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Big Reece's Surgery (& some medicine) > Endocrinology > Flashcards

Endocrinology Flashcards

1
Q

Tests for acromegaly

A 
Serum IGF1 (GH acts via IGF1)
OGTT - failure to suppress GH (false positive in anorexia, wilson's, opiate addicition) 
Pituitary function test
MRI brain
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2
Q

Rx for acromegaly

A

Somatostatin analogues - octerotide, lanreotide
Dopamine agonists - bromocriptine, cabergolien –> more for tumours co-secreting prolactin
transphjenoidal hypophysectomy (remove pituitary)

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3
Q

Symptoms of hyperprolactinaemia & Rx

A 
Decreased libido,
irregular periods
Impotence 
hypogonadism
galactorrohea
gynaecomastia

All because reduced GnRH release in hypothalamus –> feedback
Rx = Cabergoline or bromocriptine (dopamine agonist)

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4
Q

causes of Adrenal insufficiency

A

Primary
Autoimmune = Addison’s disease
TB, meningococcal septicaemia, CMV, infiltration w/ mets or amyloidosis, infarction, bilateral adrenelectomy,

2º = pituitary disease
3º = hypothalamic disease

iatrogenic = steroid therapy

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5
Q

Signs and symtoms of Adrenal insufficiency

A

Dizziness, anorexia, wt loss, D&V, abdo pain, weakness, depression
Postural hypotension
Increased pigmentation - scars, buccal mucosa, skin creases
Loss of body hair in women

Addisonian crisis - hypotensive shock, tachycardia, pale, clay, oliguria, precipitated by infection or surgery

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6
Q

Adrenal insufficiency Ix

A

9am cortisol <100 = diagnostic,

if 100-550 do short synthACTHen test –> serum cortisol <550 after 30 mins = adrenal failure

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7
Q

Rx for addisonian crisis

A

Rapid IV fluid resus
50ml of 50% dextrose
200mg IV hydrocortisone bolus followed by 100mg 6hrly until BP stable
Treat cause

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8
Q

Rx for chronic adrenal insufficency

A

Hydrocortisone 3x a day –> double dose if illness or stress
Mineralocroticoid replacement w/ fludrocortisone

if also have hypothyroidism, replace hydrocortisone first or will get an addisonian crisis

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9
Q

Carcinoid symptom Hx and Ex

A

Usually small bowel carcinoma secreting serotonin –> appendix, rectum
hormones release are metabolised in liver, so don’t usually have symptoms until hepatic mets (release hormones into veins), or release into systemic circulation from bronchial or retroperitoneal tumours

Paroxysmal flushing
telangiectasia 
diarrhoea
crampy abdo pain
whjeeze
sweating 
palpitations
Right sided murmurs - TS, TR or PS 
Nodular hepatomegaly if metastatic 
Dietary tryptophan defiecency = niacin deficiency= pellagra --> diarrhoea, dementia, dermatitis

Carcinoid crisis - profound flushing, bronchospasm, tachycardia, fluctuating blood pressure

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10
Q

Ix for carcinoid syndrome

A

24h urine 5-HIAA (false positive w/ bananas, avocados, c caffeine, paracetamol)
Blood - plasma chromogranin A and B, fasting gut hormones
CT/MRI to localise tumour
Radiolabelled somatostatin analogue

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11
Q

Rx for carcinoid syndrome

A

If crisis - octerotide infusion, IV antihistamine and hydrocortisone

Avoid precipitating factors
Octerotide inhibits hormone release and tumour growth
Interferon α can be used alone or with octerotide
Supportive = ondansetron and cyphrohepatadine (5HT antagonists)
Surgery if resectable

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12
Q

21-hydroxylase deficency

A

Decreased aldosterone, decreased cortisol, increased androgens
Salt losing crisis - hypotension, hyponatraemia, hyperkalaemia –> give saline, dextrose, hydrocortisone
Males - precocious puberty
Female - ambiguous genitalia, hirtuism

High 9am follicular phase 17OH progesterone and high testosterone
ACTH stimulation = inappropriate elevated 17OH progresterone after IM synthactetin
Rx - dexamethasone/hydrocrotisone + fludrocortisone

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13
Q

11ß hydroxylase

A

raised 11 deoxycorticosterone, a mineralocorticoid –> hypertension, hypokalaemia
Raised androgens
raised 9am follicular phase 17OH progesterone and testosterone

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14
Q

Congenital adrenal hyperplasia

A

AR disease
Defect in one of the enzymes in steroidogenesis
Decreased cortisol –> Inceeaaed ACTH –> hyperplasia and build up of precursors (usually androgens)

This causes infertility, especially in women, if not treated w/ steroids to suppress ACTH and androgen formation
If pursuing fertility - give steroids, can use cloiphine to women
If not pursuing fertility - oral contraceptives or cyproterone acetate (anti-androgen)
If women gets pregnant, check partner for CAH –> if he carries/has it, foetus can have CAH and get virilised (female foetus gets male features wo/ testicles) –> give dexamethasone in all pregnancies

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15
Q

17 α hydroxylase

A

Increased aldosterone - HTN, hypokalaemia
Decreased androgens
Ambigous male genetalia
Females - failure to develop 2º sexual characteristics at puberty

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16
Q

Low dose dexamethasone test

A

failure to suppress cortisol = cushing’s

17
Q

High dose dexamethasone test (and inferior peetrosal sinus sampling )

A

Not often done any more as can inferior peetrosal sinus sampling
if in inferior peetrosal sinus sampling central ACTH is 2x more than peripheral ACTH (or 3x larger after CRH admission) = pituitary disease –> shows high ACTH release from pituitary

in high dose dexamtheasone test, if there is a pituitary adenoma there will be suppression of cortisol as there’s still some feedback mechanism,
if there is ectopic ACTH release, it will fail to suppress at high dose

18
Q

Cushing’s disease

A

1º disease of the adrenals (adenoma or carcinoma) - high cortisol, low ACTH
2º of pituitary (adenoma = Cushing’s disease) - high ACTH, high cortisol
ectopic release e.g small cell lung carcinoma or pulmonary carcinoid syndrome - very very high ACTH, high cortisol

note raised ACTH will cause pigmentation
also glucocorticoids also have a mineralocorticoid effect so might get HTN

Treat the tumour + can use metryapone or keotconazole to suppress cortisol synth

19
Q

Cranial diabetes insipidus

A 
failure to release ADH 
Idiopathic
tumours - pituitary
infiltrative - sarcoidosis
Infection - meninigits
Vascular - anneyrusm 
Trauma - head injury

Will fail to concentrate urine (osmolarity >600) on water deprivation, but urine osmolarity will rise >50% when desmopressing given
Rx= desmopressin intransailly

20
Q

Nephrogenic diabetes insipidus

A 
Kidney does't respond to ADH
Idiopathic
Drugs (lithium)
Post-obstructive uropathy
pyelonephritis
pregnancy
osmotic dieresis e.g DM

Will fail to increase urine osmolarity both with water deprevation and w/ desmopressin
Rx = Sodium + protein restriction, thiazide diuretics

21
Q

Conn’s syndrome vs other 1º aldosteronism

A

Conn’s syndrome = adrenal adenoma –> adrenalectoym
Other cause is hyperplasia of the adrenal cortex –> Rx = spironalactone/epleronone

Both cause hypokalaemia (muscle weakness, nephrogenic DI, paraesthesia, tetany) and HTN
Both have low blood K+, high urine K+, high aldosterone concentration and high aldosterone:renin ratio
Both fail to suppress following salt load
CT/MRI helps visualise adrenals

Postural test - test aldosterone, renin and cortisol lying down at 8am, and then after 4hr of being upright
Adenomas are ACTH sensitive which drops after morning so will suppress aldosterone release a bit
Bilateral adrenal hyperplasia responds to posture so will increase renin and aldosterone

22
Q

Primary hyperparathyroidism vs 2º

A

Primary = raised calcium, decreased phosphate
2º (chronic renal failure or vit D deficiency) –> low.normla calcium, caused phosphate, decreased vit D
long term 2º can cause 3º - like 1º

raised Ca causes stones bones moans groans.
Rx for hypercalcaemia = IV fluids then avoid thiazide diuretics and maintain hydration
Rx for raised PTH - parathyroidectomy (usually subtotal)

23
Q

1º vs 2º hypogonadism

A

1º = hypergonadotrophic (high FSH and LH) –> gonadal dysgenesis (e.g Turners, Kelinfelters, undescended testits), or damage (mumps, torsion, trump, autoimmune, surgery)

2º = hypogonadotrophic (low FSH and LH) —> functional (stress, anorexia), hyperprolactaemia (prolactinoma causes pituitary stalk compression and suppresses GnRH), pituitary tumours, Kallmann;s

24
Q

Signs of Paget’s disease of bone

A

Insidious onset pain aggravated by wt bearing and movement
headaches
Bitemporal skull enlargement with frontal bossing
Spinal kyphosis
anterolateral bowing of femur, tibia and forearm
Skin over involved bone is warm
Sensorineural deafness due to compression of vestibulecholear nerve

Increased all phos
X-ray - enlarged deformed bones w/ mixed lytic/scleoritc appearance
Bone scan = hot spots are active areas

25
Q

Rx for Paget’s

A

Bisphosphonate - fortnightly IV pamiodronate

26
Q

What are the signs of PCOS

A

oligomenorrhoea or amenorrhoea
Infertility
Hirtuism
Male patter hair loss
acne
Acathosis nigricans - velvety thickening and hyperpigmentation of skin on axilla and neck –> caused by severe insulin resistance
associated w/ obesity, T2DM, dyslipidaemia
Raised LH and testosterone, raised LH:FSH ration, decreased SHBG
Polycystitc ovaries on USS

27
Q

What is the Rx for PCOS

A

Reduce wt, exercise, stop smoking
Oligomenorrhoea - COCP or intermittent progestin
Hirtuism - COCP (using estradiol + cypoterone acetate)
Can add anti-androgens if not responsping as long as reliable contraception is in place e.g spironolactone, flutamide
Metformin
Clomifene citrate can innate ovulation if modest wt loss doesn’t;t help

28
Q

what causes SIADH & what are the signs

A

Brain - haemorrhage, meningitis, abscess, trauma, tumour, Gillian Barre
Lung -SMALL CELL LUNG CANCER, pneumonia, TB, abscess
Tumours - lymphoma, leukaemia, pancreases
Drugs - vincristine, opiates, carmazepine, chlorpropamide

The signs are the same as hyponatraemia - headache, N&V, muscle cramps, irritability, confusion, drowsiness, decreased reflexes, extensor planters, convulsions, coma

29
Q

How do you diagnose SIADH and how do you treat it

A

Decreased plasma osmolarity and Na+
Increased urine osmolarity >100
Increased urine Na >20
No other cause - hypovolaemia, oedema, renal failure, adrenal insufficency, hypothylroidism

Rx = water restriction, tolvaptan (vasopressin receptor agonist)
Can give slow hypertonic saline & frusemide is severe depleted Na+ –> can’t correct quickly as may cause central pontine myelinosis

30
Q

3 treatments for hyperthryodisim

A

1) antithyroid drugs - carbimazole, propylthiouracil (+ β blockers)
2) radioactive iodine
3) surgery

Big Reece's Surgery (& some medicine) (6 decks)

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