Miscellaneous- Endo Flashcards
Causes of hypoglycaemia
Diabetics- excess insulin or se of sulfonylureas
Non-diabetics- EXPLAIN (exogenous drugs, pitiatary insufficiency, liver disease, addisons, insulinoma, non-pancreatic neoplasm)
What is HHS
Hyperosmolar hyperglycaemia is a medical condition resulting in marked hyperglycaemia, hyperosmolality and mild/no ketosis
What is the tx for HHS
1) normalise osmolality
2) Fluid replacement
3) slow infusion of insulin
4) correct potassium if required and give lmwh
What are the lab values for DKA (glucose, ph, bicarbonate and ketones)
Glucose >11.1
Ph<7.3
Bicarbonate<15mmol
Ketones >3mmol
What is the treatment for DKA
1) fluid replacement IV 0.9% saline
2) intravenous infusion of insulin (administer slowly, 18-25 risk of cerebral oedema0
3) correction of electrolytes
4) long insulin should be continue, short insulin should be stopped
Causes of hyperglycaemia
Withdrawal/reduced insulin utilisation
Increase glucose production
Secondary to pancreatitis, Cushing/acromegaly, use of gloucocorticoids
Complication of diabetes
Micro vascular- nephropathy, neuropathy, retinopathy
Macrovascular- mi, stroke, pvd (gangrene)
What is a prolactinoma
Benign lactrophs adenoma secreting prolactin
What inhibits the production of prolactin
Dopamine
Sx of prolactinomas
Oligomenorrhaea/ammenorrhoea Loss of libido Erectile dysfunction Galactorrhoea Infertility Osteoporosis Opthamaloplegia Headaches decrease facial hair Weight gain
Tx for prolactinoma
1st line- dopamine agonist- cabergoline or bromocriptine
2nd line- transpenoidal surgery
Secretion of GH from anterior pituitary acts on the liver. What does the liver secrete in response to this
IGF-1
What are the sx of acromegaly
Large forehead- frontal bossing Large nose Large hands and feet Large protruding jaw Large tongue Arthritis from imbalanced growth of joints Skin tags Profuse sweating Headaches Visual lesions
(exams will refer to increase in shoe size or ring size)
What substance can suppress GH
High levels of glucose
What are the ix for acromegaly
1st line- measure serum IGF-1 , Random serum growth hormone
GS- OGTT- Whilst measuring GH, high levels of glucose suppress GH
Tx for acromegaly
1st line- transphenoidal surgery
2nd line- Somatostatin analogues- octreotide
3rd line GH antagonist- pigvisomant
4th line- dopamine agonist- cabergoline or bromocriptine
What substance inhibits GH SECRETION
Somatostatin
What is Cushing syndrome
General term referring to excessive levels of cortisol
What is Cushing disease
Excess glucocorticoids resulting from inappropriate ACTH secretion due to pituitary tumour
What are the causes of Cushing
ACTH Dependant-
Ectopic tumour
Pituitary adenoma
ACTH Independent
Iatrogenic
Adrenal adenoma
List 5 functions of cortisol
1- increase in carbohydrate and protein catabolism
2- increase deposition of fat and glycogen
3- Na retention
4- increase k+ renal loss
5- diminished host responses to infection
Signs and symptoms of Cushing
Purple striae Moon face Buffalo hump Hirsuitism Acne Central obesity Irregular menses/ED Mood changes- depression, lethargy, psychosis Osteoporosis Increase bp HTN Increase glucose Proximal muscle weakness
Gold standard Ix for Cushing and the results presented
1mg dexamethasone
Low cortisol levels= normal
Normal/high cortisol levels= Cushing’s syndrome
8mg dexamethasone
Low cortisol- Cushing diseases (pit tumour)
Normal/high cortisol-
ACTH low- adrenal Cushings
ACTH high- ectopic ACTH
Tx for cushings
GS- removal of tumour
Drugs-Metyrapone or ketoconazole (ek flash)
Drug class- Adrenal Steroid Synthesis Inhibitor
What is cranial and nephrogenic diabetes insipidus
Cranial- decreased secretion of ADH
Nephrogenic- insensitivity to ADH
Where is ADH secreted from
Supraoptic nucleus in posterior pituitary
List 5 causes of cranial and nephrogenic DI
Cranial
- CNS infections
- idiopathic
- head trauma
- brain/pituitary surgery
- congenital
- subarachnoid haemorrhage
- autoimmune disorders
Nephrogenic
- electrolyte abnormalities (hyper/hypokalaemia)
- systemic diseases
- medications (lithium, cisplatin, gentamicin)
- CKD
- uropathy
- inherited
What is the serum and urine osmolality in DI
Serum osmolality high
Urine osmolality is low
What is the Ix required in order to diagnose DI and it’s specific type
Gs- water deprivation test (urine osmolality low, serum osmolality high)- diagnoses DI
Desmopressin test- distinguishes which type
Cranial- (low serum osmolality, high urine osmolality)
Nephrogenic- (low urine osmolality, high serum osmolality)
Sx of DI
Polyuria Polydipsia Children may have nocturia No glycosuria Dehydration Sx of hypernatraemia
Tx for cranial and nephrogenic DI
Cranial- give synthetic arginine vasopressin analogue desmopressin (DDAVP)- desmomelt tablets
Nephrogenic- treat the underlying cause
Low sodium diet
What are the three characteristics that are concurrent with SIADH
1- euvolaemia
2- hyponatraemia
3- increase urine na+ (high urine osmolality)
Causes of SIADH
- malignancy- ectopic or pituitary tumour
- drugs- CARDISH (chemotherapy, antidepressants, recreational, diuretics, inhibitors (ssris, ACEI), sulfonylureas, hormones (desmopresssin))
- trauma
- post operative
- neurological- meningitis, encephalitis, SAH
Sx of SIADH
- absence of hyper/hypovolaemia
- n+v
Fatigue
Headaches
Muscle aches and cramps
Hyponatraemia
Ix for SIADH
Diagnosis of exclusion. Short synacthen test to exclude adrenal insufficiency
Serum sodium- low
Urine sodium- high
Tx for SIADH
Acute severe hyponatraemia- IV hypertonic saline solution (3%)
Acute mild hyponatraemia- fluid restriction
Rx- tolvaptan- ADH receptor blocker
What is hypokalaemia
Serum potassium <3.5mmol/l
Causes of hypokalaemia
- increase GI loss (D+V)
- reduced potassium intake- anorexia nervous a, bulimia
- ckd
Increase availability of insulin
Increased potsssium excretion- loop diuretics
Liquorice abuse
Sx of hypokalaemia-
Muscle weakness Hypotonia\hyporeflexia (sign) Cramps Tetany Palpitation Constipations Lethargy
What ecg changes are seen in hypokalaemia
Small/inverted T waves
Prolonged PR interval
ST depression segments
U waves
What is the definition of hyperkalaemia
Serum potassium >5.5mmol/l
Causes of hyperkalaemia
Insulin deficiency Tumour lysis syndrome Haemolysis Trauma Extensive burns Acidosis ACE inhibitors/NSAIDs
ECG changes associated with hyperkalaemia
Tall tented t waves
Long PR interval
Wide QRS complex
Absent/small P waves
Ventricular fibrillations
Sx of hyperkalaemia
PHADI M Palpitations Hypereflexia Anxiety Diarrhoea Irritability Muscle cramps
Tx of hyperkalaemia
If cardiotoxicity present on ecg- stabilise cardiac membrane by IV CALCIUM GLUCONATE/CHLORIDE
If no cardiotoxicity- combined insulin/dextrose infusion w/ nebulised salbutamol
Additionally Remove potassium- calcium reasonium
What is conns syndrome
Aka primary hyperaldosteronism. Too much aldosterone secreted by adrenal glands
Causes of primary hyperaldosteronism
- bilateral cortical adenoma *
- bilateral adrenal adenoma
- familial hyperaldosteronism
What is the role of the hormone aldosterone and where is it secreted from
- increases sodium reabsorbtion from DCT
- increases potassium excretion from DCT
Secreted from zona glomerulosa of adrenal cortex
What are the Sx of conns syndrome
HTN lethargy (low potassium) Mood disturbances (low potassium) Difficulty concentrating (low potassium) Nocturia Polyuria Weakness/cramps Parasthesia
Ix for conns
Plasma potassium is low
GS- Aldosterone to renin ratio
high aldosterone and low renin- primary hyperaldosteronism
high aldosterone and high renin- secondary hyperaldosteronism
Tx for conns
1st line- aldosterone antagonist- spironolactone, eplerenone
Gs- laparoscopic adrenalectomy
Sx of hyponatraemia
Altered mental status Oedema Nausea and vomiting Poor skin turgor Low urine output
What are the complications of hyponatraemia
Seizures
Coma
Death
Cerebral oedema
Sx of hypernatraemia
Diarrhoea and vomiting
Impaired thirst
Weight loss
Decreased jugular venous pressure (hypovolaemia)
CNS manifestations- intracranial haemorrhage, seizures, death
What is Addison’s disease
Primary adrenal insufficiency (low cortisol, high ACTH)
An autoimmune condition where adrenal glands have been damaged, resulting in reduced secretion of cortisol and aldosterone
What are the causes of Addison’s disease
UK and developed countries- autoimmune Most common cause worldwide- TB Metastases Meningococcal septicaemia HIV
Sx of Addison’s disease
Hyperpigmentation of the palmar creases Lean Weight loss Weakness Lethargy Vitiligo Loss of pubic hair in women Loss of libido Nausea and vomiting
Signs
Hyponatraemia
Hyperkalaemia
Ix of Addison’s disease
1st line- FBC, electrolytes (low Na, high K), serum glucose (low)
Gold standard- short syncathen test (synthetic ACTH given but cortisol still low)
Other- presence of 21-hydroxylase adrenal autoantibodies (non-specific)
Tx for Addison’s disease
1st line- hydrocortisone (glucocorticoid) + fludrocortisone (mineralocorticoid)
Tx in Addisonian crisis
Intensive monitoring Paraenteral steroids (IV hydrocortisone) IV fluid resuscitation Correct hypoglycaemia Monitor electrolytes and fluid balances
What is secondary adrenal insufficiency
Characterised by ⬇️cortisol ⬇️ACTH, normal aldosterone and normal renin
What are the levels of aldosterone and renin in Addison’s disease
⬇️aldosterone
⬆️renin
What are the causes of secondary adrenal insufficiency
Exogenous glucocorticoids Adrenal adenoma/carcinoma Surgery Infection Hypoplasia of pituitary gland
Sx of secondary adrenal insufficiency
Weakness Lethargy Anorexia Vomiting Hypoglycaemia Hypotension
Ix for secondary adrenal insufficiency
Gs- short syncacthen test- cortisol will increase
Tx for secondary adrenal insufficiency
Glucocorticoid replacement- prednisalone, hydrocortisone
What is carcinoid syndrome
Is the release of serotonin and other vasoactive peptides into the Systemic circulation from a carcinoid tumour
What cells do carcinoid tumour arise from
Neuroendocrine cells
Where do carcinoid tumours most commonly arise from
GI tract, lungs, ovaries, thymus
- small intestine malignancy most common
- appendix the most common site in GI tract
- Liver most common site for metastasise
Sx of carcinoid syndrome
Flushing- upper face and trunk Diarrhoea Bronchospasm Fibrosis, heart valve thickening Pellagra (niacin deficiency) Dermatitis
Ix for carcinoid syndrome
1st line- urinary 5 hydroxyindoleacetic acid test (raised levels)
Gs- chromagranin-A-octreoscan (pts should avoid banana, chocolate and caffeine)
Other- CXR/CT/MRI chest and pelvis
Tx for carcinoid syndrome
- surgery
Somatostatin analogue- octreotide
What is serotonin syndrome
An excess of synaptic serotonin in the CNS
What is the classical triad of manifestations in serotonin syndrome
Neuromuscular excitation
Autonomic effects
Altered mental status
Sx of serotonin syndrone
Neuromuscular excitation- hypereflexia, clonus, tremors
Autonomic hyperactivity- vomiting, diarrhoea, hypertension, tachycardia, hyperthermia, mydriasis
Altered mental status- confusion, anxiety, agitation
What is phaechromocytoma
A tumour arising from catecholamine producing chromaffin cells of adrenal glands
What is the classic triad of symptoms in phaechromocytoma
Palpitations
Headaches
Diaphoresis
Sx of phaechromocytoma
Perspiration Palpitations Pallor Pain (headache) High bP
Ix for phaechromocytoma
24hr urine collection for catecholamines, metanephrines, normetanephrines, creatinine and serum free meta and normetanephrines (elevated)
CT/MRI Scan
Tx for phaechromocytoma
Surgery
Alpha blockers- Doxazosin
Beta blockers- propanalol
Causes of hypercalcaemia
CHIMPANZEES
Calcium supplements Hyperparathyroidism Iatrogenic (thiazide) Milk alkali Padgett disease of the bone Acromegaly and Addison’s Neoplasia Zollinger-Ellison syndrome Elevated vitamin D Elevated vitamin A Sarcoidosis
What is the definition of Impaired Glucose Tolerance
A glucose level of 7.8-11mmol/L after an oral glucose tolerance test
What substance is responsible for the hyperpigmentation in addisons?
Pro-opromelanocortin (POCM)- a precursor to both ACTH and MSH (Melanocyte Stimulating Hormone)
What is the MOA and SE of carbimazole
MOA- inhibits thyroid peroxidase
SE- agranulocytosis
How do you calculate anion gap
(Na + k)-(cl+hco3)
List 5 Sx of hyperthyroidism
Weight loss Heat intolerance Diarrhoea Oligomneorrhoea Increased sweating
List 5 Sx of hypothyroidism
Weight gain Constipation Menorrhagia Cold intolerance Lethargy Dry skin/coarse hair Lateral loss of 1/3 eyebrow
List 3 primary and secondary causes of hyperthyroidism
Primary-
Graves
Toxic multi modular goitre
Toxic adenoma
Secondary Lithium Amiadorone Overdose of levothyroxine Gestational Iodine excess
Tx for hyperthyroidism
Carbimazole- inhibits thyroid peroxidase
Propylthiouracil
Name two se of levothyroxine
Osteoporosis
Arrhythmias
Most likely cause of primary Hyperparathyroidism
Solitary adenoma (80%)
Hyperplasia
Multiple adenoma
Carcinoma
Definitive/gs tx for primary Hyperparathyroidism
Total parathyroidectomy
Give 5 symptoms of hypercalcaemia
Abdominal pain Renal stones Polyuria Bone pain/fractures Depression
Name 3 types of cancers that can cause SIADH
Small cell lung cancer
Lymphoma
Prostate cancer
Pancreatic cancer
List 3 complications of acromegaly
OSA
T2DM
Cardiomyopathy
HTN
When is metformin contraindicated
When eGFR is less than 30n
