Endocrinology (Quesmed) Flashcards
What is Acromegaly?
What usually causes it?
It is a hormone condition due to Excess Growth Hormone Secretion, usually due to a secreting Pituitary Adenoma
What are the signs of Acromegaly?
- Outward growth of the Jaw and Head with increased Interdental Spacing and Macroglossia
- Increased Sweating (Oily)
- Large Heads and Feet
Coarse Facial Features
Headaches
!!!!Erectile Dysfunction
Mood Disturbances
Voice Change
Fatigue
What investigations should be ordered in Acromegaly?
What is done first?
What big thing is measured next?
What are the 2 imaging options?
IGF-1 (to Screen)
If it is raised or equivocal- measure GROWTH HORMONE following the intake of Oral Glucose (ORAL GLUCOSE TOLERANCE TEST) to see if Growth Hormone is Inappropriately Suppressed (this Confirms)
If Acromegaly has been diagnosed, an MRI should be performed to assess the size and the extent of the tumour
If MRI is contraindicated, CT is second line. If the tumour is too close to the optic chiasm, assess Visual Fields
What is the management of Acromegaly?
Trans-sphenoidal Surgery
If Refractory or if they can not undergo surgery-
- Somastatin Receptor Ligands (OCTREOTIDE)
- Pegvisomant (GH Analogue)
- Cabergoline (Dopamine Agonist)
- Radiotherapy
Measure IGF1 and random Growth Hormone 3 months after the surgery
What are the complications of Acromegaly?
One that happens in 80% of people?
3Cs and 3Hs what is seen in Congestive cardiac failure (2)
5 more
Sleep Apnoea (happens in 80%)
Congestive Heart Failure (Cardiomegaly and LVH- ECHOCARDIOGRAPHY to CHECK for THIS)
Hyperhidrosis
Carpal Tunnel Syndrome
Hypertension
!!!!!!!Cerebrovascular Disease
!!!!!!Hypopituitarism
Arthritis
Increased Risk of Colonic Polyps that can turn cancerous (so COLONOSCOPY every 5 years)
!!!!Visual field defects
Ischaemic Heart Disease
Type 2 Diabetes Mellitus
What kind of Tumours are associated with the 3 Multiple Endocrine Neoplasias (MEN)?
MEN1 (3Ps)
- Pituitary
- Pancreas
- Parathyroid
MEN2a (3Cs)
- Calcitonin (Medullary Thyroid)
- Calcium (Parathyroid)
- Catecholamines (Pheochromocytoma)
MEN2b (Big and Belly)
- Medullary Thyroid
- Phaeochromocytoma
- Mucosal tumours (GI Tract)
What is Adrenal Insufficiency?
Destruction of Adrenal Cortex leading to reduction of Glucocorticoid Production
What are the Primary Causes of Adrenal Insufficiency? (Addison’s)
What should be suspected if there is haemorrhagic shock?
What is the most common cause and most common cause in the developing world?
What 3 are the least common but still happen?
Autoimmune (most common)
Surgical removal
Trauma
Infections (TB- most common in developing world)
Haemorrhage (Waterhouse-Friderichsen Syndrome) (look for SHOCK)
Infarction
!!!!!(Neoplasm, Sarcoidosis, Amyloidosis (less common))
What are the Secondary Causes of Adrenal Insufficiency?
(Brain causes)
Congenital
Base of Skull Fracture
Surgery/ Radiotherapy
Neoplasm
Infiltration or Infection of the Brain
!!!!!CRH Deficiency
What are the signs of Adrenal Insufficiency?
What is only seen in Primary?
!!!!Fatigue and Weakness
!!!!GI Symptoms (nausea, vomiting, weight loss)
!!!!Syncope
- Hyperpigmentation (due to HIGH ACTH Precursors)- Palmar Creases- !!!!only seen in PRIMARY- not secondary
- Hypotension
- Hypoglycaemia
- Hyponatraemia, Hyperkalaemia and !!!!!Weight Loss- Addison’s
so SALT CRAVING
What Investigations should be ordered in Adrenal Insufficiency/ Addison’s?
What is the first line and second line?
When are the Renin and Aldosterone levels affected and how are they affected?
What things should be done to establish the cause?
!!!!!FIRST LINE- Morning Serum Cortisol (low)
SECOND LINE- Short Synacthen (Cortisol Levels do not rise)
LOW Sodium
Low Glucose
Low Cortisol
Low Aldosterone (in Addison’s)
HIGH Potassium
High Renin (in Addison’s)
ACTH is high in Primary Insufficiency, low in Secondary Insufficiency
ACTH (Short Synacthen Test) is used to confirm the diagnosis
To Establish Cause-
1) Adrenal Auto-antibodies
2) Chest Xray
3) CT of the Adrenals
4) MRI of the Brain
What is the management of Adrenal Insufficiency?
What should be done in an Addisonian Crisis?
Hydrocortisone for Glucocorticoid Replacement
Fludrocortisone for Mineralocorticoid Replacement
What is the management of Addisonian Crisis?
- Aggressive Fluid Resuscitation (1L of Saline) and IV Steroids (Hydrocortisone)
- !!!!!!Glucose is used if there is Hypoglycaemia
What are some facts about Amiodarone Induced Thyrotoxicosis?
What investigations should be ordered?
TFTs should be completed as part of drug monitoring with Amiodarone
Amiodarone can directly trigger thyroid disease through Thyroiditis or can trigger an underlying Autoimmune Thyroid Disease
To correctly diagnose the type of Amiodarone Induced Thyrotoxicosis- check the Patient’s Antibody Status and undertake Specialist Imaging of the Thyroid Gland like
1) Thyroid Uptake Scan
2) Colour Flow Doppler Ultrasound
Amiodarone Induced Thyrotoxicosis Type 1 show NORMAL UPTAKE on scans and INCREASED VASCULARITY on Doppler Imaging
Amiodarone Induced Thyrotoxicosis Type 2 show DECREASED UPTAKE and REDUCED VASCULARITY
What is the Management of Amiodarone Induced Thyrotoxicosis?
Steroids plus Antithyroid (Carbimazole)
Discuss whether Amiodarone needs to be continued
What are the Mechanisms of Action of the 7 types of Antidiabetics?
Biguanides (Metformin)
- Increase Peripheral Insulin Sensitivity and Hepatic Glucose Uptake
Sulfonylureas (Gliclazide)
- Depolarise Islet Cells in the Pancreas increasing the Insulin Release
Thiazolidinediones (Pioglitazone)
- Increases Peripheral Insulin Sensitivity
SGLT2 Inhibitors (Dapgliflozin)
- Increase Urinary Glucose Loss
DPP4 Inhibitors (Sitagliptin)
- Inhibit GLP1 Breakdown
GLP1 Analogues (Exenatides)
- Increase Insulin Secretion and Sensitivity
Intestinal Alpha-Glucosidase Inhibitors (Acarbose)
- Delay Intestinal Carbohydrate Absorption
What are Carcinoid Tumours?
Malignant tumours that develop in the Neuroendocrine System. The Appendix and Small Intestine are common origins. 5-10% of the tumours secrete Hormones- especially SEROTONIN
What are the signs of Carcinoid Tumours?
What are the 3 core symptoms?
*Diarrhoea
*Flushing
*Wheeze
Abdominal Pain
Pulmonary Stenosis
These symptoms are caused by Serotonin and its breakdown products on the Systemic Circulation.
Patients with Gastrointestinal Carcinoid Tumours only experience these symptoms if they have LIVER METASTASES, as the products of the tumours can drain straight into the Hepatic Veins without undergoing metabolism in the liver itself.
What is the management of Carcinoid Tumours?
Octreotide to inhibit the tumour products
Surgical Resection to decrease the Tumour Size
What investigation should you order if you suspect Carcinoid Tumours?
Urinary 5HIAA (it is a product of Serotonin)
What is Charcot Arthropathy?
The Bones and Joints get destroyed after the Sensory Nerves are Lost
It is a Chronic Destructive Disease of the Bone and Joints in Patients with Neuropathy
It is characterised by Painful or Painless Bone and Joint Destruction in Patients with Limbs that have lost Sensory Innervation
Bones get destroyed after sensory nerves stop working
What is the main cause and other cause of Charcot Arthropathy?
Diabetes causing Autonomic and Peripheral Neuropathy
Also SYPHILIS can cause it
What is the main differential to rule out in Charcot’s Arthropathy?
Osteomyelitis
What are the signs of Charcot’s Arthropathy?
Swollen, red, inflamed joint that is most likely painful in the context of NEUROPATHY
5Ds
Destruction
Deformity
Degeneration
Dense Bones
Debris
Generally affecting the TARSOMETATARSAL JOINTS in the feet
What is the management of Charcot Arthropathy?
Conservative (Avoid using the joints/ bones)
- Prolonged Immobilisation (Offloading)
- Orthotics (braces, splints)
Medications (Bone, Nerve, Pain)
- Bisphosphonates
- Neuropathic Pain Agents
- Topical Anaesthetics
Surgical
- Resection of Bony Prominences
- Deformity Correction
- Amputation
What are the causes of Cushing’s Syndrome?
ACTH-dependent= Pituitary Tumour, Ectopic ACTH-producing Tumours
Non-ACTH dependent= Adrenal Adenomas, Adrenal Carcinomas
What are the signs of Cushing’s Syndrome
Moon Face
Obesity with Centripetal Obesity
Striae
Bruising
Interscapular and Supraclavicular Fat Pads (Buffalo Hump)
!!!!!!!!!!Erectile Dysfunction (Impotence)
!!!!!!!Osteopenia and Osteoporosis
!!!!!!!Acne and Hirsutism
!!! Opposite of Adrenal Insufficiency -HYPOKALAEMIA and HYPERTENSION
HYPERGLYCAEMIA
Proximal Myopathy
Thin Skins
Thin Limbs
What Investigations should be ordered in Cushing’s Syndrome?
FIRST= Wean them off any steroid medications they are on
To confirm High Cortisol=
1) Low dose Dexamethasone Suppression Test
2) 24 Hours Urinary Cortisol
To Localise it=
1) Plasma ACTH
2) High dose Dexamethasone Suppression Test
3) !!!!!!Inferior Petrosal Sinus Sampling
4) MRI of the Pituitary
5) CT Chest and Abdomen (suspected Tumour)
What is the management of Cushing’s Syndrome?
First= MEDICAL THERAPY before Surgery
Medical=
- Metyrapone (to block Synthesis of Steroids)
- Also can give Ketoconazole (Adrenolytic Agent), Mifepristone (Glucocorticoid Antagonist) and Pasireotide (Somatostatin Receptors)
Surgical=
- Pituitary Tumour Resection
- If high cortisol continues after surgery- Radiotherapy is needed
Post surgery= Steroid Replacement, give them a STEROID CARD and MEDIC ALERT BRACELET
What is Nelson’s Syndrome?
After a Bilateral Adrenalectomy has been done (like AFTER CUSHING’s TREATMENT)
There is LOSS of feedback to the brain so we get high CRH from the hypothalamus
This leads to an increase in Anterior Pituitary activity and the formation of an Adenoma
This causes Headaches, Visual Field Defects and Skin Pigmentation
How does Cortisol increase Plasma Glucose?
It Inhibits Insulin-mediated Glucose Disposal
What is the most common type of Ectopic ACTH Production? And what are the investigations that should be ordered?
Small Cell Lung Carcinoma- Increased Skin Pigmentation
- Plus look out for signs of OTHER Lung conditions (COPD, Weight Loss, Pneumonia)
NO Suppression of cortisol in Low or High Dose Dexamethasone administration
High ACTH
What is the most common cause of Exogenous Cushing’s Syndrome?
Oral Corticosteroids
What are the investigations for a Pituitary Adenoma in Cushing’s?
!!!!!!!!!!!!!Both Cortisol and ACTH are SUPPRESSED after High Dose Dexamethasone
Cortisol High after Low Dose Dexamethasone
Cortisol Normal after High Dose Dexamethasone
ACTH high
Perform MRI of the Pituitary
What are some of the main side effects of Steroids?
1) Cushing’s symptoms
2) Psychiatric- Mania, Psychosis, Depression
3) Increased appetite
4) IMMUNOSUPPRESSION
5) !!!!!!GLAUCOMA and CATARACTS
6) !!!!!!Intracranial Hypertension
MINERALOCORTICOID
- Fluid Retention
- Hypertension
What should be suspected if a patient presents with Cushing’s like Symptoms with Raised 24 Hour Cortisol and raised ACTH but NORMAL DIURNAL VARIATION of Cortisol?
What other test can you use to differentiate this?
Chronic Alcoholism
Use the Insulin Test to differentiate
What is Diabetes Insipidus?
It is the Abnormal Quantity of ADH (Cranial Cause)
or Abnormal Response to ADH (Nephrogenic Cause)
What are the signs of Diabetes Insipidus?
Large Volumes of Dilute Urine
(>3 litres in 24 hours and Serum Osmolality<300)
Patients also have Nocturia and Excessive Thirst
Signs of Hypernatraemia
- Lethargy
- Thirst
- Weakness
- Confusion
- Coma
What are the causes of Cranial (5) and Nephrogenic (4) Diabetes Insipidus?
Cranial
- Head Trauma
- !!!!!!!!!Inflammatory Disease (Sarcoidosis)
- Cranial Infections (Meningitis)
- Vascular Conditions (Sickle Cell Disease)
- Rare Genetic Cause
Nephrogenic
- Drugs (Lithium)
- !!!!!!!!!!!!! Metabolic Disturbance (Hypercalcaemia, Hyperglycaemia, Hypernatraemia, Hypokalaemia)
- Chronic Renal Disease
- Rare Genetic Cause (Wolfram’s Syndrome)
What investigations should be ordered in Diabetes Insipidus?
What can be done to confirm if still uncertain?
Baseline=
1) Urea and Electrolytes
2) Blood Glucose (to rule out Diabetes Mellitus)
3) Urine Dip
4) Paired Serum and Urine Osmolality
SERUM Osmolality is raised (>290), URINE Osmolality is low (<700)
SERUM Sodium is raised, URINE Sodium is low
You can also do a Fluid Deprivation Test if the diagnosis is unclear
What is the management of Cranial and Nephrogenic Diabetes Inspidus?
What should be monitored with treatment for Cranial Diabetes Insipidus?
Cranial
- Desmopressin
- Sodium should be monitored as there is a risk of HYPONATRAEMIA
Nephrogenic
- !!!!!!!!!!!!THIAZIDES
- Correcting Metabolic Abnormalities and stopping any offending drugs
- High dose Desmopressin can be used
- Other treatments= Thiazide Diuretics and NSAIDs to reduce Urine Volume
What are the causes of Diabetic Ketoacidosis?
Infection (so may have Fever cos of this)
Dehydration
Fasting
First Presentation of Type 1 Diabetes
What are the signs of DKA?
There is basically just 4 with others linked to them
1) Fruity Acetone Breath
2) !!!!!!Hyperventilation (Kussmaul)
3) Abdominal Pain
4) Vomiting
- Therefore-
Dehydration
!!!!!Hypovolaemic Shock
Drowsiness
Coma
What investigations should be ordered if DKA is suspected?
What metabolic sign is seen?- consider the fact that they are going to be vomiting a lot
Blood Glucose (>11.1mmol/L)
Blood Ketones (>3mmol/L)
pH<7.3 or Bicarbonate<15
Blood Gas
Urinary Ketones and Glucose
HYPOKALAEMIA may be present- ECG may show HYPOKALAEMIA or ISCHAEMIC Changes
What are the 5 types of Diabetic Neuropathy?
Distal Symmetry Sensory Neuropathy
- MOST COMMON
- Caused by loss of Large Sensory Fibres
- Glove and Stocking Distribution
- Often Affecting Touch, Vibration and Proprioception
Small-fibre Predominant Neuropathy (Touch is NOT AFFECTED- so no tingling- just loss of pain and temp)
- Caused by loss of Small Sensory Fibres
- Presents with Deficits in Pain and Temperature Sensation in a Glove and Stocking Distribution along with episodes of Burning Pain (Touch Preserved)
Diabetic Amyotrophy (Amyotropy= Hips/ Thighs instead of Glove/ Stocking)
- Caused by Inflammation of Lumbosacral Plexus or Cervical Plexus
- Severe pain around Thighs or Hips
- Proximal Weakness
Mononeuritis Multiplex (loss of REFLEXES in the affected area)
- Invariable Pain
- Neuropathies involve TWO Peripheral Nerves
Autonomic Neuropathy (Non-myotome/dermatome specific)
- Postural Hypotension
- Gastroparesis
- Constipation and Urinary Retention
- Arrhythmias
- Erectile Dysfunction
What is the first line treatment of Diabetic Neuropathy?
Pregabalin, Duloxetine and Gabapentin
What is the first line management of Gastroparesis in Autonomic Neuropathy in Diabetes?
Stabilise the Blood Sugar Levels
What are the types of Diabetes Retinopathy?
Non-Proliferative Diabetic Retinopathy (NPDR)
Proliferative Diabetic Retinopathy (PDR)
What is seen in the Fundoscopy for Diabetic Retinopathy?
If Milder Disease-
- Dots (Microaneurysms)
- Hard Yellow Exudates (Lipid Deposits)
- Blots (Haemorrhages)
If Significant Ischaemia-
- Engorged Tortuous Veins
- !!!!Cotton Wool Spots
- Large BLOTS (Haemorrhages)
In PDR, new blood vessels can be seen in the retina
What is Diabetic Maculopathy?
It is a Macular Oedema caused by Leakage of the Vessels close to the Macula
What 3 features on Ophthalmology warrant IMMEDIATE Referral to an Opthalmologist in Diabetes Retinopathy?
- Proliferative Retinopathy (New Blood Vessels)
- Vitreous Haemorrhage
- Advanced Retinopathy with Retinal Detachments
What are the 5 possible causes of Erectile Dysfunction?
- Vascular Diseases (Atherosclerosis)
- Autonomic Neuropathy (Penile Denervation due to Diabetes or !!!!!Increased Alcohol Intake)
- !!!!!!Drugs (Antihypertensives)
- Psychogenic
- !!!!!Endocrine Causes (!!!!!Prolactinoma, Hypogonadism)
What are the 7 possible causes of Erectile Dysfunction?
- Vascular Diseases (Atherosclerosis)
- Autonomic Neuropathy (Penile Denervation due to Diabetes or Increased Alcohol Intake)
- Drugs (Antihypertensives)
- Psychogenic
- Endocrine Causes (Prolactinoma, Hypogonadism)
- Pelvic Surgery (Bladder, Prostate)
- Anatomical Abnormalities (Peyronie’s Disease)
What investigations should be ordered in Erectile Dysfunction?
Sexual and Psychological History
9am TESTOSTERONE is the most important
Blood Tests- Full Blood Count, Urea and Electrolytes, Thyroid Function, Lipids, Testosterone, Prolactin
What is the management of Erectile Dysfunction?
Oral Phosphodiesterase Inhibitors (Sildenafil)
Psychosexual Therapy
Vacuum Aids
Intra-cavernosal Injections
Prosthesis
Tell them to STOP CYCLING if they cycle more than 3 times a week
What are the Contraindications and Cautions of using Sildenafil?
Contraindicated in:
1) !!!!!!Those taking Nitrates
2) Uncontrolled Hypertension (>170/100)/ Hypotension
3) Arrhythmias
4) Unstable Angina
5) Stroke (last 6 months)
6) Recent Myocardial Infarction (last 3 months)
7) Heart Failure (last 6 months)
Caution in:
1) Angina
2) !!!!Peptic Ulcer
3) !!!!!!Liver or Kidney Impairment
4) !!!!!Peyronie’s Disease
5) !!!!!!Complex Antihypertensive Regimes (Remember this is a cause of Erectile Dysfunction as well)
What are the possible results of a Fluid Deprivation Test?
(Does giving Desmopressin help with the Urine Osmolality?)
1) Cranial Diabetes Insipidus-
- Low Urine Osmolality (<300) after Fluid Deprivation
- But Normalised Osmolality after DESMOPRESSIN is given as issue is that the hormone isn’t produced
- Treat with Desmopressin
2) Nephrogenic Diabetes Insipidus-
- Urine Osmolality is low even after Desmopressin is given as issue is that there is resistance to the hormone
- Treat the reversible causes and ensure Adequate Fluid Intake. Desmopressin, Thiazide Diuretics and Prostaglandin Synthase Inhibitors can be given
3) Primary Polydipsia-
- Urine Osmolality is normal after Fluid Deprivation and after Desmopressin
What are the causes of Galactorrhoea in Men?
What are the 4 drugs associated with it?
- Idiopathic
- Prolactinoma
- !!!!!!!Drugs- Antipsychotics, SSRIs, Cimetadine, Beta Blockers
- Metabolic Conditions- Hypothyroidism, Liver Disease, Chronic Renal Impairment
What is the management of Galactorrhoea in Men?
Switch medications if that is the suspected cause
!!!! If they have a significant mental health issue (like Schizophrenia), then give a dopamine agonist like Cabergoline/ Bromocriptine to help counter the side effects of the Antipsychotic they are taking
But this can make the original drug less effective
What are the causes of Smooth and Nodular Goitres?
Which 2 drugs cause a smooth goitre and which condition causes a painful one?
What 2 infiltrations can cause Smooth Goitres?
Smooth Goitres-
- Grave’s Disease
- Hashimoto’s Disease
- Drugs (Lithium and Amiodarone)
-!!!!!Iodine Deficiency or Excess
- De Quervain’s Thyroiditis (PAINFUL)
- !!!!!!!!!!!!!!!!!Infiltration (Sarcoid/ Haemochromatosis)
Nodular Goitres (Cysts and Cancers)-
- Toxic Solitary Adenoma
- Non-Functional Thyroid Adenoma
- Multinodular Goitre
- Thyroid Cyst
- Cancer
What investigations should be conducted if there is a Goitre in the context of Hyperthyroidism?
Ultrasound Scan and Radioisotope Scan
