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Scientific Basis of Medicine > The case of the GP under pressure > Flashcards

The case of the GP under pressure Flashcards

1
Q

primary and secondary hypertension - what is the difference?

A

Primary - essential or idiopathic HTN
Secondary - Renal, endocrine, other (e.g. pregnancy, drugs)

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2
Q

Secondary Hypertension causes - CHAPS

A

Cushings
Hyperaldosteronism
Aortic coarctation
Pheochromocytoma
Stenosis of Renal Arteries

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3
Q

Secondary Hypertension causes - CHAPS

A

Cushings
Hyperaldosteronism
Aortic coarctation
Pheochromocytoma
Stenosis of Renal Arteries

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4
Q

Pheochromocytoma

A

Adrenal medullary tumour that secretes excess catecholamines (Adrenaline, noradrenaline and dopamine from chromaffin cells - sometimes called intra-adrenal paraganglioma)

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5
Q

Paraganglioma

A

Neuroendocrine tumours that arise from sympathetic and parasympathetic ganglia, tumours of sympathetic ganglia have the ability to secrete excess catecholamines

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6
Q

The distinction between Pheochromocytoma and …. is an important one because of implications for associated neoplasms, risk for malignancy, and genetic testing.

A

The distinction between Pheochromocytoma and Paraganglioma is an important one because of implications for associated neoplasms, risk for malignancy, and genetic testing.

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7
Q

The distinction between … and Paraganglioma is an important one because of implications for associated neoplasms, risk for malignancy, and genetic testing.

A

The distinction between Pheochromocytoma and Paraganglioma is an important one because of implications for associated neoplasms, risk for malignancy, and genetic testing.

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8
Q

What is released when you have pheochromocytoma?

A

Too much adrenaline released from the adrenal gland

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9
Q

Common Pheochromocytoma and Paraganglioma Symptoms (classic symptoms - 3)

A

Classic Symptoms in 40%

  • High BP
  • Headache
  • Sweating

Other symptoms include:
Flushing
Anxiety/panic
Palpitation
Abdo pain
Dizziness
etc

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10
Q

Case 1 - 58 YO man, developed hypertensive crisis during surgery for oral cancer
PMH: Hypertension and Ramipril
Developed anxiety and palpitation recently but put it down to recent diagnosis of oral cancer
Two nose bleeds in 10 years

A
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11
Q

Pheochromocytoma - Male vs Female

A

M=F

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12
Q

Pheochromocytoma - what decades of life?

A

3rd to 5th

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13
Q

Is pheochromocytoma rare?

A

Yes - investigate if clinically indicated

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14
Q

Pheochromocytoma: Paroxysms, ‘Spells’

A

10-60 min duration
Frequency - daily to monthly
Spontaneous
Precipitated Spells: diagnostic procedures, drugs, strenuous exercise, movement that increases intra-abdo pressure)

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15
Q

Pheochromocytoma: Hypotension

A

Hypotension occur in many patients
Mechanisms - loss of postural reflexes due to prolonged catecholamine stimulation

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16
Q

Pheochromocytoma: Features

A

N/V,
Hypercalcemia - associated MEN2, PTHrP secretetion by Pheo
Mild glucose intolerance
Lipolysis - weight loss and ketosis
Finish slide

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17
Q

Pheochromocytoma: Differentials

A

Hyperthyroidism
Arrhythmias
Hypoglycaemia
Migraine
Panic Attack
Alcohol Withdrawal
Recreational Drugs

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18
Q

Pheochromocytoma: Differentials

A

Hyperthyroidism
Arrhythmias
Hypoglycaemia
Migraine
Panic Attack
Alcohol Withdrawal
Recreational Drugs

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19
Q

Catecholamine synthesis and metabolism

A

Adrenaline - then others

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20
Q

Investigations - Pheochromocytoma

A

24hr work up
Finish slide

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21
Q

False positive - Pheochromocytoma

A

Finish slide

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22
Q

Imaging - Pheochromocytoma

A
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23
Q

What scan is this?

A

SPECT MIBG

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24
Q

blood pressure equation

A

blood pressure equation BP = CO x SVR

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25
Q

global prevalence of hypertension …% population

A

global prevalence of hypertension 22% population

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26
Q

how much of hypertension is primary? around …%

A

how much of hypertension is primary? around 90%

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27
Q

renal causes of secondary hypertension (3)

A

renal artery stenosis glomerulonephritis polycystic kidney disease

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28
Q

Endocrine causes of secondary hypertension (4)

A

renal causes of secondary hypertension

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29
Q

drugs causing secondary hypertension (5)

A

COCP NSAIDs steroids cocaine antidepressants

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30
Q

contributory factors to hypertension (6)

A

high BMI excessive salt excess alcohol lack of exercise stress caffeine

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31
Q

risk factors for hypertension(8)

A

male increasing age family history ethnicity smoker hyperlipidaemia diabetes low social status

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32
Q

Where is renin produced?

A

juxtaglomerular apparatus

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33
Q

what triggers renin production?

A

decreased renal perfusion

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34
Q

what does renin do?

A

converts angiotensinogen to angiotensin I

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35
Q

What converts angiotensin I to angiotensin II?

A

Angiotensin converting enzyme (ACE)

36
Q

Where is ACE released from?

A

pulmonary epithelium

37
Q

Action of Angiotensin II(3)

A

Vasoconstriction Release of aldosterone increased ADH secretion from pituitary

38
Q

Where is aldosterone produced?

A

zona glomerulosa of adrenal cortex

39
Q

action of aldosterone

A

increased tubular retention of sodium and water. lose potassium

40
Q

Where does aldosterone act?

A

distal convoluted tubule and collecting duct

41
Q

what causes hyperaldosteronism with low renin?

A

conn’s syndrome bilateral adrenal hyperplasia congenital adrenal hyperplasia

42
Q

presentation of someone with high aldosterone to renin ratio …

A

presentation of someone with high aldosterone to renin ratio hypertension hypokalaemia normal/high sodium metabolic alkalosis

43
Q

treating conn’s syndrome or adrenal hyperplasia?

A

laparoscopic adrenalectomy

44
Q

treating conn’s syndrome or adrenal hyperplasia if bilateral disease

A

aldosterone antagonists e.g. spironolactone

45
Q

what causes high aldosterone with high renin (4)

A

treating conn’s syndrome or adrenal hyperplasia if bilateral disease aldosterone antagonists e.g. spironolactone

46
Q

presentation of someone with low aldosterone to renin ratio?

A

hypertension high creatinine

47
Q

treatment for someone with a low aldosterone to renin ratio (4)

A

medical therapy renal angioplasty stent incision surgical repair

48
Q

causes of renal stenosis (3)

A

atherosclerosis autoimmune phenomena genetic causes

49
Q

complications of hypertension

A

atherosclerosis, strokes, CCF, CHD, LVH, renal failure, hypertensive retinopathy

50
Q

acute target organ damage caused by hypertension

A

retinal haemorrhage stroke encephalopathy pulmonary oedema MI AKI aortic dissection

51
Q

phaeochromocytoma - what is this?

A

adrenal medullary tumour that secretes excess catecholamines from chromaffin cells

52
Q

List 3 catecholamines

A

dopamine, norepinephrine, epinephrine

53
Q

paraganglioma

A

neuroendocrine tumour arising from sympathetic or parasympathetic ganglia

54
Q

can paragangliomas secrete catecholamines?

A

yes if arise from sympathetic ganglia

55
Q

primary hypertension

A

high blood pressure with no known cause

56
Q

secondary hypertension

A

secondary hypertension high blood pressure caused by the effects of another disease

57
Q

classic triad of phaeo symptoms

A

classic triad of phaeo symptoms high blood pressure headache sweating

58
Q

high blood pressure headache sweating = classic triad of…

A

Phaeochromocytoma

59
Q

other symptoms of phaeochromocytoma (aside from sweating, headache, high BP)

A

Phaeochromocytoma

60
Q

what are phaeo spells like?

A

symptoms appear for 10-60mins, can be spontaneous or precipitated

61
Q

What can precipitate a spell of phaeo symptoms?

A

invasive procedures drugs strenuous exercise micturition

62
Q

how can phaeos cause postural hypotension?

A

loss of postural reflexes due to prolonged catecholamine stimulation

63
Q

how can phaeos cause hypercalcaemia ?

A

can secrete PTH related protein which acts in same way

64
Q

phaeos impact on lipids and glucose

A

causes lipolysis and glucose intolerance

65
Q

when should you investigate for phaeos?

A

HTN at a young age incidentaloma found resistant HTN HTN crisis

66
Q

usual age of phaeo presentation

A

30-50

67
Q

differentials for pheochromocytoma?

A

hyperthyroidism arrythmias hypoglycaemia panic attack alcohol withdrawal

68
Q

zones of adrenal cortex

A

zona glomerulosa, zona fasciculata, zona reticularis

69
Q

What does the zone glomerulosa secrete?

A

mineralocorticoids (aldosterone)

70
Q

what does zone fasciculata secrete?

A

glucocorticoids (cortisol)

71
Q

what does zona reticularis secrete?

A

androgens

72
Q

how is noradrenaline converted to adrenaline?

A

PNMT enzyme (phenylethanolamine N-methyltransferase)

73
Q

what does PNMT enzyme need to function?

A

presence of cortisol

74
Q

why is adrenaline the only catecholamine not released by paragangliomas?

A

no cortisol present so PNMT can’t work

75
Q

1st investigations for PPGL

A

urinary and plasma metanephrines

76
Q

what should you do if metanephrines slightly raised

A

repeat test if still elevated clonidine suppression test

77
Q

Clonidine suppression test Used to test for …

A

pheochromocytoma Clonidine is an anti-hypertensive agent that is a central alpha-2 receptor agonist so should lower BP

78
Q

reasons for falsely elevated metanephrines? (4)

A

paracetamol cocaine caffeine chocolate

79
Q

imaging for phaeos (3)

A

CT MRI MIBG

80
Q

MIBG scan

A

nuclear medicine scan that detects neuroendocrine tumours

81
Q

pre-op treatment for pheochromocytoma ?

A

alpha adrenergic blockers beta blocker if patient tachycardic CCB

82
Q

how long is the pre-op treatment for phaeos?

A

7-14 days, also high sodium diet and fluid intake

83
Q

Familial Pheochromocytoma

A

Familial Pheochromocytoma hereditary cause of tumours

84
Q

syndromes associated with phaeochromocytomas

A

MEN2 von-hippel-lindau NF1 mutation SDHD mutation

85
Q

SDHD

A

SDHD a protein that if mutated can cause paragangliomas or phaeos

86
Q

surgery for pheochromocytoma

A

surgical excision of tumour, can be partial or total adrenalectomy

87
Q

indications for genetic screening with phaeos

A

bilateral tumours paraganglioma presence unilateral with family history young onset

Scientific Basis of Medicine (35 decks)

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