Other metabolic and endocrine

Question 1

What is gynaecomastia? Causes?

Answer 1

• Enlargement of glandular breast tissue in males due to hi oestrogen and low testosterone
• Pseudogynaecomastia = breast enlargement due to obesity

Causes

• medications: spirolactone, antipsychotics etc
• low testosterone: hypothamus or pituitary pathology, testicular damage, Klinefelter syndrome, older age
• hi oestrogen: newborns from mum, obesity, leading cell tumour, liver cirrhoses, hyperthyroidism

Question 2

Ex of gynaecomastia

Answer 2

Breast ex

• uni or b/l firm tissue +/- pain
• in pseudo it would be more soft due to adipose tissue

Testicular ex
- lumps, atrophy, reduced hair (signs of reduced testosterone

Consider examining for signs of liver disease and hyperthyroidism

Ix not necessary unless no cause identified: bloods, breast USS

Question 3

Mx of gynaecomastia

Answer 3

(1. ) Rx underlying causes e.g. stop any causative drug, hypogonadism with testosterone
(2. ) If Asyx + no underlying cause: WW + reassure if no underlying cause

(3. ) Refer
- any man with red flags
- unclear underlying cause
- if causing significant distress e.g. pain /psychological stress

(4. ) Mx
- Tamoxifen
- Surgery: mastectomy or liposuction - where medical rx fails

Question 4

What is galactorrhea? Causes? Presentation?

Answer 4

• Breast milk production due to elevated prolactin during pregnancy and breastfeeding.
• Usually it is inhibited by DA
• Causes: idiopahthic, prolactinoma, antipsychotics, primary hypothyroidism, PCOS, acromegaly

Syx

• B/l galactorrhea
• Pituitary tumour: headache, bitemporal hemianopia
• Ammenorhea (PL surpasses GnRH and thus FSH)
• reduced libido
• erectile dysfunction
• gynaecomastia

Question 5

Ix and Mx of galactorrhea?

Answer 5

Ix

(1. ) Ex: thyroid, neuro, breast
(2. ) Bloods: PL, TFT. UE, LFT, pregnancy test
(3. ) Consider MRI if pituitary tumour suspected

Mx

• Identify causes and Rx e.g. change medication, hypothyroidism, hyperprolactinaemia
• DA antagonists e.g. Cabergoline
• Surgery for prolactinomas/macroadenomas

Question 6

What is lactose intolerance? Presentation?

Answer 6

• Lack of lactase, so body is unable to absorb lactose so ferments in GI tract. This is not the same as milk or diary allergy as it is NOT an immune reaction.
• RF: African/Asian, premature, small intestine related disease (coeliac, crohns)

Presentation 
Syx present 30mins-2hrs after eating:
- Bloating
- Diarrhoea
- Gas
- Abdo cramps + pain
- Nauseous

Question 7

Ix and Mx of lactose intolerance?

Answer 7

Investigations
DX: Reduce amount of diary food and see if syx improve
- Hydrogen breath test: lactose consumed and hydrogen levels measured in breath (inc in LI).
- Lactose tolerance test: lactose consumed and serum glucose measured (reduced in LI).

Management

• Cutting down on foods/drinks with lactose
• Lactose free products e.g. soya, oat, almont
• Ca and Vit D supps may be needed
• Lactate supps

Question 8

What is phaeochromocytoma? Presentation?

Answer 8

Caarecholamine secreting adrenal medulla tumour.
RF: MEN2, neurofibromatosis, von Hippel-Lindau syndrome

Syx: due to hi adrenaline + noradrenaline

• HTN (90%)
• Headaches
• Palpitations
• Sweating
• Anxiety
• Tremor

Question 9

Ix and Mx of phaeochromocytoma?

Answer 9

Ix

• 24hr urinary metanephrines (hi)
• Abdo CT/MRI

Mx

• Adrenalectomy
• Prior to surgery, stabilise pt: alpha blocker (phenoxybenzamine), followed by Bb

Question 10

What is Conn’s Syndrome? Presentation? Ix? Mx?

Answer 10

• Primary hyperaldosteronism where adrenal gland produces too much aldosterone.
• Aldosterone: inc Na resorption, inc K + H+ secretion

Syx: HTN often resistant to antihypertensive Rx

Ix

• Renin: aldosterone ratio (Hi aldo, low renin)
• BP: HTN
• UE: hypokalaemia
• ABG: alkalosis (elevated HCO3)
• CT/MRI – look for cause e.g. tumour

Mx

• Aldosterone antagonist e.g. eplerenone or spironolactone
• Laparoscopic adrenalectomy