Endocrinology Flashcards
1
Q
Define Adrenal Insufficiency
A
Destruction of adrenal cortex with reduced adrenal output
Can be Primary (Addison’s) or Secondary
2
Q
Causes of Adrenal Insufficiency
A
AI most common in developed countries
TB most common in rest of world
Primary: Addisons, Adrenectomy, Trauma, Infection, Haemorrhage, infarction, neoplasm
Secondary: Congenital, Trauma, CAH
Other: Suppression of axis, AIDS patients, Critically ill
3
Q
Symptoms of adrenal insufficiency
A
Hypotension Hypovolaemic shock Fever Vomiting Fatigue Weakness Anorexia
4
Q
Signs of adrenal insuffciency
A
Hyperpigmentation
Hypotension
Postural hypotension
5
Q
What things would make you consider addisons?
A
Hypothyroidism / Women on thyroxine
Unexplained hypotension in T1DM
Presence of other AI conditions
Low Na+ and Low K+
6
Q
Investigations for Adrenal insufficiency
A
Electrolytes (Low Na+, Raised K+) FBC ( Anaemia, mild eosinophilia, WBC) Glucose (Low) LFTs (Raised) ACTH (Raised in Primary, low/normal in secondary)
7
Q
Management for Adrenal insufficiency
A
Medical emergency bracelet
Steroids (Hydrocortisone + Fludrocortisone in prmiary disease)
Double dose of hydrocortisone for surgery, infections
8
Q
Manage acute Adrenal insufficiency
A
ICU
High dose Hydrocortisone Paternally
IV Fluid
9
Q
Complications of Adrenal insufficiency
A
Adrenal crisis
Osteoporosis
Reduced QOL
10
Q
Prognosis of Adrenal insuffciency
A
If untreated = fatal
Lifelong treatment but normal life
11
Q
What is Acromegaly?
A
Growth hormone stimulates production of IGF-1. This is produced in liver and many other tissues.
12
Q
What causes Acromegaly?
A
Usually caused by a pituitary tumour (1:3 microadenoma to macroadenoma)
Rarely, ectopic GH from non-endocrine tumours e.g. Lung cancer, cancer of the pancreas
Insidious onset and slow progression
Several familial causes (MEN1, Mccube-albright’s syndrome or familial isolated pituitary adenoma)
13
Q
What are the risk factors for acromegaly?
A
GPR101 over-expression MEN1 Isolated familial acromegaly McCune-albright's syndrome Carney's complex
14
Q
What are the signs and symptoms of Acromegaly?
A
Coarsening of facial features Soft-tissue and skin changes Carpal tunnel syndrome Joint pain and dysfunction Snoring (macroglossia) Alterations in sexual functioning History or family history of inherited syndromes Fatigue Hypertension, arrhythmias Organomegaly Increased appetite, polyuria/polydipsia Headaches Visual field defects Signs and symptoms of hypopituitarism Cranal nerve palsies (ophthalmoplegia)
15
Q
What investigations are done for Acromegaly?
A
Serum IGF-1 (elevated) Oral glucose tolerance test (GH value >1 microgram/L) Random serum GH Pituitary MRI or CT scan (Adenoma) Plasma cortisol (May be low) TSH and free T4 (abnormal) Estradiol or testosterone Visual field testing
16
Q
How do you manage Acromegaly?
A
Somatostatin analogues (Octreotice) Dopamine agonists (Bromocriptine, cabergoline and quiagolide) Pegyisomant (PEG)
17
Q
How do you manage Acromegaly in pregnancy?
A
Medical therapy withheld during pregnancy
Short-acting octreotide used as needed when attempting to conceive
Patients with macroadenomas monitored for headaches and visual symptoms
Cabergoline safe to the foetus
18
Q
What are complications of acromegaly?
A
Cardiac complications Sleep apnoea Osteoarticular complications Impaired glucose tolerance and diabetes Pre-cancerous polyps Carpal tunnel syndrome Hypopituitarism
19
Q
What is Carcinoid syndrome?
A
Constellation of symptoms caused by systemic release of humoral factors from carcinoid tumours (tumour of neuroendocrine cells)
20
Q
What causes carcinoid syndrome?
A
Slow-growing neuroendocrine tumours
Mostly derived from serotonin-producing enterochromaffin cells (Neural crest origin)
Common sites: Appendic, ileum, Rectum
Produce secretory products: Serotonin, Histamin, Tachykinins, kallikrein and prostaglandins
75-80% with it have small bowel carcinoids
21
Q
What is important to know about Carcinoid syndrome in the bowel?
A
Hormones released into the portal circulation will be metabolised by the liver so symptoms dont appear untill there are hepatic metastases
22
Q
What are the Risk factors for carcinoid syndrome?
A
None
23
Q
What are the Symptoms of Carcinoid syndrome?
A
Paroxysmal flushing Diarrhoea Crampy abdominal pain Wheeze Sweating Palpitations
24
Q
What are the signs of carcinoid syndrome?
A
Telangiectsia
Congestive cardiac failure (Due to tricuspid incompetence/pulmonary stenosis from serotnonin induced fibrosis)
Right-sided murmurs
Nodular hepatomegaly
Carcinoid crisis (When mediators flood out - often during surgery) [Profound flushing, Bronchospasm, Tachycardia, Fluctuating blood pressure]
25
What are the investigations for Carcinoid syndrome?
24hr urine collection (Check 5-HIAA levels)
Blood (Plasma chromogranin A and B, Octreoscan, fasting gut hormones)
CT/MRI scan (Localise tumour)
Radioisotope scan (Radiolabelled somatostatin analogue (octreotide) localises the tumour)
Investigations for MEN-1
Echo and BNP investigates carcinoid heart disease
26
What is Cushing's syndrome?
Clinical manifestation of pathological hypercortisolism from any cause.
27
What is caused by Cushing's syndrome?
Exogenous corticosteroid exposure is most common cause of cushing's syndrome
Majority caused by ACTH-secreting pituitary adenomas
10-15% of pituitary tumours secrete ACTH
New gene ubiquitin-specific protease 8, mutated in Cushing's disease
Adrenal overproduction of cortisol in 30-40% of carcinomas, resulting in ACTH-independent cushing syndrome
28
What are the Risk Factors for Cushing's syndrome?
```
Exogenous corticosteroid use
Female
20-45
Pituitary adenoma
Adrenal adenoma
Adrenal carcinoma
Neuroendocrin tumours
Thoracic or bronchogenic carcinoma
```
29
What are the signs and symptoms of Cushing's syndrome?
```
Truncal obesity
Buffalo hump
Supraclavicular fat pads
Weight gain
Facial fullness
Moon facies
Facial plethora
Proximal muscle wasting and weakness
Diabetes or impaired glucose tolerance
Skin atrophy
Purple striae
Easy bruising
Hirsutism
Acne
Pigmentation
Oedema
```
30
What are the investigations for Cushing's syndrome?
Pregnancy test (Negative)
Serum Glucose (Raised)
Late-night salivary cortisol (Raised)
1mg overnight dexamethasone suppression test (morning cortisol >50)
24-hour urinary free cortisol (>50)
48-hour 2mg dexamethasone suppression test
31
How do you manage Cushing's syndrome?
```
Tumour resection (Trans-sphenoidal microsurgery or Bilateral adrenelectomy)
Medications for those who are unfit for surgery or with an unknown tumours
```
32
What medications are used for Cushing's syndrome?
Drugs (Metyrapone, Ketoconaxole and mitotane)
| Pituitary radiotherapy
33
What are the complications of Cushing's syndrome?
Adrenal insufficiency secondary to adrenal suppression
CVS Disease
HTN
DIabetes mellitus
OSteoporisus
Nephrolithiasis
Nelson's syndrome
Treatment- related central hypothyroidism/GH deficiencies
Treatment related adrenal insufficiency/hypogonadism/DI
34
What is Cushing's disease?
Cushing's syndrome caused by a pituitary adenoma specifically
35
What is Diabetes Insipidus?
Diabetes insipidus is caused by hyposecretion of, or insensitivity to the effects of ADH aka AVP.
Its failure to act causes an inability to concentrate urine in the distal renal tubule, leading to passage of a lot of urine
Passes >3 litres of urine in 24hrs with low osmolality (<300mOsml/kg)
36
What are the 2 major forms of Diabetes insipidus?
Cranial
| Nephrogenic
37
What is Cranial DI?
Decreased ADH secretion, reducing the ability to concentrate urine and so causes polyuria and polydipsia
38
What is Nephrogenic DI?
Decreased ability to concentrate urine because of resistance to ADH in the Kidney
39
What are the 2 other forms of DI?
Gestational
| Primary polydipsia
40
What is Gestational DI?
Degaradtion of Vasopressin by a placental vasopressinase. associated with increased complications of pregnancy
41
What is primary polydispia?
AKA Dipsogenic DI - caused by a primary defect in osmoregulation of thirst. Reported in TB meningitis, MS and Neurosarcoidosis
42
What causes cranial DI?
Acquired
- Idiopathic
- Tumours
- Intracranial surgery
- Head injury
- Granulomata (sarcoidosis, TB, Wegner's granulomatosis)
- Infections (Encephalitis, Meningitis, cerebral abscess)
- Vascular disorders (Haemorrhage/thrombosis, aneurysms, SCD, sheehan's syndrome)
- Post Radiotherapy
Inherited
- Autosomal recessive (Wolfram's syndrome)
- AD mutations of vasopressin gene
43
What causes Nephrogenic DI?
```
Acquired
- Idiopathic
- Hypokalaemia
- Hypercalcaemia
- CKD
- Other metabolic derangements
- Drugs (Ofloxacin, orlistat, lithium)
- Renal tubular acidosis
- Pregnancy
- Post obstructive uropathy
Congenital/genetic nephrogenic DI
- X linked mutations in V2 ADH-receptor gene
- Autosomal recessive defect in aquaporin 2 (AQP2) gene - water channel in distal renal tubule
- Sporadic nephrogenic DI with general learing disability and intracerebral calcificaiton (very rare)
```
44
What are the risk factors for Diabetes insipidus?
```
Pituitary surgery
Craniopharyngioma
Pituitary stalk lesions
Traumatic brain injury
Congenital pituitary abnormalities
Medication
AI disease
Family history/genetic mutations
Pregnancy
Subarachnoid haemorrhage
Renal sarcoidosis/amyloidosis
Hypercalcaemia or hypokalaemia
Release of obstructive uropathy
Previous CNS infection
```
45
What are the symptoms of Diabetes insipidus?
```
Polyuria
Nocturia
Polydipsia
In children: Enuresis (bed wetting), Sleep disturbance
Sensorineural deafness and visual failure
Visual field defects
Motor deficits
Skin lesions
```
46
What are the signs of Diabetes Insipidus?
Urine output >3L/day
Fluid intake < fluid output, signs of dehydration (tachycardia, reduced tissue trigor, postural hypotension)
Signs related to teh cause
47
What are the investigations for Diabetes Insipidus?
Plasma glucose
U&Es
Urine specific gravity
Simultaneous plasma and urine osmolality
MRI of pituitary, hypothalamus and surrounding tissues, including the pineal gland
Fluid deprivation test with response to desmopressin!
48
What results are seen in the fluid deprivation test?
Normally:
- Increased plasma osmolality
- Increased ADH secretion
- Increased water reabsorption
- Increase in urine osmolality (Urine >600 mosmol/kg)
In psychogenic polydipsia:
- Urine osmolality is slightly lower than a normal person
In Diabetes insipidus:
- Lack of ADH means that urine cannot be concentrated
- Urine osmolality is LOW (<400 mosmol/kg)
Cranial - urine osmolality rises >50% following administration of desmopressin; Nephrogenic has a rise of <45% after desmopressin
49
What is the management of Diabetes insipidus?
Treat Cause!
Cranial DI - MRI to find cause, give desmopressin, if mild: chlorpropamide/carbamezapine to potentiate residual effects of any residual vasopressin
Nephrogenic diabetes insipidus - Sodium and/or protein restriction helps with polyuria, thiazide diuretics e.g. bendroflumethiazide
50
What are the complications of DI?
Desmopressin worsens MI in susceptible patients, may be a need for nitrates/other anginal methods
Need careful management of fluid balance and therapy following surgery
Patients with genetic causes of Nephrogenic DI are prone to bladder dysfunction and hydroureter/hydronephrosis
Hypernatraemic dehydration
Thrombosis
Bladder and Renal dysfunction
Iatrogenic hyponatraemia
51
What is Diabetes Mellitus?
Lack of effective endogenous insulin
Leading to serious microvascular (Retinopathy, Neuropathy and Nephropathy) or Macrovascular (stroke, renovascular disease, limb ischaemia, heart disease) problems
52
What is Type 1 diabetes mellitus?
```
Immune destruction of the pancreas
Insulin dependent diabetes
Usually young
Diabetic ketoacidosis
Quite high glucose
```
53
What is Type 2 diabetes mellitus?
```
Resistance to action of insulin
Non-insulin dependent diabetes
Maturity onset diabetes (30-70 years old)
Often overweight
Very high glucose
```
54
What is the cause of T1DM?
Destruction of pancreatic beta cells
AI process
Associated with other AI conditions
90% carry HLA DR3 +/- DR4
Latent autoimmune diabetes of adults is a form of T1DM with slower progression to insulin dependence
T1DM prone to ketoacidosis have sufficient insulin to suppress ketone body
Auto antigens: GAD, Insulin, Insulinoma-associated protein 2, Cation efflux zinc transporter
55
What are the risk factors for T1DM
Geographical region
Genetic predisposition
Infectious agents
Dietary factors
56
What are the symptoms of T1DM?
```
Polyuria
Nocturia
Tiredness
Weight loss
DKA symptoms ( Caused by: Surgery, UTI, MI, pancreatitis, chemo, psychotics, wrong dose)
- Drowsiness
- Confusion
- Kussmaul breathing
- Ketotic breath
```
57
What are the signs of T1DM?
Diabetic retinopathy
Neuropathy
Monitor BP
Associated with AI conditions: Vitiligo, Addison's disease, AI thyroid disease
58
What are the investigations for Diabetes mellitus?
```
Urinalysis > Random glucose (>7.1) > Fasting glucose (>11.1) > OGTT > HbA1c
U&Es - Nephropathy and hyperkalaemia
Lipid profile
Urine A:CR - detect microalbuminaemia
Urine - glycosuria, ketonuria, MSU
```
59
What investigations are done for Ketoacidosis?
Capillary blood glucose > Urine dipstick > ABG (metabolic acidosis)> Plasma osmolality
FBC (leucocytosis)
Fasting C-peptide (Low)
AI markers (Positive)
60
What is the management of T1DM?
Patient education
- Short acting insulin 3x daily or long acting insulin once daily
Insulin pumps
Monitor: Capillary blood glucose, HbA1c every 3-6 months.
Screen and manage complications
61
How do you manage DKA?
```
If Systolic BP <90 give 500ml saline
50U soluble insulin
Continue untill:
Ketones <0.3
Venous pH >7.30
Venous bicarbonate >18
Potassium replacement
Thromboprophylaxis
Broad spectrum ABx
```
62
What are the complications of T1DM?
```
Diabetic Ketoacidosis
Hypoglycaemia
Retinopathy
Diabetic kidney disease
Peripheral or autonomic neuropathy
Cardiovascular disease
```
63
What are the macrovascular complications of T1DM?
Retinopathy
Neuropathy
Nephropathy
64
What are the complications of T1DM treatment?
```
Weight gain
Fat hypertrophy at insulin injection sites
Hypoglycemia
- Personality changes
- Fits
- Confusion
- Coma
- Pallor
```
65
What is T2DM?
Increased peripheral resistance to insulin action, impaired insulin secretion and increased hepatic glucose output. Associated with Obesity, lack of exercise, calorie and alcohol excess
66
What causes T2DM?
```
Genetic predisposition characterised by insulin resistance
Causes:
Obesity
Genetics
Pancreatic disease
Endocrine disease
Drugs
Circulating autoantibodies
```
67
What are the Risk factors for T2DM?
```
Metabolic syndrome
Obesity
Asian ethnicity
TB drugs
SSRIs
Pregnancy
Acromegaly
Renal failure
Cystic fibrosis
PCOS
Werner's syndrome
```
68
What are the symptoms of T2DM?
May be incidental
Polyuria
Polydipsia
Tiredness
Present with hyperosmolar hyperglycaemic state
Infections
Assess cardiovascular RFs (HTN, Hyperlipidaemia, Smoking)
69
What are the signs of T2DM?
```
Calculate BMI
Waist circumference
Blood pressure
Diabetic foot (Dry skin, reduced SC tissue, Ulcerations, Gangrene, Charcot's arthropathy, Weak foot pulses)
Skin changes
- Necrobiosis lipoidica diabeticorum
- Granuloma annulare
- Diabetic dermopathy
```
70
What are the investigations for T2DM?
Urinalysis > Random glucose > Fasting glucose > OGTT > HbA1c
Diagnosed with: Plasma glucose (>7.1), Plasma glucose (>11.1)
Monitor: HbA1c, U&Es, Lipid profile, eGFR,Urine A:CR
Ankle-brachial index (= 0.9)
71
What is the management of T2DM?
Glycaemic control
Initial:
- Lifestyle advice (smoking cessation, diet, exercise)
- Metformin [a Biguanide] increases insulin sensitivity
HbA1c >53 add sulphonylurea [gliclazide]
HbA1c >57 at 6 months consider: Insulin, Glitazone, sulphonylurea, GLP analogues and DPP4 inhibitors, A-glucosidase inhibitors)
Screen for complications, pregnancy, hyperosmolar hyperglycaemic state
72
What are the complications of T2DM?
```
Diabetic kidney disease
Impaired vision
Lower extremity amputation
Cardiovascular disease
Congestive heart failure
Stroke
Infection
Peridontal disease
Treatment-related hypoglycaemia
Depression
Obstructive sleep apnoea
Diabetic ketoacidosis
Non-ketotic hyperosmolar state
Autonomic or peripheral neuropathy
```
73
What is Diabetic Ketoacidosis?
Medical emergency with a significant morbidity and mortality
| Characterised by hyperglycaemia, acidosis and ketonaemia
74
What are the precipitating conditions?
Infection
Discontinuation of insulin
Inadequate insulin
CVS disease
Drug treatments (Steroids, thiazide-like diuretics or SGLT2 inhibitors)
Menstruation
Physiological stress (pregnancy, trauma and/or stress)
75
What is Graves' disease?
AI thyroid condition associated with hyperthyroidism. Associated orbitopathy occurs in 25% of cases and is usually mild
76
What causes Graves' disease?
AI condition, caused by TSH receptor antibodies
| 80% genetic, 20% environmental
77
What are the Risk Factors for Graves' disease?
```
Family history of AI thyroid disease
Female sex
Tobacco use
High iodine uptake
Lithium therapy
Biological agent and cytokine therapies
Radiation
Radioiodinetherapy for benign nodular goitres
Stress
```
78
What are the signs and symptoms of Graves' disease?
```
Heat intolerance
Sweating
Palmar erythema
Weight loss
Palpitations
Tremor
Tachycardia (may be AF)
Urticaria/pruritis
Diffuse goitre
Orbitopathy
Lid lag
Pretibial myxoedema
Proptosis
Onycholysis (detachment of nail from nail bed)
```
79
What are the investigations for Graves' disease?
TSH (suppressed/low)
Serum free or total T4 (Raised)
Serum free or total T3 (elevated)
Total T3/T4 or fT4/fT3 (high compared to thyroiditis)
80
What is Hyperparathyroidism?
An endocrine disorder in which autonomous overproduction of PTH results in derangement of calcium metabolism. In approximately 80% of cases, over-producton of PTH is due to a single parathyroid adenoma, and less commonly, multi-gland involvement may occur
81
What are the types of hyperparathyroidism?
Primary
Secondary
Tertiary
82
What is Primary Hyperparathyroidism?
```
Parathyroid adenoma most common and familial forms are well defined
May be due to external radiation - lithium therapy
Familial causes (MEN1/2a), HPT-JT or familal isolated hyperparathyroidism
```
83
What are the risk factors for primary hyperparathyroidism?
```
Female sex
Age >50-60 years
Family history
MEN (1,2a or 4)
Current or history of lithium treatment
HPT-JT
History of head and neck irradiation
```
84
What are the signs and symptoms for Primary hyperparathyroidism?
```
History of Osteoporosis/Osteopenia
Family history
Nephrolithiasis
Bone pain
Poor sleep
Fatigue
Anxiety
Depression
Memory loss
Myalgia
Paraesthesia
Muscle cramp
Constipation
Overt neuromuscular dysfunction
Abdominal pain
```
85
What are the investigations for primary hyperparathyroidism?
Serum Calcium (raised)
Serum intact PTH with immunoradiometric or immunochemical assay
Serum ALP
Serum phosphorous
24 hour urinary calcium
Tc99m sestamibi scanning and ultrasonography
MRI neck
86
What is the management of primary hyperparathyroidism?
```
Mild, asymptomatic disease:
- Elevated calcium
- 1/3 will have features of HPT
-Avoid dehydration
-Avoid thiazide diuretics
Surgical treatment: parathyroid surgery to remove abnormal glands
Surgical treatment
Medical treatment
```
87
What are the guidelines for surgical treatment?
```
Age under 50
Creatinine clearance <60
Nephrolithiasis
DXA of less than -2.5
Vertebral fracture
```
88
What is the medical treatment for primary hyperparathyroidism?
HRT and Raloxifene in post menopausal women
| Cincalcet reduces serum Calcium and PTH levels and raises serum phosphorous
89
What are the complications for primary hyperparathyroidism?
```
Neck haematoma following surgery
Recurrent and superior laryngeal nerve injury
Hypocalcaemia post-surgery
Pneumothorax post-surgery
Osteoporosis
Bone fractures
Nephrolithiasis
```
90
What is Secondary hyperparathyroidism?
Most commonly in CKD
Parathyroid glands become hyperplastic after long-term stimulation on response to chronic hypocalcaemia
Seen in all patients with dialysis-dependent CKD
Occur in any condition with chronic hypocalcaemia
91
What are the risk factors for secondary hyperparathyroidism?
```
Ageing
Chronic renal failure
Absence of dairy and fish
Malabsorption
Hepatic dysfunction
Genetic disorder
Obesity
Medication use
```
92
What are the signs and symptoms of secondary hyperparathyroidism?
Features of chronic renal failure
Features of underlying malabsorption syndrome
Muscle cramps and bone pain
Perioral tingling or paraesthesia in fingers or toes
Chvostek's/trousseau's sign
Bowed legs or knocked knees
Fractures
93
What investigations are done for Secondary hyperparathyroidism?
Serum Calcium (Decreased)
Serum Intact PTH (Raised)
Serum creatinine (Raised)
Serum Urea Nitrogen (Raised)
94
What is the management of secondary hyperparathyroidism?
Mostly medical - treat underlying conditions
In CKD (calcium supplementation, correct Vit. D analogues, calchimimetics [cincalet])
Parathyroidectomy
95
What are the complications of secondary hyperparathyroidism?
Osteodystrophy
Osteoporosis
Uraemia
Calchiphylaxis
96
What causes tertiary hyperparathyroidism?
Occurs after prolonged secondary glands become autonomous, producing excessive PTH even after cause of hypocalcaemia is corrected
97
How does tertiary hyperparathyroidism present?
Symptoms and signs are due to hypercalcaemia so can be similar to primary hyperparathyroidism
98
What investigations are done for tertiary hyperparathyroidism?
```
Serum Calcium (Raised)
Serum PTH (Raised)
Serum phosphate (Raised)
```
99
How do you manage tertiary hyperparathyroidism?
Cincalet
Total or subtotal parathyroidectomy recommended
Auto transplantation is an easily accessible site
100
What is Hypogonadism?
Female: Impairment of ovarian function
Male: A syndrome of decreased testosterone production, sperm production or both
101
What are the causes of Female hypogonadism?
Primary - Gonadal dysgenesis, gonadal damage, premature ovarian failure, androgen excess
Seconary - Functional, pituitary/hypothalamic tumours, Hyperprolactinaemia, Congenital GnRH deficiency, Post pill amenorrhoea
102
What are the Risk Factors for female hypogonadism?
Turner's/Kallman's
T2DM
Alkylating agents/opioids/glucocorticoids/ sex hormones/ GnRH analogues
103
What are the symptoms of female hypogonadism?
```
Night sweats
Hot flushing
Vaginal dryness
Dyspareunia
Decreased libido
Infertility
Oligo/amenorrhoea
Features of Turner's: Short, cubitus valgus, poor breast development
```
104
What are the signs of female hypogonadism?
Pre-pubertal (Delayed puberty, Eunuchoid)
Post-pubertal (Regression of secondary sexual characteristics, Perioral and periorbital wrinkles)
Kallman's syndrome - anosmia
Turner's syndrome - Short, low posterior hairline, high arched palate, widely spaced nipples, short 4th and 5th metacarpals, congenital lymphoedema)
AI primary ovarian failure
105
What investigations are done for female hypogonadism?
```
Pregnancy test (Negative)
Serum oestradiol (Low)
Serum FSH/LH
Serum prolactin
TFTs
Karyotype
Pelvic imaging
Screen for fMRI
Pituitary function test
Visual field testing
Turner's syndrome
AI oophoritis
```
106
What causes Male hypogonadism?
Primary:
- Gonadal dysgenesis
- Gonadal damage
- Rare causes: Renal failure, liver cirrhosis or alcohol excess
Secondary:
- Pituitary/hypothalamic lesion
- GnRH deficiency (Kallman's)
- Hyperprolactinaemia
- Genetic mutations
- Laurenec-moon-biedl syndrome
- Age
- Prader-willi syndrome
107
What is Laurence-moon-biedl syndrome?
Secondary cause of hypogonadism seen by obesity, polydactyly, retinitis pigmentosa, learning difficulties)
108
What are examples of gonadal dysgenesis?
Klinefelter's syndrome
| Undescended testicles
109
What are the risk factors for male hypogonadism?
```
Age
Kallman's
Prader willi
Klinefelter's
T2DM
Alkylating agents
Opioids
Glucocorticoids
Sex hormones
GnRH analogues
Hyperprolactinaemia
```
110
What are the symptoms of Hypogonadism?
```
Delayed puberty
Decreased libido
Impotence
Infertility
Symptoms of underlying disease: (Intellectual dysfunction [Klinefelter's])
```
111
What are the signs of Hypogonadism?
```
Measure testicular volume using Prader's orchidometer (15-25mL)
Pre-pubetal:
- Signs of delayed puberty (High pitched voice, Decreased pubic hair/ small or undescended testicles/ small penis)
- Gynaecomastia
- Eunuchoid proportions
- Features of underlying cause
Postpubertal:
- Decreased hair
- Soft and small eyes
- Gynaecomastia
- Fine perioral wrinkles
- Features of underlying cause (Visual defects)
```
112
What investigations are done for male hypogonadism?
```
Serum total testosterone (Low)
Sex hormone binding globulin
Albumin
LH and FSH
Karyotyping
Secondary
- Pituitary functions test
- MRI of hypothalamus
- Visual field test / smell test
- Iron testing
Assess bone age
```
113
In both forms of Hypogonadism (male and female), what is seen when discovering LH and FSH?
In primary: Raised
In secondary: Normal/Low
114
What is Hypopiruitarism?
Partial or complete deficiency of one or more pituitary. May arise from a congenital defect during development of the pituitary gland or as a result of acquired diseases of the pituitary gland, the parasellar structure, or the hypothalamus
115
What can cause Hypopituitarism?
```
Neoplastic causes
Vascular causes
Inflammation and infiltrative lesions
Infection
Congenital
Radiotherapy
PItuitary surgery
Other
```
116
What neoplasms cause hypopituitarism?
Pituitary adenoma
Craniopharynigioma
Sellar meningiomas
Pituitary metastases
117
What vascular issues cause hypopituitarism?
Pituitary apoplexy
Sheehan syndrome
Intrastellar aneurysms
118
What inflammatory and infiltrative lesions cause hypopituitarism?
Lymphocytic hypophysitis
Hypophysitis
Haemochromatosis
Sarcoidosis, TB and langerhans cell histiocytosis X
119
What infections
| cause hypopituitarism?
Pituitary abscess formation
Pituitary Tuberculomas
Fungal pituitary disease occurs as a complication of aids but uncommon
120
What are the congenital causes of hypopituitarism?
Pituitary or hypothlamic origin
Transcription factor defects
Mutations in PROP1 cause of familial and sporadic congenital pituitary hormone deficiencies
121
What are the other (Radiotherapy, Pituitary, other) causes of Hypopituitarism?
May follow treatment with external radiation
Pituitary surgery
Traumatic brain injury
Empty sella syndrome
Hypothalamic damage from mass lesions, infections, radiation
Chronic opiate use leads to deficiencies of gonadotrophin
122
What are the Risk Factors for hypopituitarism?
```
Pituitary tumour
Pituitary apoplexy
Pituitary surgery
Cranial radiation
Traumatic brain injury
Genetic defects
Hypothalamic disease
Inflammatory disorders
Empty sella syndrome
Syphillis
Tuberculous meningitis
Severe postpartum haemorrhage (Sheehan)
```
123
What are the signs and symptoms of ACTH deficiency?
Acute: Weakness, dizziness, nausea, vomiting, circulatory collapse, fever, shock
Chronic: Fatigue, pallor, anorexia, weight loss
Children: Delayed puberty, failure to thrive
Hypoglycaemia, hypotension, anaemia, lymphocytosis, eosinophilia, hyponatraemia
124
What are the signs for TSH deficiency?
Tiredness, Cold intolerance, constipation, hair loss, dry skin, hoarseness, cognitive slowing
Weight gain, bradycardia, hypotension
Children: Delayed development, growth restriction and intellectual impairment
125
What are the signs and symptoms of Gonadotrophin deficiency?
Women: Oligomenorrhoea, loss of libido, dyspareunia, infertility, osteoporosis
Men: loss of libido, impaired sexual function, mood impairment, loss of facial, scrotal and body hair, decreased muscle mass, osteoporosis, anaemia
126
What are the signs and symptoms of Growth hormone deficiency?
Decreased muscle mass
Dyslipidaemia, premature atherosclerosis
Children: Growth restriction
127
What are the signs of ADH deficiency?
Polyuria
Polydipsia
Decreased urine osmolality
Hypernatraemia
128
What may also present with features attributable to the underlying cause?
Space-occupying lesions - headaches or visual field deficits
| Large lesions involving hypothalamus - polydipsia and inappropriate ADH
129
What investigations are done for hypopituitarism?
```
Pituitary functions test
Dynamic tests
Serum electrolytes
Serum and urine osmolality
MRI/CT pit
Metyrapone testing of adrenal axis
```
130
How do you manage hypopituitarism?
Apoplexy - IV hydrocortisone + surgery
ACTH - Oral corticosteroids + IV/IM for stressful events
TSH - Levothyroxine after adrenal replacement
Female (with gonadotrophin-releasing hormone) - oestrogen with progesterone, if want fertility: Gonadotrophins.
Males with GNRH - testosterone + gonadotrophins if want to be fertile
Growth hormone - recombinant human growth hormone
ADH - Desmopressin
Anti-CTLA-4 Ab therapy associated hypophysitis - high dose glucocorticoids
131
What are the complications of hypopituitarism?
```
Male infertility
Female infertility
Corticosteroid over-replacement
Thryoxine over-replacement
Desmopression over-replacement
Growth hormone over-replacement
Testosterone over replacement
```
132
What is Hypothyroidism?
Insidious onset with significant morbidity.
| Clinical features often subtle and nonspecific
133
What are the three types of hypothyroidism?
Primary
Secondary
Transient
134
What causes primary hypothyroidism?
```
AI hypothyroidism
Iatrogenic
Drugs
Congenital defects
Infiltration of the thyroid
```
135
What causes secondary hypothyroidism?
Isolated TSH deficiency
Hypopituitarism - neoplasm, infiltrative, infection and radiotherapy
Hypothalamic disorders - neoplasm and trauma
136
What causes transient hypothyroidism?
Withdrawal of thyroid suppressive therapy
Postpartum thyroiditis
Subacute/chronic thyroiditis with transient hypothyroidism
137
What are the Risk factors for hypothyroidism?
```
Iodine deficiency
Female sex
Middle age
Family history of AI thyroiditis
AI disorders
Graves' disease
Post-partum thyroiditis
Turner's and Down's
Primary pulmonary hypertension
MS
Radiotrharpy
Amiodarone, Lithium
T1DM
Textile workers
```
138
What are the symptoms of hypothyroidism?
```
Tiredness
Lethargy
Cold intolerance
Dry skin
Hair loss
Slowing of intellectual activity
Constipation
Decreased appetite with weight gain
Deep hoarse voice
Menorrhagia and later oligomenorrhia or amenorrhoea
Impairedhearing due to fluid in middle ear
Reduced libido
```
139
What are the signs of Hypothyroidism?
Dry coarse skin, hair loss and col peripheries
Puffy face, hands and feet (myxoedema)
Bradycardia
Delated tendon reflex relaxation
Carpal tunnel syndrome
Serious cavity effusions e.g. pericarditis or pleural effusion
140
What are the other presentations for Hypothyroidism?
```
AKI
Female sexual dysfunction
Hypercholesterolaemia
Can develop into myxoedema: Expressionless dull face with peri-orbital puffiness; swollen tongue, sparse hair, pale, cool skin with rough, doughy texture; enlarged heart
Megacolon/intestinal obstruction
Cerebellar ataxia
Psychosis
Encephalopathy
```
141
How does Hashimoto's and atropic thyroiditis present?
Subclinical AI thyroiditis represents early stages of chronic thyroiditis with a soft/firm thyroid gland, usually normal in size or slightly enlarged
142
How does postpartum thyroiditis present?
Occurs in 5-7% within first 6 months
| Most show remission but some may progress to permanent
143
How does subacute thyroiditis?
Referred to as granulomatous, giant cell or de quervian's thyroiditis
Viral infection produces local symptoms and exquisite tenderness of the thyroid gland with nodularity
144
What investigations cause hypothyroidism?
```
Serum TSH - elevated
Free serum T4 - low
Serum cholesterol - often raised
FBC - anaemia
Fasting blood glucose - elevated
Serum CK - may be raised
Serum sodium - may be decresed
Antithyroid peroxidase antibodies - may be elevated
```
145
How do you treat clinical hypothyroidism?
Levothyroxine and maybe liothyronine
For some, it starts at 25 micrograms daily up by 25 every 4 weeks - including: Cardiac disease, severe hypothyroidism, over 50 years old
Drugs e.g. ferrous sulphate, calcium supplemets, rifampicin and amiodarone interfere with T4 absorption
146
How do you treat subclinical hypothyroidism?
Occurs when a patient has TSH over normal but T4 in normal range
TSH > 10 benefits from levothyroxine
Treat those with a history of radio-iodine treatment or positive thyroid
147
How do you treat hypothyroidism in special groups ?(Children, pregnancy, older patients with comorbidity, myxoedema coma)
Children - Levothyroxine can cause pseudotumour cerebri in children
Pregnancy - Wait untill euthyroid to be pregnant
Measure TFT during first, second and third trimester
Older patients - Start at 25 and up in 25mg segments every 4 weeks
Myxoedema coma - elderly patients, presents with reduced consciousness, seizures, hypothermia, features of hypothyroidism
148
What are complications of hypothyroidism?
```
Angina
Resistant hypothyroidism
Atrial fibrillation
Osteoporosis
Myxoedema coma
Complications in pregnancy
```
149
What is Multiple endocrine neoplasia?
An AD condition characterised by a predilection to develop tumours of endocrine glands. They are functioning hormone producing tumours in multiple organs.
150
What are the types of MEN?
MEN 1
- Pituitary adenomas
- Parathyroid tumours
- Pancreatic islet-cell tumours
- Fascial anglofibromas and collagenomas
MEN 2a
- Parathyroid tumours
- Medullary thyroid cancers
- Phaeochromocytoma
MEN 2b
- Same as Men 2a with: marfanoid appearance, neuromas of the GI tract
151
What are the signs and symptoms of MEN1?
Age of onset of tumours is teenage years
Diagnosis in 4th decade of life
Symptoms and signs depend on organs affected!
Pituitary tumours may cause visual defects
152
What symptoms and signs are seen in different MEN1 tumours?
Parathyroid tumours - Hyperparathyroidism - Hypercalcaemia + Nephrolithiasis
Hypergastrinaemia - Zollinger-Ellison syndrome (gastrin secretion)
Hyperinsulinaemia - cancer of pancreatic islet cells
Hyperprolactinaemia
Hypersomatotrophinaemia
153
What are the signs and symptoms of MEN2?
Medullary thyroid cancer - HTN, Episodic sweating, Diarrhoea, pruritic skin lesions, lump in neck
Hypercalcaemia - renal stones, abdominal moans and psychic groans (Constipation, polyuria/polydipsia, depression, kidney stones, fatigue)
154
What are the investigations for MEN1?
Screening first or second degree relatives
Hormone hypersecretion blood tests
DNA testing
155
What are the investigations for MEN2?
Phaeochromocytoma test - 24hr urine metanephrines (followed by abdominal MRI)
Medullary thyroid cancer test - elevated calcitonin conc..
Parathyroid tumours - simultaneously elevated Ca2+ and PTH
156
What is Obesity?
```
A BMI >30
OR defined as waist circumference
- Men
- Low risk = <94cm
- Very high risk = >102cm
- Women
- Low risk = <80cm
- Very high risk = >88cm
```
157
What are the causes for Obesity?
There are genetic factors that affect the risk of becoming obese
There are a few monogenomic forms of obesity (e.g. Leptin deficiency, prader-willi syndrome)
158
What are the signs and symptoms of Obesity?
Noticing that you are gaining weight
Symptoms of complications: T2DM, CHD, Obstructive sleep apnoea
High body weight, BMI, waist circumference
159
What are the investigations for obesity?
```
Measure serum lipids
Measure HbA1c
Hormone profile check
TFTs - hypothyroidism can cause obesity
Other investigations depend on comorbidities
```
160
What is Osteomalacia?
Disorder of mineralisation of bone matrix (Osteoid). There is normal bone but its mineral content is low
161
What causes Osteomalacia?
```
Vitamin D deficiency
- Lack of exposure to sunlight
- Dietary deficiency
- Malabsorption
- Decreased Hydroxy vit-D
- Decrased 1alpha hydroxy vit D
Renal osteodystrophy
Drug-induced - anti-convulsants
Renal phosphate wasting
Fanconi syndrome (phosphaturia, glycosuria, aminoaciduria)
Renal tubular acidosis
Hereditary hypophosphataemic rickets
Tumour induced osteomalacia
```
162
What are the Risk Factors for Osteomalacia?
```
Dietary calcium and Vitamin deficiency
Chronic kidney disease
Limited sunlight exposure
Inherited disorders
Hypophosphaturia
Anticonvulsant therapy
Mesenchymal tumours
Fanconi's syndrome
Pregnancy
Obeisty
Poverty
Alcoholism
Living in countries at high latitude
```
163
What are the symptoms of Osteomalacia?
Osteomalacia
- Bone pain
- Fractures, especially femoral neck
- Proximal myopathy - waddling gait
- Weakness
- Malaise
164
What are the symptoms for Rickets?
Rickets
- Hypotonia
- Growth retardation
- Skeletal deformities
- Knock-kneed, bow legged
165
What are the signs for Osteomalacia?
Bone tenderness
Proximal muscle weakness
Waddling gait
Sign of hypocalcaemia (Trousseau's sign, chvostek's sign)
166
What are the signs for Rickets?
```
Bossing of frontal and parietal bones
Swelling of costochondral junctions
Bow legs in early childhood
Knock knees in later childhood
Short stature
```
167
What are the investigations for Osteomalacia?
```
Serum calcium level (Low)
Serum 25-hydroxy-vit D (Low)
Serum Phosphate level (Low)
Serum urea and creatinine (Ratio elevated)
Intact PTH (High)
Serum ALP (High)
24-hour urinary calcium (Low)
```
168
What is the management of osteomalacia?
Vitamin D and calcium replacement
In malabsorption/hepatic disease: Give Vit D2 (ergocalciferol)
In renal disease or vitamin D resistance give alfacalcidol
Monitor 24hr urinary calcium and weekly plasma calcium
Also monitor: Serum calcium, phosphate, ALP, PTH, Vitamin D
Treat underlying cause!
169
What are the complications of Osteomalacia/rickets?
Insufficiency fractures or pseudofractures
Secondary hyperparathyroidism
Metastatic calcification in renal failure
Hypercalcaemia
Hypercalciuria and kidney disease
170
What is Osteoporosis?
Reduced bone density (-2.5 on DEXA) resulting in bone fragility and increased fracture risk. This is reduced bone mass
171
If trabecular bone affected what types of fractures are common?
Crush fractures of vertebrae (hence littleness and dowagers humps of old women)
172
If cortical bone is affected, what type of fractures are common?
Long bone fracture more likely
173
What causes Osteoporosis?
```
Primary
- Idiopathic
- Post-menopausal
Secondary
- Malignancy
- Endocrine (Cushing's disease, thyrotoxicosis, primary hyperparathyroidism, hypogonadism)
- Drugs - corticosteroids, heparin
- Rheumatalogical
- Gastrointestinal (Malabsorption, liver disease, anorexia)
```
174
What are the Risk factors for Osteoporosis?
SHATTERED + L
```
S - Steroid use
H - Hyperparathyroidism, hyperthyroidism, hypercalciuria
A - Alcohol and tobacco use
T - Thin (BMI <22)
T - Testosterone low
E - Early menopause
R - Renal or liver failure
E - Erosive/inflammatory bone disease
D - Dietary calcium
+
L - Low/malabsorption
```
175
What are the symptoms of Osteoporosis?
```
Often asymptomatic until fractures occur
Characteristic features:
- Neck of femur (after minimal trauma)
- Vertebral fractures (leading to loss of height, stooped posture)
- Colles' fracture
```
176
What are the signs of osteoporosis?
Often NO signs until complications develop
- Tenderness on percussion
- Thoracic kyphosis
- Severe pain when hip flexed and externally rotated
177
What are the investigations for osteoporosis?
```
Calcium (Normal in primary)
Phosphate (Normal in primary)
ALP (Normal in primary)
X-ray diagnosign fractures
Isotope bone scan
DEXA scan
```
178
On a DEXA scan what does the T score indicate?
T >-1 is normal
T -1> or >-2.5 is osteopenia
T
179
What is Paget's disease of the bone?
Characterised by excessive bone remodelling at one (monostotic) or more (polyostotic) sites resulting in bone that is structurally disorganised
Increased bone turnover with increased number of osteoblases and osteoclasts with resultant remodelling, bone enlargement, deformity and weakness
180
What causes Paget's disease of the bone?
Unknown
Genetic factors and viral infection
Excessive bone resorption by abnormally large osteoclasts followed by increased bone formation by osteblasts in a disorganised fashion
Results in an abnormal pattern of lamellar bone
Marrow spaces filled by an excess of fibrous tissue with a marked increase in blood vessels
181
What are the Risk factors for Paget's disease of the bone?
```
Family history
Age > 50 years
Male sex (45-74 years)
Infection
Environmental factors
```
182
What are the symptoms of Paget's disease of the bone?
```
Asymptomatic
Present with insidious onset pain, aggravated by weight bearing and movement
Headaches
Deafness
Increasing skull size
Fractures
```
183
What are the signs of Paget's disease of the bone?
Bitemporal skull enlargement with frontal bossing
Spinal kyphosis
Anterolateral bowing of femur, tibia or forearm
Skin over affected bone may be warm
Sensorineural deafness
184
What investigations are done for Paget's disease of the bone?
Very high ALP
Ca2+ and phosphate - normal
Bone radiographs (enlarged, deformed bones), lytic and sclerotic appearance, lack of distinction between cortex and Medulla
Skull changes (Osteoporosis circumscripta, enlargement of frontal and occipital areas, cotton wool appearance)
Bone scan (assess extent of skeletal involvement, pagetic bone lesions)
Resorption markers (monitor disease activity)
185
What is a Phaeochromocytoma?
Tumour arising from catecholamine-producing chromaffin cells of the adrenal medulla. Occasionally extra adrenal (Phaeochromocytomas or paragangliomas)
186
What are the causes for Phaeochromocytoma?
90% in adrenal medullary catecholamine-producing chromaffin cells
5-10% are multiple
May be sporadic, 40% are hereditary in adults and up to 40% in children
MEN 2A, 2B, von hippel-lindau syndrome
187
What are the Risk factors for Phaeochromocytoma?
MEN 2A/2B
Von Hippel-Lindau
Succinate dehydrogenase
Neurofibromatosis type 1
188
What are the signs and symptoms of Phaeochromocytoma?
```
Headache
Palpitations
Diaphoresis
Hypertension
Hypertensive retinopathy
Pallor
Impaired glucose tolerance/diabetes mellitus
Family history of endocrine disorders
Orthostatic hypotension
Hypercalcaemia
Cushing syndrome
Diarrhoea
Fever
Papilloedema
Abdominal masses
```
189
What are the investigations for phaeochromocytoma?
24-hour urine collection (Raised catecholamines, normetanephrines and creatinine)
Plasma catecholamines (elevated)
Genetic testing (familial disorders)
Complete blood count (Eryhtrocytes)
Serum calcium (elevated)
Serum potassium (Low)
MRI of abdomen and pelvis (hyper-intense to liver)
CTAP (masses, cenral area of low attenuation)
190
What is a non-functioning pituitary tumour?
Benign tumours of the pituitary gland formed from pituitary cells that do not produce any active pituitary hormones
The adenomas can be classes as microadenomas (<1cm) or macroadenomas (>1cm)
191
What are the histological classifications of pituitary tumours?
Chromophobe (70%) - most non-secretory, some cause hypopituitarism, 50% produce prolactin
Acidophil (15%) - secrete GH or prolactin
Basophil (15%) - secrete ACTH
192
What are the causes of Pituitary tumours?
No specific cause
Cause symptoms due to local pressure effect
Can occur as part of MEN 1 syndrome
193
What are the Risk Factors for Pituity tumours (non-functioning)?
MEN 1
Familial isolated pituitary adenomas
Can occur as part of MEN 1 syndrome
194
What are the signs and symptoms of non-functioning pituiary tumours?
```
Develop VERY SLOWLY
Headaches
Pressure on surrounding structures:
- Optic chiasm - Bitemporal hemianopia)
- Cavernous sinus - Palsy CN III, IV, VI
- Normal pituitary gland - Panhypopituitarism
```
195
What are the investigations for non-functioning pituitary tumours?
MRI
CT
Bloods - check hormone levels
Visual field testing
196
What is PCOS?
Hormonal disorder characterised by oligomenorrhoea/amenorrhoea and hyperandrogenism (clinical or biochemical)
Frequently associated with: Obesity, Insulin resistance, T2DM, Dyslipidaemia
197
What is the cause of PCOS?
Environmental and genetic factors
Hyperinsulinaemia results in increased ovarian androgen synthesis and reduced hepatic sex hormone binding globulin
Leads to an increase in free androgens (Which gives rise to the symptoms)
198
What are the Risk factors for PCOS?
```
Family history of PCOS
Premature adrenarche
Low birth weight
Fetal androgen exposure
Environmental endocrine disruptors
```
199
What are the symptoms of PCOS?
Menstrual irregularities
Dysfunctional uterine bleeding
Infertility
Hyperandrogenism: Hirsutism, Male-pattern hair loss, acne
200
What are the signs of PCOS?
Hirsutism
Male-pattern hair loss
Acne
Acanthosis nigricans (signs of severe insulin resistance) - velvety thickening and hyperpigmentation of skin of the axilla or neck
201
What are the investigations for PCOS?
Serum LH - High
Serum LH:FSH - High
High testosterone, androstenedione and DHEA-S
Test for: Hyperprolactinaemia, Hypo/hyperthyroidism
CAH
Cushing's syndrome
Look for impaired glucose tolerance
202
What are the diagnostic criteria for PCOS?
Must have atleast 2 of the following:
- Amenorrhoea/Oligomenorrhoea
- Clinical/biochemical signs of androgen excess (elevated free testosterone)
- PCOS seen on USS
203
What is Primary hyperaldosteronism?
Aldosterone production exceeds the body's requirements and is relatively autonomous with regard to its normal chronic regulator, the renin-angiotensin II system
204
What causes primary hyperaldosteronism?
Aetiology unknown in most cases
Genetic basis
Excessive aldosterone levels act at the distal renal tubule, promoting sodium retention, which results in water retention and volume expansion with hypertension.
There is excretion of potassium resulting in hypokalaemia
205
What are the risk factors for primary aldosteronism?
Family history of primary aldosteronism
| Family history of early onset of hypertension and/or stroke
206
What are the signs and symptoms of primary aldosteronism?
```
Hypertension
20-70 years old
Nocturia
Polyuria
Lethargy
Mood disturbances (Irritability, anxiety, depression)
Difficulty concenctrating
Paraesthesia, muscle cramps
Muscle weakness
Palpitations
```
207
What are the investigations for Primary hyperaldosteronism?
```
Plasma potassium (normal or low)
Aldosterone/Renin ratio (>70)
```
208
How do you manage primary hyperaldosteronism?
Unilateral:
Unilateral laparoscopic adrenalectomy with preoperative aldosterone antagonists (spironolactone) and post-operatively.
Bilateral:
No adrenal lesions, aldosterone antagonists
2nd line: laparoscopic adrenalectomy with pre- and post- operative spironolactone
Familial hyperaldosteronism type I:
Glucocorticoids > Aldosterone antagonists
Children: Amiloride > eplenerone
209
What are the complications of Primary hyperaldosteronism?
```
Peioperative complications
Stroke
Myocardial infarction
Heart failure
Atrial fibrillation
Impaired renal function
Aldosterone antagonist or mineralocorticoid receptor antagonist-induced hyperkalaemia
```
210
What is a prolactinoma?
Benign lactotroph adenomas expressing and secreting prolactin
211
What causes a prolactinoma?
Different types of prolactinoma:
- Microadenoma
- Macroadenoma
- Giant pituitary adenomas
- Malignant prolactinoma
212
What are the risk factors for prolactinoma?
Female gender (20-50)
Genetic predisposition
Oestrogen therapy
Male gender (30-60)
213
What are the symptoms for Prolactinoma?
```
Amenorrhoea or Oligomenorrhoea
Galactorrhoea
Loss of libido
Erectile dysfunction
Visual deterioration (e.g. bitemporal hemianopia)
Headaches
Dry Vagina
Reduced beard growth
```
214
What are the signs for prolactinoma?
```
Osteoporosis
Ophthalmoplegia
Infertility
Hypopituitarism
Cranial nerve palsies
```
215
What investigations are done for Prolactinoma?
```
Exclude pregnancy
TFTs (Normal)
Serum Prolactin (Raised)
Pituitary MRI (Characteristic features)
Visual-field exam
```
216
What managements are done for Prolactinoma in pre-menopausal women?
Asymptomatic Microprolactinomas - observe
Symptomatic microprolactinomas - Dopamine agonist (Cabergoline then bromocriptine) > Combined oral contraception > Trans-sphenoidal surgery > Sellar radiotherapy
Microprolactinomas who desire pregnancy or macroprolactinomas - Dopamine agonist (Cabergoline then bromocriptine)> Trans-sphenoidal surgery > Sellar radiotherapy
217
What managements are done for post-menopausal women?
Microadenomas - observations
| Macroadenomas - Dopamine agonist (Cabergoline > Bromocriptine) > Trans-sphenoidal surgery > Sellar radiotherapy
218
What are the complications for Prolactinoma?
Visual field impairment
Anterior pituitary failure and/or diabetes insipidus
Hypopituitarism associated with radiotherapy
Cabergoline-associated valvular insufficiency
Pituitary apoplexy
Cerebrospinal fluid leakage
219
What is SIADH?
Continuous secretion of ADH, despite the absence of normal stimuli for secretion. Plasma vasopressin concentration is inappropriate for teh existing plasma osmolarity
220
What is the cause SIADH?
Drugs (SSRI, amiodarone, carbamezapine)
Pulmonary processes (Infections)
Malignancy (Gastro, lung)
CNS disorders: CNS infections, brain trauma
Lung: Pneumonia, TB, abscess, aspergillosis
Anaesthesia and postoperative state
Nephrogenic SIADH or pseudo siadh caused by gain of function mutations in V2
221
What are the risk factors for SIADH?
```
Age >50 years
Pulmonary condition (e.g. pneumonia)
Nursing home residence
Malignancy
Medicine associated with SIADH induction
CNS disorders
Postoperative state
Endurance exercise
```
222
What are the symptoms for SIADH?
```
Decreased urine volume, concentrated urine
Mild hyponatraemia
Headache
Nausea/vomiting
Muscle cramp/weakness
Irritability
Confusion
Drowsiness
Convulsions
Coma
```
223
What are the signs for SIADH?
```
Mild hyponatraemia (no signs)
Severe hyponatraemia (reduced reflexes, extensor plantar reflexes)
Signs of underlying cause
```
224
What investigations are done for SIADH?
```
Serum Sodium (<135)
Serum Osmolality (<280)
Serum Urea (<3.6)
Urine sodium (>40)
Urine osmolality (>100)
Serum cortisol (>138)
CXR
CT/MRI
```
225
What is the management for SIADH?
Severe symptoms
IV hypertonic saline + fluid restriction, treat cause + furosemide
Mild to moderate: Treat cause + fluid restriction
Asymptomatic (Na+ = 125)
Fluid resuscitation + treat underlying cause
How do you treat ongoing SIADH?
Fluid restriction + treat underlying cause > Tolvaptan > Sodium chloride > Demeclocycline
226
What are the complications of SIADH?
Central pontine myelinolysis - brain used to hyponatraemia.
| Overcorrection of hyponatraemia, seizures, death and come can occur
227
What is thyroid cancer?
Malignancy arising in the thyroid gland
228
What are the types of Thyroid cancer?
```
Papillary
Follicular
Medullary
Lymphoma
Anaplastic
```
229
What are the causes of thyroid cancer?
Unknown
230
What are the risk factors for Thyroid cancer?
Childhood exposure to radiation
Medullary thyroid cancers may be familial or associated with MEN 2a or 2b
Lymphoma associated with Hashimoto's thyroiditis
231
What are the symptoms of Thyroid cancer?
Slow-growing neck lump
Discomfort swallowin
Hoarse voice
232
What are the signs of thyroid cancer?
Palpable nodules or diffuse enlargment of thyroid gland
Cervical lymphadenopathy > suspect malignancy
Patient is usually euthyroid!
233
What are the investigations for Thyroid cancer?
TFTs (TSH normal)
Bone profile
Thyroid autoantibides if hashimotos/graves
Tumour markers (thyroglobulin (papillary and follicular), calcitonin (medullary))
CXR with thoracic inlet (goitres and mets)
USS
Radionulcide scan
FNA cytology
234
What are thyroid nodules?
Abnormal growth of thyroid cells that forms a lump in the thyroid gland
235
What causes thyroid nodules?
Vast majority of thyroid nodules are benign, small proportion turn into thyroid cancer
Most nodules are adenomatous and most are multiple
Nodules are usually non-functioning
236
What are the risk factors for thyroid nodules?
Family history
Age
Women
Radiation
237
What are the symptoms for Thyroid nodules?
Asymptomatic
Potential pain/rarely tracheo-oesophageal compression
Nodular goitre rather than smooth
Single nodule more likely to be malignant
238
What are the signs for thyroid nodules?
Nodule moves when swallowing
| Check for regional lymphadenopathy (consider malignancy)
239
What investigations are done for thyroid nodules?
```
TFTs (normal, can be hypo)
Ultrasound
FNA (Allows cytological analysis)
Radionuclide isotope scanning (Checks iodine uptake)
CT/MRI - detect spread
```
240
What is thyroiditis?
Inflammation of the thyroid gland
241
What causes thyroiditis?
```
Hashimoto's - AI condition
De Quervian's thyroiditis - Painful dysphagia, pyrexia (Virus attacks - present hyperthyroid, once virus void, euthyroid)
Post partum thyroiditis
Drug-induced thyroiditis
Acute or infectious thyroiditis
Riedel's thyroiditis
```
242
What are the symptoms of thyroiditis?
Hypothyroidism (Fatigue, constipation, dry skin, weight gain, cold intolerance, acute or infectious thyroiditis, riedel's thyroiditis)
Of rapid enlargement of the thyroid gland:
- Dyspnoea
- Dysphagia
- Tenderness
243
What are the investigations for thyroiditis?
```
Histology: diffuse lymphocytic and plasma cell infiltration with formation of lymphoid follicles
TSH - Raised
Anti-TPO / Anti-thyroglobulin antibodies
Thyroid ultrasound
Radiomuclide isotope scanning
CRP/ESR raised
```
244
What is the management of thyroiditis?
Pharmacological
- Thyroid hormone replacement - oral levothyroxine sodium
- Titrate dose based on patients need
Surgical
- Considered if large goitre causing symptoms
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What are the complications of Thyroiditis?
Thyroid hormone over-replacement
Hyperlipidaemia
Hashimoto's encephalopathy
Myxoedema coma
