Endocrinology

Question 1

Carcinoid syndrome Management (localised)

Answer 1

NO distant mets

Surgical resection + peri-op octreotide infusion (prevents crisis)

Question 2

Carcinoid syndrome Management (metastatic)

Answer 2

Resection + octreotide infusion if suitable
NOT suitable;
Octreotide 100-600mg/day SC then 20-30mg IM once dose established. Alternative: IFN a
Second line: hepatic transarterial embolisation
Third: radionucleotide therapy with labelled SSAs

Question 3

Complications of carcinoid syndrome

Answer 3

Crisis: flushing, severe BP drop, bronchospasm. Mx = octreotide
Carcinoid heart dx: tricuspid and pulonary regurg -> RHF (oedema, SOB) Mx: Na/H2O restriction +/- loop diuretic +/- digoxin

Question 4

Prognosis of carcinoid syndrome

Answer 4

95% 5yr survival
80% with liver mets
Poorer with cardiac disease

Question 5

Graves Disease Management Thyroid storm

Answer 5

1. Propylthiouracil 500-1000mg PO loading dose, then 250mg PO every 4hrs OR carbimazole
   
   2. AND hydrocortisone 300mg IV loading dose then 100mg TDS
   3. AND propranolol 60-80mg PO immedaite release evry 4-6hrs
   4. AND Iodine/K iodide (Lugol solution) 5 drops (250mg) PO Every 6hrs
   5. Potential adjuncts: colestyramine (bile acid sequester to reduce enterhepative circulation of thryoid hormones Lithium (reduces hormone secretion)

Question 6

Graves management subclincal

Answer 6

Treat TSH <0.1mlU/L in >65yo and post-menopausal women (not on oestrogens or bisphosphonates), OR patients with Cardiac RF/disease, osteoporosis or symptoms of hyperthyroidism

Question 7

Graves anti-thyroid drugs management symptomatic (not pregnant/lactating)

Answer 7

1. Medical: Carbimazole 20-40mg/day PO adjust dose to response (usual maintenance 5-15mg/day)
   a. Second option: propylthiouracil 150-400mg/day
   b. Alternative: Block and replace (high dose anti-thyroid plus levothroxine)
   Adjunct: propranolol for symptom relief

Question 8

Graves disease management options categories

Answer 8

1. medical
2. radioiodine
3. sugery

Question 9

Graves management medical (not antithyroid)

Answer 9

Radioiodine + PO pred 30-40mg OD PO 4wks then taper dose

Question 10

Graves management surgery

Answer 10

Thyroid surgery

(sub)total resection preferred to eliminate risk of future hyperthyroid

Question 11

Graves disease monitoring

Answer 11

MONITOR TFTs at 6 weeks, 3 months, 6 months, 12 months

Question 12

Graves disease management pregnant/lactating

Answer 12

1. Propylthiouracil 50-300mg/day over three doses +/- propranolol
   Surgery only in second trimester in patients with anti-thyroid allergies

Question 13

Graves disease Complications

Answer 13

Thyroid storm
Hypothyroidism: dose adjustment +/- levothyroxine
Arrhythmias (AF): beta blockade and anti-thyroid
Orbitopathy: drops, sun glasses consider short course low dose steroid
Dermatopathy: topical steroids
Radio + surgery: permanent hypothyroidism
Surgery: recurrent laryngeal n. injury

Question 14

Graves prognosis

Answer 14

Generally good especially with good monitoring
Not ‘curable’ options are to supress gland with meds or definitive management will mean life long replacement
Thyroid storm carries 20-30% mortality (likely factor of other comorbidities)