Endocrinology Flashcards
What is T1DM
Autoimmune destruction of pancreatic islet cells leading to
reduced insulin
What is T2DM
Hypersecretion of insulin by depleted beta cell mass.
Increasing insulin resistance
Main comps of diabetes
Retinopathy, neuropathy, nephropathy, skin infection (low immunity)
What do alpha cells produce in pancreas?
glucagon
What does insulin do to cells?
allows glucose to enter
pres of t1DM
Polyuria, polydipsia, weight loss, lethargy,
DKA problems… (dehydration, breathing, abdo pain)…
Initial Ix in DM
Urine dip, fasting glucose, random glucose, GTT, HbA1c
For comp:
Urine - protein
BP for HTN
Fasting lipid - hyperlipidaemia
Where is neuropathy in DM
glove and stocking
mx of nephropathy in DM
ACEi/ARB
How can you minimise CV risk in diabetes
BP control + diet + smoking + statin -> QRISK
How to reduce chest infections in DM
Pneumococcal vaccine and annual influenza
What causes diabetic foot
Peripheral artery disease, neuropathy + infection
How does diabetic food present?/
Ulcers (neuropathic painless and punched out or arterial), loss of pulses
*Charcot foot
Name 2 things you might see in diabetic eye?
Microaneurysm - from physical weakness
Hard exudates - lipoproteins from leakage
Haemorrhages - rupture of weakened capillaries small dots, blots or flame (track along nerves in superficial retinal haemorrhages)
Cotton wool spots - build up of axonal debris
Neovascularisation
How do diabetic eye present?
Painless, patch loss of vision
Mx of diabetic eye
Optimise glycaemic control
Blood pressure control
Lipid control
Laser photocoagulation
General non pharma mx of diabetes
Diabetes education
Diet and exercise - low sugar, low fat, high starchy carb
Exercise and smoking advice
Maximise glucose control - DAFNE for type 1
Name 3 things checked annually in diabetes
Educate + modifiable RFs
Check BMI
Check complications: hypos, HOHS, DKA
Assess CVS: BP, pulses, bruits
Inspect injection sites - lipodystrophy
Foot check - neuropathy and pulses
Urine dip - protein, nitrites, ketones
Check eyes - acuity and ophthalmoscopy -> refer opthalmology
Ask erectile dysfunction
Bloods: HbA1c and home capillary monitoring results, random lipids
What is the target hba1c
<48mmol
42-27 is pre-diabetes
Pharma control of type 2 diabetes
1- metformin
if hba1c >58
2- add Gliptin or sulfonylurea or pioglitazone
if hba1c >58
3- add another
if hba1c>58
4- insulin
how does metformin work
Increases insulin sensitivity (GLUT 4), decreases gluconeogenesis
Ci to metformin
CKD, eGFR < 30
common SE metformin
GI upset
How does gliptin work?
DPP-4 inhibitors (DPP-4 destroys incretin)
Raised incretin -> produce more insulin when needed
SE: pancreatitis
How does sulfonylurea work?
CI?
SE?
Increase panc insulin secretion
[Suuuuuplements insulin]
Pregnancy
*Hypo, weight gain
how does piaglitazone work? SE? CI?
Increases insulin sensitivity
Weight gain, fluid retention and osteoporosis
Heart failure and osteoporosis
[PIG - big full of water]
Eg of rapid acting insulin you can take before meals
Humalog or Novorapid
Eg of long acting insulin
detemir
Mx of concious hypo?
10-20g short acting carb e.g. glass of lucozade, x3 glucose tablets, glucogel
Mx unconcious hypo
IM glucagon
Why does being unwell increase risk of DKA
Stress response to illness -> increased cortisol
Cortisol increases blood sugars and decreases insulin
Triggers of DKA?
pres?
Missed insulin, infection, intoxication, ischaemia, infarction
n/v, GCS, abdo pain, kussmal, dehydration
What is kussmal respiration?
deep hyperventilation to correct acidosis
ECG of hypokalaemia
PRSTTU
PR prolonged
ST depression
Flattened/inverted T wave
Prominent U wave after T
3 Ix in DKA ? what are you expecting to see?
Plasma glucose: high >11 or known DM
Plasma ketones: high >3mmol/l
ABG: metabolic acidosis pH < 7.3
Bicarb <15
[Urine dip: ketones (++) and glucose ]
Mx of DKA ?
For acidaemia?
ABCDE sats etc… + catheterise
IV NaCl
IV insulin : 0.1U/kg/hr
Correct K as it falls
Acidaemia: IV bicarbonate
DKA complications - cerebral oedema, hypoK/hyperK, hypoG/hyperG, AKI
Monitoring in DKA
Electrolytes and bicarb - 1-2 hours, pH, fluid balance hourly, glucose hourly, ECG
Characteristic features of Hyperosmolar hyperglycaemic state
T2DM
very high blood glucose >40 + v.high serum osmolality
Triggers of HOHG
Infection, MI, dehydration, inability to take normal meds, thiazides + loop, poor con
What happens in untreated HOHG
Extreme dehydration + altered mental state ± seizures ± delirium
Ix in HOHG
Urinalysis: glycosuria +++. Ketonuria +
Capillary glucose > 30
Serum osmolality > 320mmol/L
U+E -> AKI
ABG -> normal
Blood cultures -> rule out sepsis
Mx of HOHG
ABCDE
IV access, ECG, SaO2, BP
Treat cause
Safely normalise osmolality - replace fluid and electrolytes
Normalise blood glucose
IVNaCl
IV insulin
Complications of Mx of HOHG
Cerebral oedema, central pontine myelinosis
What is metabolic syndrome? 2 key criteria?
Cluster of common abnormalities including insulin resistance, impaired glucose tol, reduced HDL, elevated triglycerides and HTN
Truncal obesity
raised BP
name 2 medications causing obesity
Glitazone, sulfonylurea Anticonvulsants Antidepressants: tricyclics and mirtazapine Lithium Progesterone only contraception BB Corticosteroids
name 2 conditions cauing obesity
hypothyroid, PCOS, cushings, hypogonadism
Ix in obesity
Hormone profile: sex hormones and cortisol
TFT
What drug can you use for obesity? when?
Orlistat: only after diet, behaviour and exercise
When would you continue orlistat
Continue beyond 3/12 only if lose 5%
Name 2 surgeries for bariatrics
Restrictive: gastric banding
Malabsorptive: biliopancreatic diversion
Both: roux en y gastric bypass (RYGB
Which 2 hormones are involved in gynaecomastia
Oestrogens stimulate, androgens inhibit
Causes of gynaecomastia. Name 3
Low testosterone androgen resistance, Klinefelter’s, viral orchitis (mumps), renal disease
High oestrogen
neoplasms secreting HCG (e.g. seminoma) or ectopic BCG lung, RCC, adrenal tumour (oestrogen), CAH, *liver disease - increased prod androstenedione and aromatisation to oestrogen), obesity, hyperThyroid
Name 2 medications causing gynaecomastia
Antipsychotics, TCA (increase prolactin)
Digoxin
spironnolactone (inhibits testosterone)
blood Ix in gynaecomastia
Kidney function, LFT, TFT
Hormones:\
Estradiol, testosterone, prolactin, bHCG, AFP, LH
gynaecomastia…
LH high + test low = ?
LH low + test low = ?
LH high + test high = ?
LH high + test low = testicular failure
LH low + test low = increased oestrogens
LH high + test high = androgen resistance or neoplasm
When would you image gynaecomastia
Imaging: USS or mammography if suspicious or unilateral + needle core biop
most common cause of hypothyroid?
Presentation?
Hashimotos
Iodine deficiency is more common in developing world!
Other - thyroidectomy, radioactive iodine, lithium, Amiodarone, De Quervain;s
Bradycardia, constipation, low of concentration, menorrhagia, cold intolerance, thin skin, thin hair, depressed, fatigue, weight gain, decrease appetite, carpal tunnel
Hypothyroid main complication ? presentation?
myxoedema coma
hypoventilation + seizures + hypothermia + decreased consciousness
Mx of myxoedema coma
IV levothyroxine
+ IV hydrocortisone (after blood cortisone) - this is because primary hypothyroidism can also come with primary adrenal insufficiency. Secondary hypothyroidism can be associated with hypopituitarism leading to secondary adrenal insufficiency. Additionally, levothyroxine may cause adrenal insufficiency due to the increase in the metabolism of cortisol.
+ resp support
2 key antibodies in hashimotos
Anti-TPO (anti-thyroid peroxidase)
anti-Tg (antithyroglobulin)
How to differentiate 1 /2 hypo thyroid disease?
Primary: high TSH, low T3/T4,
secondary: low TSH, low T3/T4
Mx of hypothyroid ? 2 comps with mx?
Levothyroxine (T4) for life
Osteoporosis
Arrhythmia
Antibody in graves
Anti-TSH
Ix in hyperthyroid ? If orbital involvement?
TFT: TSH low, high T3/T4
AAb: anti-TSHR (99%) at Grave’s + anti thyroglobulin + anti TPO
Anti-TPO + Anti-TSH = GRAVES!
Anti-TPO + Anti-Tg = Hashimotos!
Imaging:
- USS ?cancer
Thyroid uptake scan. This uses radioisotopes and hot = overactivity, no uptake for DeQuervain’s (subacute thyroiditis - gives hyperthyroidism for a few days then hypothyroidism for a few weeks after)
Orbital -> visual field testing, CT/MRI head
Usual Mx of hyperthyroid
BB - propanolol
Lubricating eye drops
Carbimazole
propylthiouracil - if pregnant
Which antithyroid drug cant be used in pregnancy?
carbimazole -NOT IF PREG
what mx is often used in Relapsed Grave’s or toxic nodular ? When can this not be used
radioactive iodine
preg / breastfeeding
2 specific complications of thyroid surgery?
hypoparathyroidism
damage to recurrent laryngeal nerve
how does a thyroid storm present
Hyperpyrexia > 41
CVS: HR > 140, hypotension, AF, CHF
GI: Nausea, jaundice, vomiting, diarrhoea, abdominal pain
NEURO: Confusion, agitation, delirium
Ix in thyroid storm?
Sepsis screen, TFT, ECG, CXR, ABG
Mx of thyroid storm
ABCDE
Resus: O2, IV fluids, NG tube if vomiting
Antithyroid Rx
Oral carbimazole or propylthiouracil
IV propanolol IV hydrocortisone (treats possible relative adrenal insufficiency)
Keep cool with tepid sponging not paracetamol
What causes increased PTH release
low ca
PTH main organs affected?
Bone - increases osteoclasts -> release Ca
Kidney
1 - increases fit D metabolism by the kidneys -> this secondarily increases Ca absorbtion in GI
2 - Increases reabs Ca, decreases reabs PO4
Who gets primary hyperparathyroid?
Main comps?
postmenopausal women (benign adenoma on parathyroids)
Osteoperosis + peptic ulcers, hypercalcaemia
Cause of secondaery hyperparathyroid?
low Ca -> PT hyperplasia. However calcium still stays low.
almost always associated with kidney, liver or bowel disease
Which hormone inhibits osteoclast activity?
calcitonin
Produced by para-follicular (medullary) C cells of thyroid
What does the excess ca absorption from bone -> in hyperparathyroid?
osteopenia and osteoporosis
(if extreme = osteitis fibrosa cystica (salt + pepper pot skull + subperiosteal resorption )
Sx of high Ca
*Bones, stones, abdominal moans, thrones, psychic overtones
Ix in raised Ca?
What addtional Ix might you do if you think this is longstanding?
Obvious cause: thiazide and lithium
Repeat plasma albumin adjusted calcium
Check renal function
Measure PTH - HyperPT often finding post raised Ca
Longstanding:
DEXA (annual)
Renal tract imaging USS
X-ray: skull and hand
mx of mild primary HPT
Surveillance
Check creatinine and Ca 6 months
DEXA yearly
Vitamin D *suppresses PTH
Avoid dehydration, thiazide diuretics -
increase fluids
Surgery is the definitive mx of primary HPT. Complications?
Hypothyroidism, recurrent laryngeal nerve damage
Hungry bone syndrome (due to rapid deposition of Ca in bone)
Medical management of low bone density in HPT
Bisphosphonates
Association secondary HPT
Presentation?
CKD (5)
vit D deficiency
High PTH, low Ca, Low vit D, high PO4
CKD pres with PROMINENT BONE PAIN
main complications of 2ndary HPT
Progress to tertiary -> high Ca -> Skeletal and cardiac calcification
Measure levels of what in secondary HPT? Whats high/low
High PTH,
low Ca,
PO4 high in renal disease, low in vitamin D deficiency [vit D increases PO4 absorption]
Mx of 2ndary HPT ?
Correct vitamin D deficiency
In CKD: Ca supp, correct vit D, phosphate binders, calcimimetics (only at end-stage kidney disease)
What is tertiary HPT
ongoing hyperplasia of PT glands after correction of underlying renal disorder CKD
i.e. after prolonged secondary hyperplasia of all 4 glands
Mx of tertiary HPT
Cinacalcet [hes a cina that cal with cet]
Total or subtotal parathyroidectomy
Appearance of people with pseudohypoparathyroid
Low IQ, short stature, short 4th and 5th metacarpals
mx of hypoparathyroid
If tetany - urgent IV Ca
Diet: rich in Ca and vit D
Calcium and vit D
DDx for hyperCa causes
Name 3
HPT
Malicnancy - squamous cell lung Ca, breast Ca
Endocrine - thyrotoxicosis, phaeo, primary adrenal insufficiency (Addison’s)
Drugs: thiazide diuretics, vitamin D
What is meant by groans, thrones, stones, and psychic overtones
Abdominal groans
Anorexia, nausea and vomiting, abdo pain, PUD, acute pancreatitis
Thrones
Polyuria, polydipsia, dehydration
Stones - if long standing
Renal colic
Psychic overtones
Depression, dementia, confusion, memory
Ix in hyperCa and why?
High corrected Ca (<3 = PHPT, >3 = malignancy)
Albumin - high -> with high urea = dehydration
Alk phos - normal in myeloma, raised in bony mets
Calcitonin - B cell lymphoma
PTH - high = PHPT, low = granulomatous or adrenal
*XR - bone abnormalities, cysts, pathological fractures etc
Mx of acute high Ca (<3.5) ?
0.9% saline - hydration and increase urinary excretion
Loop diuretic - furosemide for fluid overload
After rehydration –> IV bisphosphinates.
what should you give post re-hydration of acute high Ca
IV bisphosphonates
Causes of hypocalcaemia?
Sx of hypoCa
Causes = low PTH (surgery or radiotherapy), fit D deficiency, CKD, acute pancreatitis
Paresthesia: fingers, toes, mouth
Tetany (emergency)
Carpopedal spasm (wrist flexion and fingers drawn together)
Muscle cramps
QT in hypo vs hyper Ca
Hypo Prolonged QT
shortened in hyperCa
What are Chvostek’s and Trousseua’s signs?
hypoCa
Chvostek’s sign - latent tetany
Tap facial nerve -> face spasms
Trousseua’s sign - from increased neuromuscular excitability
Inflate a BP cuff above systolic - look for carpopedal spasm
name 3 Ix for hypoCa ? 2 more for things to exclude causes
Adjusted Ca
Serum Mg
Serum PO4
Serum PTH
Evaluate vit D metabolism
ECG
Exclude:
CKD (U+E), acute panc (amylase), rhabdo (check CK)
Mx of acute hypoCa (seizures / tetany) ? What to do if hypoMg
10ml 10% calcium gluconate slow IV infusion, repeat as necessary
Oral calcium
Monitor Ca
If hypomagnesaemia - correct otherwise Ca will not respond
Chronic mx of hypoCa
Ca
vit d
Hormones and basic function from ant pit
GH: stimulates liver to produce IGF-1 and counteracts insulin
Prolactin: promotes growth of mammary glands and reproductive organs
FSH: stimulates release of sex steroids
LH: stimulates release of sex steroids
ACTH: adrenocorticotropic hormone: stimulates adrenal cortex to release glucocorticoids and androgens
TSH
2 hormones from post pit
vasopressin
oxytocin
Name 2 local effects of pit ademonas
Cavernous sinus = CN 3, 4, 5a, 5b, 6
Optic chiasm
Headaches: retro-orbital and bilateral worse on waking
Visual field defect: bitemporal hemianopia
Ocular nerve palsies - squint
What is the key DDx of pit adenoma local effects
Craniopharyngioma
from Rathke’s pouch, between pit and floor V3
General mx of pit adenoma
Surgery: transsphenoidal
Key SE of pit surgery
pituitary dysfunction -> adrenal insufficiency, DI, SIADH
Pharma mx of prolactinoma?
bromocriptine
Pharma mx of GH adenoma
somatostatin
Effect of high prolactin pn women? men?
Women
menstrual dysfunction + galactorrhoea -> low oestrogen
(due to inhibits GNRH -> reduced gonadotropin (FSH + LH) secretion )
Men
hypogonads, decreased libido, erectile dysfunction
Which class of drugs causes high prolactin
antipsychotics - raise PL
Antidepressants
MEN1 gene associations
parathyroid tumours, prolactinoma, pancreatic islet tumour
Ix in raised prolactin
PRL: normal < 400, if mild el = 400-1000 - repeat before referral
> 5000 = true prolactinoma
TFT
Exclude pregnancy
Assess other pituitary function
MRI pituitary
medical mx of prolactinaemia
Dopamine agonist
-bromocriptine
Main SEs of bromocriptine
sleepiness, hypotension,
cardiac/retroperitoneal/pulmonary fibrosis - monitor
With pit adenoma what sreious complication are you worried about? how does it present?
pituitary apoplexy
Haemorrhage / infarction of gland
Sudden onset headache, visual symptoms
What two hormones involved in acromegaly
GH
IGF1
Name 3 features of acromegaly
Due to tumour - headaches / visual field defect
big hands / feet
thick nose, frontal bossing , macroglossia, coarse facial features
skin - thick dark oily
carpal tunne
cardiac - HTN / LVH / arrythmia
T2DM
Name 3 Ix for acromegaly
IGF1 - raised
GTT
GH
pit MRI
Glucose
Visual field testing
mx acromegaly
transsphenoidal surgery
2nd line - somatostatin analouges
3rd line - bromocriptine
Layers of adrenals
The deeper you get the sweeter it gets
GFR - Salt sugar sex
Zona glomerulosa - mineralocorticoids - aldosterone
Zona fasciculata - glucocorticoids - cortisol
Zona reticularis - androgens - DHEA - dehydroepiandrosterone
Effects of cortisol?
RIDGE Suppression of reproduction Suppression of immunity Suppression of digestion Suppression of growth Mobilisation of energy
What syndrome has high cortisol
cushings
What are the 2 types of cushings syndrome ?
1 cause of each?
Most common cause?
ACTH dependent
Excessive ACTH pit pit (Cushing’s disease),
ectopic ACTH producing tumours (due to lung cancer, small cell)
ACTH independent
Adrenal adenoma/adrenal carcinoma/excess glucocorticoids
most common is excess glucocorticoids - IATROGENIC
Name 3 features on presentation of cushings syndrome
buffalo hump moon face wiehg t gain proximal muscle wasting Diabetes hypertension osteoperosis infection depression
Ix for cushings (excluding imaging)
Treatment
Glucose - elevated
dexamethasone supression test
24hr urinary free cortisol
Tx = ketoconisole, metyrapone, SURGERY
What happens in addisons
Destruction of adrenal cortex and subsequent reduction in output of adrenal hormones: glucocorticoids (cortisol), and mineralocorticoids (aldosterone)
Causes of adrenal insufficiency
Primary addisons (autoimmune) Surgical Metabolic failure: CAH e.g. 21-hydroxylase deficiency
Secondary
steroids
TB
Noticable effect of decreased cortisol in addisons
pigmentation of skin
Antibody in addisons
Anti-21 hydroxylase
Sx of chronic addisons
thin, tanned, tired, tearful and tumbling
Fatigue and weakness
GI: Anorexia, nausea, vomiting, weight loss
Cravings for salt and salty food
Muscle cramps
Faintness due to hypotension
Mood: confusion, personality change, irritable
Signs of addisons
pigmental palmar crease and buccal mucosa, hypotension, postural hypotension
how to differentiate 1/2 addisons
ACTH levels
High = primary, low = secondary
Ix addisons
ACTH
Sodium - low, Potassium high
Cortisol - low
Renin (high), aldosterone (low)
CT adrenals
synacthen test
What is the Dx Ix for addisons
Short synacthen test:
Take cortisol level
Give 250 mcg synacthen IM (synth ACTH). In 30 mins retake cortisol
If cortisol rises then exclude Addison’s >500nmol/L
Electrolytes in addisons
Hyponatraemia, hyperkalaemia, hypoglycaemia, metabolic aci
Mx addisons
patient education
medical emergency bracelet
Glucocorticoid - hydrocortisone
mineralcorticoid - fludrocortiosone
What to monitor in addisons
symptoms, signs, BP, electrolytes
Annual
TFT, glucose + HbA1c, coeliac
Biggest Rf for addisonian crisis
long term steroids
Presentation of addisonian crisis ? progress to?
Malaise, fatigue, nausea/vomiting, low-grade fever, muscle cramps, confusion
Dehydration: hypotension and hypovolaemic shock
Mx of adisonian crisis ? monitor what?
IV/IM hydrocortisone
rehydrate
more hydrocortisone and glucose over 24 hrs
Continuous cardiac and electrolyte monitoring (ECG, reg U+E)
What is conns
primary hyperaldosteronism
What happens in conns
hypernatraemia, water retention and hypokalaemia
What might you think the cause is if someone presents with HTN, hypokalaemia, or alkalosis in someone not on diuretics
conns
presentation of conns
Oedema
Hypertension
Hypokalaemia - weakness, cramps, parasthesia
Metabolic alkalosis - secretion of H+ in exchange for K+ (more K+ in urine) in intercalated cells
Polyuria from reduced ability of kidney to concentrate urine
Ix in conns
U+E: hypernatraemia, hypokalaemia
BP: high
*Aldosterone: renin ratio (high ald, low renin - normal renin exludes Dx)
>800 = imaging required
ECG for arrhythmia
CT/MRI for adrenal adenoma
Mx of conns
medical
spronolactone - aldosterone antagonist
Laparoscopic adrenalectomy (only if unilateral)
give 3 causes of hyper K
Renal
AKI / CKD
Addisons
hyperkaeamia RTA
Drugs
spironolactone ACEi, ARB, NSAID, BB, Digoxin, heparin
rhabdomyolysis, burns, trauma, blood transfusion
DKA
Presentation of hyperK
KEVIN!!!! Kevin is in hospital for an AKI but he also has diabetes and takes loads of meds and hes tired, flaccid and depressed.
Non-specific: weakness + fatigue, flaccid paralysis, depressed tendon reflexes
Palpitations + chest pain
Ix in Hyper K
Medication review
U/E
ABG
ECG
Seen on ECG in hyper K
PPRQRST P - loss of P PR - prolonged - ?HB ?bradycardia QRS - widened and sinusoidal T - peaked T waves = first thing you see
Worry —> can progress to VF
Mx of hyperK
Stop drug causing
Cardiac protection
- calcium gluconate IV
Shift potassium into cells
- Insulin infusion + glucose
If needed - nebulised salbutamol/haemodialysis
Monitor ECG
Usual cause of hypoK
non-K sparing diuretics / GI fluid loss (N&V)
Alkalosis or acidosis
HypoK presentation
Investigations?
KAREN!!!!! Karen is weak, constipated and hypotonia.
weakness, muscle pain, constipation
Severe:
neuromuscular
(ascending weakness -> resp faulure,
hypotonia)
Ix:
- U&E
- ABG
- Glucose
- Serum Mg (also goes low)
- Serum Cl
- ECG
Which electrolyte accompanies low K?
Mg
Mx of low K - How do you give it?
Mild = oral K which sandoK
Severe = IV K - Dont give as a bolus as can cause fatal arrhythmia = VF
Rate should never exceed 10mmol/hr
Cardiac monitoring
Classic 4 sx in phaeochromocytoma
Episodic headache + sweating + palpitations + tremor
o/e phaeo. 3 signs
Hypertension, postural hypotension, tremor, flushing, tachycardia
Ix of phaeo
24 hour urine catecholamines, metanephrines, VMA
Abdo CT/MRI
2 drugs given pre surgery for phaeo
alpha blocker - Phenoxybenzamine
b blocker - propanolol
What do you monitor after surgery for phaeo
24 hour catecholamines + VMA 2 weeks after surgery
What is carcinoid syndrome ? usual pres?
Tumour of enterochromaffin cell
Flushing and diarrhoea
(Wheeze, palpitations, telangiectasia, abdominal pain)
What is released in carcinoid syndrome?
serotonin / other vasoactive peptides
Ix in carcinoid syndrome? name 2
Urinary 5-HT
CT CAP - to find tumour and check liver mets
Serum chromogranin A/B
mx of carcinoid
Surgical resection
+ peri-operative octreotide infusion
to prevent carcinoid crisis - continue for 48 hours post
What happens in diabetes insipidus?
large amounts of dilute urine due to hyposecretion or resistance to ADH/vasopressin (same thing) and inability to concentrate urine
where is ADH made?
hypothalamus
name 2 causes of Diabetes insipidus
Cranial
Damage to hypothalamus:
tumour, surgery, granulomatous disease, infection
Inherited AD vasopressin gene
Nephrogenic causes - CKD and lithium
Ix in diabetes insipidus
24 urine collection
urine / serum osmolality
Desmopressin stimulation test - test urine osmolality
MRI pit/hypothalamus
water deprivation tests (can kidneys concentrate urine)
Mx of cranial cause of diabetes insipidus
ADH replacement
Mx of nephrogenic cause of diabetes insipidus
drink adequate fluid
If you correct SIADH too fast what could you cause \?
central pontine myelinolysis
most common cause of hyponatraemia
thiazine diuretics
Name 3 causes of SIADH
Pulmonary processes: pneumonia, lung cancer (esp small cell)
CNS disorders: infection, trauma, MS, haemorrhage, malignancy
Malignancy: lung, GI, GU, lymphoma
Drugs: SSRIs, ACE-i, chemo drugs
How does SIADH present
confusion, nausea, irritability, vomiting
Ix in SIADH
Na - low
low serum osmolalaity
High urine Na
Normal renal / adrenal
What happens to Na levels in SIADH with normal saline infusion
they don’t respond
Mx SIADH
IV hypertonic saline
treat cause
furosemide if fluid overoad
Big old risky with very low Na
cerebral oedema
Risk of correcting low Na quickly in cerebral oedema
osmostic demyelination
water moves out brain a bit fast
What is the dexamethasone suppression test ?
give steroids -> should lower cortisol
If doesnt - positive test -> pit adenoma or ectopic source eg Small cell lung Ca
hypovolemic and hypernatraemic?
Give 5% dextrose
If really high Na just give normal saline as dont want to bring down too fast
Hyperkaeamia
mild >5.5
severe >6.5
Calcium normal range
Severe >3.5
Malignancies causing hyperC
breast
myeloma
SCLC
bone mets
signs for GRAVES
EYES - lid lag
ophthalmoplegia
exophthalmos/proptosis
pretibial myxoedema
clubbing
SGLT
gliflozin
SE: thrust
Work by increasing excretion of glucose from urine
GLT1 agonist
exenatide
