Surgery - Endocrine Flashcards
acute onset N/V, ab pain, hypoglycemia, hypoTN after stressful event in steroid-dependent pt - what is happening?
Acute adrenal insufficiency
Potentially lethal post op complication
Preop steroid use is main cause
Panadrenal insufficiency - what are you missing?
- what will you see clinically?
- what will you see on labs
- what do you do?
Aldo (low Na, high K)
Cortisol (hypoglycemia)
Catecholamines (epi, norepi)
Will have refractory hypotension
METABOLIC ACIDOSIS
HypoNa
HyperK
Hypoglycemia
Tx: + steroids (hydrocortisone) ASAP
ACTH stimulation test to dx
Tx SIADH
Tx DI
SIADH
- Demeclocycline
DI
- Desmopressin
Sestamibi scan
Used to ID enlarged parathyroid glands
- can be minimally invasive parathyroid surgery
Most common location for missing inferior parathyroid gland
In thymus
Tertiary hyperparathyroidism
After renal transplant, parathyroids don’t respond to normal renal function and continue to overproduce PTH
How do you lower BP in pheo?
+ a- and b- blockers
NEVER to b-blockade alone b/c unopposed a-stimulation can be fatal from teh catecholamines
Pheo 10% rule
MEEB
10% are: malignant extra-adrenal epi producers bilateral
Diagnostic tests for gastrinoma
Where is gastrinoma?
Serum gastrin measurement
Gastric ulcer analysis
Secretin stimulation test (test function of pancreas - will increase gastrin in gastrinomas BUT normally supposed to suppress gastrin)
Duodenum and head of pancreas is where most tumors are
–> find via MRI or CT
MEN 1 syndromes
Parathyroid
Pituitary
Pancreatic endocrine (Z-E, insulinomas, VIPomas)
MEN 2a syndromes
Medullary thyroid carcionma
Pheo
Parathyroid
MEN 2b syndromes
Medullary thyroid carcionma
Pheo
Oral/intestinal ganglioneuromatosis (marfanoid habitus)
Addison’s disease
Adrencortical insufficiency
Hyper K Hypo Na Hypo glycemia Fever wt loss dehydration hyperpigmentation in chronic
VIPoma characteristics
Diarrhea
Hypo K
Leg crams
Decreased acid in stomach
“Pancreatic cholera” –> usually in head of pancreas
Thyroid diagnostics
- how do you eval?
- cold vs. hot nodule?
- what do you use to discriminate cysts from nodules?
- FNA to evaluate
- Cold nodule = 15% chance malignant
- Hot nodules = rarely cancerous
- US used to follow size or recurrence of cysts after FNA –>Good for discriminating cysts from nodules
Complications of thyroid surgery
Injury to recurrent laryngeal N (CN 10 = Vagus)
- Found in tracheoesophageal grooves, dive behind cricothyroid muscle
- Larynx, posterior cricoarytenoid, lateral cricoarytenoid
- Unilateral injury = hoarseness
- Bilateral injury = cord paralysis/airway obstruction and may need tracheostomy
Injury to external branch of superior laryngeal N (CN 10 = Vagus)
- Cricothyroid
- Injury = deep + quiet voice, can’t hit high notes
Injury to parathyroid –> hypocalcemia, hyperphosphatemia
Blood supply and drainage of thyroid
Blood supply
- Superior thyroid A (external carotid, 1st branch)
- Inferior thyroid A (thyrocervical trunk)
- Innominate artery (aorta, 5% ppl)
Blood drainage
- Superior thyroid V
- Middle thyroid V
- Inferior thyroid V
Lymph node around pyramidal lobe?
Delphian lymph node group
Connecting thyroid to trachea
Ligament of berry
Post-op thyroidectomy cautions
- Dyspnea: recurrent laryngeal N b/l damage OR neck hematoma
- Lateral aberrant rest of thyroid = papillary cancer of lymph node b/c mets
- Monitor Ca b/c can have parathyroid damage (b/c blood supply can be compromised)
Thyroid binding globulin - what does it do?
- changes in physio states?
Which TH is active?
Thyroid binding globulin binds most thyroid hormone in blood stream
- Only free T3 is active
- ↑ TBG in preggers
- ↓ TBG in hepatic failure
Hashimoto’s
- Ab: microsomal, antithyroglobulin
- Histo: Hurthle cells, lymphocytic infiltrate
- NONtender thyroid, Low T3/T4, normal TSH
- Higher incidence of malignancy assoc w/ Hashimotos (esp papillary and lymphoma)
- Tx: TH replacement
Subacute (deQuervain’s) hypothyroidism
- Usually follows flu-like illness (VIRAL)
- Acute is bacterial illness
- Histo: granulomatous inflammation
- TENDER thyroid
- ↑ ESR
- Tx: analgesics + aspirin, steroids if more resistant, NO surgery
Riedel’s thyroiditis
- Thyroid replaced by fibrous tissue
- Rock hard NONpainful goiter
- Tx: surgery decompression, TH replacement, steroids/tamoxifen if refractory
Jod Basedow phenomenon
Iodine deficiency person given LOTS of iodine can get thyrotoxicosis
Grave’s disease
- Thyroid stimulating Ig
- Often presents in stress; if surgery, risk HYPOthyroidism
Thyroid storm
- Stress induced catecholamine surge from hyperthyroidism d/o
- Can lead to arrhythmias death
How do you monitor thyroid cancer recurrence?
Thyroglobulin
Will be 0 if got all the thyroid tissue
Papillary carcinoma of the thyroid
- age
- prognosis
- histology
- tx
- 30-40yo
- Best prognosis
- Most common, most common after radiation
- Loves mets to lungs
- Histo: Orphan annie eye nuclei, Psamomma bodies
- Prognosis based on MACIS scale = Distant mets, age at presentation, completeness of resection, extrathyroidal invasion, size of mass)
Tx:
Total thyroidectomy:
- previous head and neck radiation
- > 1.5 cm
Lobectomy:
- < 0.5 cm
Post op:
- thyroid suppression + TH + I ablation (?)
Follicular carcinoma of the thyroid
- characteristics
- spread
- treatment
- Capsular invasion determines if follicular adenocarcinoma vs. follicular adenoma –> FNA cannot dx!
- Hematogenous spread!
- Loves mets to Bone
Tx:
- lobectomy + ismuthectomy for microinvasive < 4cm
- total thyroidectomy for > 1 cm, microinvasive > 4cm
Hurthle cell is a variant
Medullary carcinoma of the thyroid
- characteristics
- testing for it
- histo
- surgery
- postop/monitoring
- Highly malignant, total thyroidectomy
- MEN 2A, 2B association
- Most (80%) are sporadic; 20% familial
- If suspected MEN2 + HTN, need to get markers for pheo –> operate on pheo 1st
- Pentagastrin stimulation test (causes increase in calcitonin)
- Histo: From parafollicular C cells makes calcitonin
- Amyloid-like material
Tx:
- Total thyroidectomy + removal of lymph nodes in central compartment of neck
Post op:
- NO I ablation and thyroid suppression b/c tumor from C cells
- Monitor w/ calcitonin and CEA levels
Anaplastic carcionma of the thyroid
- Older pts, poor prognosis
- Chemo + radiation
Hyperthyroid pharmacology
- treatments
- side effects
- Propylthiouracil —-| peroxidase and 5’deiodinase
- GOOD FOR PREGGERS
- Methimazole —-| peroxidase
- S/E: Agranulocytosis, Aplastic anemia, Hepatotoxicity = propylthiouracil, Methimazole = teratogen
Imaging studies to find source of Cushings:
- pituitary
- adrenal
PItuitary = MRI
Adrenal = CT
Imaging to find insulinoma
CT scan
Whipples triad
Suggest patient’s findings are 2/2 hypoglycemia or an insulinoma
- Symptoms known or likely to be caused by hypoglycemia (diaphoresis, lightheadedness)
- A low plasma glucose measured at the time of the symptoms
- Relief of symptoms when the glucose is raised to normal
Nesidioblastosis
Devastating hypersecretion of insulin in newborn
Needs 95% pancreatectomy
Severe necrolytic dermatitis, resistant to all forms of therapy
Mild diabetes
Anemia
Glossitis
Stomatitis
What does the person have?
How do you dx? Locate it? Treatment?
Glucagonoma
Glucagon assay is dx
CT scan used to locate tumor
Resection is curative
Somatostatin + streptozocin to help those w/ metastatic inoperable tumors
How do you tell between primary hyperaldosteronism 2/2 to hyperplasia vs adenoma?
Hyperplasia = more aldo secreted when upright (will have postural changes)
Adenoma = no postural changes
Pheochromocytoma
- work up
- treatment
Workup:
- 24hr urinary VMA, metanephrine, or free catecholamine secretion
- CT scan adrenals
Tx:
- surgery
- prep w/ alpha blocker first! Phenoxybenzamine (irreversible)
Phentolamine is for tyramine excess (also alpha blocker)
2 populations you see renovascular hypertension
Young women w/ fibromuscular dysplasia
Old men w/ arteriosclerotic occlusive disease
BOTH are resistant to anti-HTN meds
Acromegaly workup
Somatomedin C levels
IGF-1 levels
MRI of pituitary
Paralysis of upward gaze
- name?
- caused by?
Parinaud syndrome
Tumor of pineal gland
When is thyroglobulin not an accurate marker of thyroid cancer recurrence?
If there is thyroiditis like with thyroid antibodies
What side is a nonrecurrent laryngeal N on? Why does it happen
Right side
Usually happens w/ the right subclavian artery arises from the left side of the aorta and crosses behind the esophagus
Branchial cleft cyst
congenital epithelial cyst that arises on the lateral part of the neck due to failure of obliteration of the second branchial cleft (or failure of fusion of the second and third branchial arches) in embryonic development
Signs of adrenal insufficiency
Skin pigmentation Weakness wt loss HYPOtension N/V/Ab pain Hypoglycemia Hyponatremia Hypokalemia
Somatostatin actions
Inhibit most GI hormones
- insulin
- glucagon
Inhibitis
- TSH
- renin
- calcitonin
Inhibits intestinal, biliary and gastric motility
Thyroid:
- follicular cells
- parafollicular cells
What do they make?
Follicular - t3, t4
Parafollicular - calcitonin (inhibit osteoclasts)
Indications for thyroid surgery
- Malignancy / indeterminate or suspicious path
- symptomatic = compressive sx, unilobular goiter
- hyperfunctioning = toxic adenoma
Tx 2ndary hyperparathyroidsim
Not on dialysis
- vit D supplementation (calcitriol)
On dialysis:
- calcimimetics (cinacalcet) - increases sesnitivity of CaSR
- phosphate binders
If delayed sestamibi shows continued highlighting of parathyroid gland, what does this mean?
Parathyroid adenoma
Metabolically more active tissues will hold onto the dye more and this is indicative of adenoma
Suspected hyperparathyroidism 2/2 parathyroid adenoma.
US thyroid = normal
Sestamini scan = normal
What do you do next?
A 24-hour urinary calcium measurement should be performed to ensure that the patient has primary hyperparathyroidism.
If familial hypercalcemia hypocalciuria is ruled out with the 24-hour urinary test, then the surgeon should discuss with the patient about a bilateral four-gland operation for likely parathyroid hyperplasia versus taking no action at this time and repeating imaging tests in six months or trying a new imaging modality.
Hungry bone syndrome
is the constellation of hypocalcemia, hypophosphatemia, and hypomagnesemia after successful parathyroidectomy due to the sudden withdrawal of excess PTH.
Parathyroidectomy for hyperparathyroidism may result in an imbalance between osteoblast-mediated bone formation and osteoclast-mediated bone resorption that results in rapid absorption of calcium, phosphate, and magnesium into the bones.
Parathyromatosis
is caused by the rupture and/or spillage of hyperfunctioning parathyroid cells into the operative bed during an initial operation.
If the cells remain hyperfunctioning they cause recurrent hyperparathyroidism and present as multiple random nodules within the original operative field.
The other options are unlikely given this patient’s history and physical examination findings.
Papillary carcinoma of thyroid tx
Total thyroidectomy:
- previous head and neck radiation
- > 1.5 cm
Lobectomy:
- < 0.5 cm
Follicular carcinoma of thyroid tx
Lobectomy + isthmusectomy:
- well circumscribed lesion (microinvasive)
Total thyroidectomy
- > 1 cm
- microinvasive > 4 cm
Medullary carcinoma of thyroid tx
Total thyroidectomy
Central neck compartment nodes removal
Lateral neck dissection if palpable nodes
Risk of carcinoma of solitary thyroid nodule w/ PMHx of low dose head or neck radiation?
40%
Electrolyte abnormalities of high PTH/hyperparathyroidism
Low phosphorus
High Cl
Mild metabolic acidosis
Cl: PO4 ratio of 33:1 is consistent w/ dx of primary hyperPTH
PTH —| reabsorb phosphorus and bicarb
b/c more bicarb excreted, more Cl reabsorbed and Na too
Parathyroidectomy pts
Symptomatic pts
Asymptomatic < 50 yrs w/ 1+ following:
- Ca > 11.5
- 24 hr urine Ca > 400 mg
- Cr decreased by 30%
- bone mineral density > 2 SD below normal
Most common causes of hypercalcemia
HyperPTH
Malignancy
Hypercalcemia - dx test to perform?
Serum and urine protein electrophoresis
Can find malignancy causing bone destruction
Tx adrenocortical tumor
Resection
MItotane as adjuvant + glucocorticoids b/c will destroy adrenals
Poor prognosis
Meaning of:
- elevated testosterone + DHEAS
DHEAS is in adrenals - if have elevated testosterone + DHEAS is adrenal tumor
Elevated testosterone + normal DHEAS is ovariansource
DHEA is from ovaries and adrenals.
Myopathy causes
POlymyositis/dermatomyosistis
Hyper or hypothyroidism
Cushing’s disease
LE syndrome, MG
Steroids
Signs + symptoms of thyrotoxicosis
No goiter or exophthalmos
Low TSH
High T3, T4
What is happening?
How do you dx?
Factitious thyrotoxicosis b/c ingest thyroid hormone
Dx w low serum thyroglobulin levels
Sick euthyroid syndrome
Thought o be due to caloric deprivation + increase in cytokine levels
Usually in ppl w/ no previous hx of thyroid disease
Any pt w/ acute severe illness may have abnormal thyroid function tests (usually fall in total adn free T3)
Can have increase in TSH when recovering from non-thyroidal illnesses
JUST DON’T DO THYROID TESTS ON SICK PTS WHOSE PROBLEMS YOU DON’T THINK RELATE TO THYROID OR THOSE RECOVERING FROM MAJOR SYSTEMIC ILLNESSES NOT RELATED TO THYROID
