralcorticoid production (which = stim’d by ATII)

57
Q

Most common cause Addisons UK

A

Autoimmune (80%)

58
Q

Most common cause of Addisons worldwide

59
Q

Other causes Addisons

A

Overwhelming sepsis
Mets - lung/breast
Lymphoma
Waterhouse-Friderichsen syndrome

60
Q

What is Waterhouse Friderichsen syndrome?

A

Adrenal gland failure because of bleeding into the adrenal glands

61
Q

What is Waterhouse-Friderichsen syndrome most commonly caused ny

A

N.meningitides

62
Q

Sx Addisons (3)

A

W loss/malaise/weakness/myalgia
Syncope
Depression

63
Q

Signs Addisons (4)

A

Pigmentation esp on palmar creases + new scars
POstural HoTN
Signs dehydration
Loss body hair

64
Q

Ix Addisons (6)

A 
FBC
U+E
Ca
Glucose
Short ACTH stimulation/Synacthen test 
9am cortisol/ACTH test
65
Q

FBC results Addisons

66
Q

U+E results Addisons

A

Low Na
High K
Uraemia

67
Q

Ca2+ in Addisons

68
Q

Glucose in Addisons

A

Low

B/c lack of cortisol

69
Q

Short ACTH stim test/Synacthen test (for Addisons)

A

Give tetracosactide IM (ACTH analogue)
measure plasma cortisol before + at 30mins after
2nd value >550nmol/L excludes Addisons

70
Q

9am ACTH/Cortisol test Addisons

A

Raised ACTH

Low/normal cortisol confirms Addisons

71
Q

Ix for cause of Addisons (3)

A

21-hydroxylase adrenal antibodies - autoimmune disease
CXR for TB
Adrenal CT - look for TB/mets if antibodies negative

72
Q

Mx Addisons (3)

A

LT glucocorticoid cover: 15-25mg HC daily in 3 divided doses
LT mineralocorticoid cover: fludrocortisone 50-200micrograms daily
Steroid card/Addisons bracelet _ IM HC in case of Addisonian crises

73
Q

How should steroids be taken in Addisons + why

A

Avoid given late in day

B/c can cause insomnia

74
Q

When does LT mineralcorticoid cover need to be prescribed in Addisons (3)

A

If postural HoTN
If Low Na
If high K

75
Q

When should extra doses of steroids be prescribed in Addisons?

A

If strenuous exercise

Double for: surgery, febrile illness, trauma

76
Q

Def Addisonian crisis

A

Severely inadequate levels of cortisol, occurring either as 1st PS of Adrenal disease or triggered by physiological events

77
Q

PS Addisonian crisis (6)

A 
Fever
N+V
Shock 
Hypoglycaemia 
Hyponatraemia 
Hyperkalaemia
78
Q

Mx Addisonian crises

A

IV Fl

IV Hydrocortisone

79
Q

What is CAH (Congenital adrenal hyperplasia)

A

Congenital deficiency in 21-alpha-hydroxylase

80
Q

Role of 21-a-hydroxylase

A

Prod of mineralcorticoid s + glucocorticoids, but not sex hormones

81
Q

CAH - levels of difference hormones

A 
Aldosterone decreases 
Cortisol decreases 
ACTH hence rises 
Precursors e.g. progesterone build up —> alt Sex hormone pathways 
Hence testosterone increased
82
Q

CF CAH in Females

A

Virilisation of external genitalia —> clitoral hypertrophy + variable fusion of labia

83
Q

CF CAH in males

A 
Enlarged penis
Pigmented scrotum 
Salt losing crises 80% M at 1-3w age
Or
Non-salt losing M —> hypervirilisation - early pubarche, adult body odour, mom build
84
Q

Ix CAH

A

17-a-hydroxyprogesterone levels MARKLY RAISED = diagnostic

85
Q

Extra Ix for diagnosis CAH salt losers

A

Low Na
High K
Metabolic acidosis

86
Q

Mx CAH

A

Steroid cover as per Addisons

87
Q

What are CAH at risk of

A

Addisonian Crises

88
Q

Who gets Conn’s syndrome?

A

Young females

89
Q

What is COnns

A

Adrenal adenoma —> 1’ hyperaldosteronism

90
Q

What are the 2 main causes of 1’ hyperaldosteronism

A

Conns (60%)

Bilateral Adrenal hyperplasia (30%)

91
Q

PS hyperaldosteronism (3)

A

Mostly asymp
To resistant HTN —> headache
Features of hypokalaemia —> cramps/weakness/tetany

92
Q

Biochemical features Conns (2)

A

Hypokalaemia

Elevated aldosterone: renin ratio

93
Q

Ix Conns

A

Plasma Aldosterone levels NOT suppressed by fludrocortisone administration
Adrenal CT to differentiate COnns from adrenal hyperplasia
Adrenal scintigraphy - unilateral uptake in Conns

94
Q

Mx COnns (2)

A

Laparoscopic adrenalectomy

Spironolactone pre-op (control HTN/hypoK)

CP3 Medicine (29 decks)

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