MRCP Endocrinology Flashcards by Kathryn Brice

FIRST LINE investigation for acromegaly

IGF-1 (raised)

OGTT & GH levels are GOLD STANDARD for diagnosis.

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Pathophysiology in acromegaly

GH released by pituitary tumour
IGF-1 released from hepatocytes in response to elevated GH
Stimulates bone & soft tissue growth

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First line treatment for acromegaly

Trans-sphenoidal resection of pituitary tumour
Medical if unsuccessful/unsuitable:
- dopamine agonist eg bromocriptine, cabergoline
- somatostatin analogue eg octreotide

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TFTs in subclinical hypothyroidism

Raised TSH, normal T3 & T4 (usually asymptomatic)

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Drugs causing hypothyroidism

Lithium

Amiodarone

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Antibody in Hashimoto’s

Anti-TPO

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Low TSH & low T3/T4

Hypopituitarism

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High/inappropriately normal TSH & high T3/T4

Pituitary tumour (secreting TSH)

TSH should be low if T4 raised, if secreted from elsewhere it may be inappropriately normal/high despite raised T4

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Aim with levothyroxine treatment

Normalise TSH (not suppress)

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Treat Addisonian crisis

IV hydrocortisone & 0.9% NaCl

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Investigation adrenal insufficiency

Short synacthen test

Insufficiency - failure of cortisol to rise >550 at 60min

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Best first test to identify cause of hypercalcaemia?

PTH

PTH normally suppressed by hypercalcaemia

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Explain the meaning of low urine osmolality

Low urine osmolality eg <300 = Low amount of particles relative to amount of liquid
ie dilute

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Pathophysiology of cranial diabetes insipidus

Failure to secrete ADH from posterior pituitary

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Pathophysiology of nephrogenic diabetes insipidus

Failure of kidneys to respond to ADH

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Investigation of diabetes insipidus

Water deprivation test

- Failure to respond to dehydration, ie continue to produce dilute urine (low osmolality)

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Differentiating cranial/nephrogenic diabetes insipidus

After water deprivation test, give desmopressin:

Urine concentrated, ie increased osmolality (>600): Cranial
Urine remains dilute, ie low osmolality: Nephrogenic (failure to respond to synthetic ADH)

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Treatment of hyperthyroidism in pregnancy

1&2nd T: Propylthiouracil

3rd T: Carbimazole

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TSH receptor antibodies

Grave’s disease

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Post-partum haemorrhage + hypothyroidism

Sheehan’s syndrome

- fail to lactate & remain amenorrhoeic after delivery

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Hypercalcaemia symptoms

Renal stones, abdominal groans, painful bones, psychiatric moans
Also polyuria, polydipsia, thirst

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Main SE carbimazole

Agranulocytosis

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Main SE radioionide therapy (for thyrotoxicosis)

Hypothyroidism

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Hypothyroid, goitre, anti-TPO

Hashimoto’s

assoc with thyroid lymphoma

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Kartagener's syndrome

Immotile cilia (dextrocardia)

Hyperthyroid phase then hypothyroid phase, goitre

De Quervain's

Acromegaly increases chance of which cancer?

Colorectal

SNHL, mild hypothyroidism, goitre

Pendred syndrome (aut dom)

Conn's biochemistry

Hypokalaemia, hypernatraemia, HTN

Subclinical hyperthyroidism

Low TSH, normal T3 & T4 | Left untreated = AF & osteoporosis

Treat thyroid storm

Fever: paracetamol Tachycardia: IV propranolol Thyroid: methimazole/propylthiouracilm, IV dexamethasone

Hypopigmented skin spots, atrial myxoma, endocrine tumours = ?

``` Carney complex (autosomal dominant, chromosome 17) ```

Diagnosis of gestational diabetes; Fasting glucose above.. or 2h GTT glucose above..

Fasting glucose above 5.6 | 2h GTT above 7.8

What stimulates PTH release?

HyPOcalcaemia HypERphosphataemia LOW vitamin D

Name the syndrome: profuse watery diarrhoea, dehydration, hypokalaemia, metabolic acidosis

Verner-Morrison syndrome. Caused by VIPoma. Test: Plasma VIP level

Hormone profile in premature ovarian failure

High FSH & LH | Low oestradiol

Young patient, taking antacids/has dyspepsia, hypercalcaemia, alkalotic

Milk-alkali syndrome | Ingestion of large amounts of calcium and alkaline substances

Mild hypercalcaemia, low urinary calcium. Asymptomatic

Familial hypocalciuric hypercalcaemia - aut dominant - mutation CaSR gene means body doesnt detect hypercalcaemia, therefore PTH high or normal - no treatment required, benign lifelong condition

Impaired fasting glucose, normochromic normocytic anaemia, weight loss, angular stomatitis, groin/buttock/leg rash (necrolytic migratory erythema)

Glucagonoma - tumour of pancreatic alpha cells --> overproduction of glucagon - >70% are malignant. Indolent presentation so often metastasise prior to diagnosis

Thyrotoxicosis, solitary lesion. Scan: 'Hot' nodule one lobe, suppression of activity elsewhere.

Thyroid adenoma

Most frequently occurring functional pituitary tumour

Prolactinoma

Impaired glucose tolerance values

2h post OGTT, 7.8 - 11.1

How long does it take HbA1c to equilibrate?

3 months

Preceding symptoms of pituitary adenoma & sudden onset headache, normal BP.

Pituitary apoplexy - haemorrhage or infarct of adenoma

Hormone responsible for epiphyseal fusion & cessation of growth (in males and females)

Oestrogen

Initial management of amiodarone induced thyrotoxicosis

Anti-thyroid drugs & glucocorticoids

Hypokalaemia, metabolic alkalosis, low/normal BP

Bartter syndrome | - rare inherited disorder affecting thick limb of loop of Henle

Hypokalaemia, metabolic alkalosis, hypertension

Liddle syndrome

Predominantly which type of bone is affected in osteoporosis

Trabecular (sponge-like bone at the end of long bones)

Recent flu-like illness, hyperthyroid Sx, tender goitre

De Quervain's thyroiditis (subacute)

Hormone profile in pregnancy

FSH & LH suppressed Oestradiol raised Prolactin mildly raised

Secondary amenorrhoea, female excessive training/weight loss - diagnosis & hormone profile

Hypothalamic hypogonadism - Reduced secretion GnRH from hypothalamus resulting in reduced stimulation of LH & FSH in anterior pituitary - ie low LH & FSH

Raised HDL, preserved insulin sensitivity, glycosuria

Maturity-onset diabetes of the young (MODY) (think T2DM) - 10-30yrs, normal BMI - FAMILY HISTORY - ketosis not a feature - Managed with SUs

GLP-1 contraindicated if history of what?

Gastroparesis | - delay gastric emptying

Diagnosing insulinoma

Measurement of fasting blood glucose and serum insulin & c-peptide during an attack Dx: low glucose, high insulin, high c-peptide (byproduct created when insulin is produced)

Pathophysiology of insulinoma

- Insulin levels fail to fall during periods of fasting | - Increased risk of symptomatic hypoglycaemia

Excess production of what is seen in familial hypertriglyceridaemia

Very low-density lipoprotein (VLDL) | - Autosomal dominant disorder

Slow-growing, fibrous thyroid

Riedel's thyroiditis - Fibrous tissue replaces thyroid tissue - Generally hyPOthyroidism, but depends on extent to which normal thyroid tissue has been replaced - Local extension & pressure symptoms

Definitive treatment of thyroid adenoma

Radioactive iodine therapy | if contraindicated eg pregnancy, young child - surgical excision

Hard, rapidly enlarging thyroid mass, local compression, regional lymphadenopathy = ?

Anaplastic thyroid cancer | Very poor prognosis

Treatment of thyroid lymphoma

Chemotherapy & external beam radiotherapy

Tall female, inguinal hernias in childhood, normal genitals, no pubic hair

Androgen insensitivity syndrome

Anti-hypertensive of choice in phaeochromocytoma prior to surgery

Phenoxybenzamine | - alpha blocker. More potent than doxazosin

Pharmacological management of drug induced nephrogenic diabetes inspipdus

Thiazide diuretic

What is pseudo-Cushing's syndrome?

Occurs in response to prolonged heavy alcohol use and obesity. Elevation in cortisol but not to the extent of Cushing's syndrome

Pharmacological management of gastroparesis

Domperidone | metoclopramide no longer used due to SE profile

Commonest genetic mutation causing MODY

HNF-1 alpha

Very high LDL, tendon/skin xanthomas, early ACS

Heterozygous familial hypercholesterolaemia | - aut dom

Signs/symptoms of adrenal failure following life threatening illness (commonly meningococcal disease)

Waterhouse Friderichsen syndrome | - bilateral adrenal haemorrhage

Management of De Quervain's thyroiditis

Propranolol (anxiety), NSAIDs | - self-limiting

Thyrotoxicosis & REDUCED uptake on isotope scan

Subacute/De Quervain's thyroiditis | - other causes of thyrotoxicosis have increased uptake

Short stature, short 4th&5th metacarpals, seizures, bilateral basal ganglia calcification

Pseudohypoparathyroidism | - hypocalcaemia causing seizure

ABG findings in Grave's disease

- Low PaCO2 - Raised PaO2 - pH normal or raised

PCOS hormone profile

- Raised LH (abnormal GnRH release preferential towards LH) - Normal FSH - Normal oestrogen - Raised testosterone - Low SHBG (sex hormone binding globulin)

Epilepsy, port wine stain, phaeochromocytoma

Sturge-Weber syndrome

Effect of hypothyroidism on cholesterol

Raised LDL cholesterol. HDL & triglycerides can also be raised. - treat underlying thyroid disease and it will resolve

Fasting glucose above what level in pregnancy do you go straight to insulin as first line treatment? (ie bypass metformin)

Fasting glucose >7

Treatment to improve Graves ophthalmopathy

IV steroids

Gold standard treatment for PCOS

Weight loss

Hormone deficiency in congenital adrenal hyperplasia?

21-hydroxylase

Gold-standard for confirmation of charcot joint?

Indium-labelled white cell scan | can differentiate between infective causes and Charcot