The Medical and Surgical Management of Thyroid, Pituitary and Adrenal disorders Flashcards

Question

Hormone deficiency of ACTH Tx

Answer 1

Adrenocorticotropic hormone - adrenal failure - decreased pigment hydrocortisone

Answer 2

Anti-diuretic hormone - diabetes insipidus - decreased water absorption therefore polyuria and polydipsia DDAVP

Answer 3

``` Tumours Radiotherapy Trauma Infarction Infiltration of pituitary Infection of pituitary e.g syphilis Sheehan's syndrome (post partum pituitary necrosis) ```

Answer 4

Pituitary disorder XS GH secretion 4/million per year equal sex incidence

Answer 5

``` Coarse facial features Enlarged supraorbital ridges Separation of teeth Prognathism Macroglossia ``` ``` Headaches Spade-like hands Joint pain XS sweating Hypertension Impaired glucose tolerance ```

Answer 6

Investigations: IGF1, dynamic tests, MRI pituitary Surgical resection – Transphenoidal surgery, Transfacial Surgery - biochemical control 80% microadenomas 50% macro*more than 10mm* adenomas  Somatostatin analogues – 40% complete responders - inhibits GH production  Pegvisomant reduces IGF-1 to levels > 90% - growth hormone receptor antagonist - inhibitor  Radiotherapy in unsuccessful surgery

Answer 7

```  Jaw Malocclusion  Difficulty in speech due to macroglossia  Teeth mobility  Missing teeth  Teeth separation  Thickening of alveolar processes  Enlarged posterior roots  In 50% upper airways obstruction caused by pharyngeal hypertrophy and macroglossia with obstructive sleep apnoea. ```

Answer 8

Cushing's syndrome XS glucocorticoids corticotropin releasing hormone released from hypothalamus --. ACTH release from pituitary ``` CORTISOL RELEASED ON A RHYTHM Pit tumour Adrenal tumour Ectopic ACTH tumour Iatrogenic ```

Answer 9

``` Weight gain Menses problems Moon face Acne Bruising Glucose intolerance Hyper pigmentation Muscle weakness Plethora Hirsutism Oedema Can result from long term steroid use ```

Answer 10

Hormonal tests Radiological tests - MRI, CT chest and adrenal Surgery, drugs, radiotherapy

Answer 11

Addison's disease

Answer 12

``` Autoimmune Tuberculosis Fungal infections Adrenal haemorrhage Congenital adrenal hypoplasia Sarcoidosis Amyloidosis Metastatic neoplasia ``` After exogenous glucocorticoids After treatment for Cushing's (EXCESS ACTH) Hypothalamic or pituitary tumours

Answer 13

``` Weakness Skin and mucous membrane pigmentation Loss of weight, emaciation, anorexia, vomiting, diarrhoea Hypotension Salt craving - loss of salt in urine Hypoglycaemic episodes ```

Answer 14

Hormonal tests - measuring cortisol, ACTH and adrenal antibodies Radiological - MRI pituitary CT or MRI adrenals Tx - hydrocortisone replacement treatment

Answer 15

Adrenal gland is insufficient and not producing enough cortisol ACTH will increase Pigmentation due to ACTH secreted with melanin stimulating hormone which binds to skin

Answer 16

Low ACTH therefore cortisol not stimulated

Answer 17

On treatment therapy e.g asthma, rheumatoid arthritis ◦ Prednisolone > 7.5mg ◦ Hydrocortisone > 30mg ◦ Dexamethasone > 0.75mg  On replacement therapy ◦ Addison’s e.g. Hydrocortisone 20/10mg - own production is not sufficient ◦ ACTH deficiency 10/5/5mg Simple Procedures - when giving LA : double dose one hour before surgery, double dose oral medication for 24 hours Major Procedures/GA: hydrocortisone 100mg im at induction and double dose oral medication for 24 hours

Answer 18

Hyperthyroidism Pheochromocytoma Cushing's - avoid infections and pathological fractures Refer to endocrinologist

Answer 19

``` Primary aldosteronism Phaechromocytoma Acromegaly Cushing's syndrome Hypothyroidism Hyperthyroidism ```

Answer 20

10000mg excreted in kidney | 9800mg reabsorbed into body

Answer 21

Ionised - cofactor in coagulation - skeletal mineralisation - membrane stabilisation -- neuronal conduction

Answer 22

Kidney - increase Ca reabsorption - reduced phosphate reabsorption - increased hydroxylation of 25-oh bit D Bone - increased bone remodelling Gut - no direct effect - increased ca absorption

Answer 23

an example of negative feedback

Answer 24

May be appropriate - to maintain calcium balance | May be inappropriate as it can cause calcium imbalance

Answer 25

Low total serum calcium but NOT low ionised calcium e.g serum calcium = 2.08 mol/L corrected calcium = 2.28 mmol/L

Answer 26

vit D deficiency Hypoparathyroidism – post surgery, radiation, autoimmune disease – Hereditary (Autosomal dominant hypocalcaemia) – Syndromes (Di George, HDR [hypopara, deafness, renal dysplasia] etc) – Infiltration (Wilson’s disease, haemochromatosis) Chronic renal failure Magnesium deficiency -> linked to vitamin D deficiency Pseudohypoparathyroidism Acute pancreatitis Multiple citrated blood transfusions

Answer 27

``` Parasthesia Muscle spasm - hands and feet, larynx and premature labour Seizures Basal ganglia classification Cataracts Dental hypoplasia ECG abnormalities ```

Answer 28

* History of neck surgery * Presence of other autoimmune conditions * History of congenital defects and immunodeficiency * Family history to suggest genetic cause * Drug history e.g antiepileptics * Neck scar, candidiasis, vitiligo, generalized bronzing * Growth failure, hearing loss

Answer 29

Calcium reduced

Answer 30

Decreased serum calcium

Answer 31

Mild - oral calcium supplements - cholecalciferol (active form) if vitamin D deficiency - post-thyroidectomy --> calcium supplements - hypomagnesaemia --> magnesium supplements

Answer 32

``` • Malignancy – bone mets, myeloma, PTHrP, lymphoma • Primaryhyperparathyroidism • Thiazides • Thyrotoxocosis • Sarcoidosis • Familial hypocalciuric / benign hypercalcaemia • Immobilisation • Milk-alkali • Adrenal insufficiency • Phaeochromocytoma 90% ```

Answer 33

* Thirst, polyuria * Nausea * Constipation * Confusion coma * Pancreatitis * Gastric ulcer * Renal stones * ECG abnormalities * Short QT

Answer 34

* Confusion, hypotonia, hyporeflexic * Dehydration * Signs of malignancy (enlarged liver, clubbing, thyroid mass, breast lump, lymph nodes) * Faecal impaction * Irregular pulse (arrhythmia,

Answer 35

• Identify any drugs that may cause hypercalcaemia (thiazides, lithium, Vitamin D) • Identify whether presence of renal failure ? Tertiary hyperparathyroidism • Check serum PTH and if high or normal perform 24-hour urine calcium excretion (Urine Calcium/Urine Creatinine x Plasma Creatinine) * If PTH high or normal and urine calcium excretion > 0.01 mmol/l – Primary Hyperparathyroidism * If PTH high or normal and urine calcium excretion < 0.01 mmol/l – FHH * If PTH low or suppressed – exclude malignancy, hyperthyroidism, Addison’s, sarcoidosis, granulomatous disorders

Answer 36

reduced bone resorption calcium reabsorption and calcium absorption from gut • About 20 to 30% of patients with cancer • 80% are due to bony metastases (breast, thyroid , kidney, lung, prostate) • 20% due to PTHrP release (others secrete Vitamin D, ectopic PTH) • Osteoclastic Hypercalcaemia

Answer 37

• Bones – Osteitisfibrosacystica – Osteoporosis - erosions of bone - osteitis and cysts • Kidney stones • Psychic groans – confusion • Abdominal moans – Constipation – Acute pancreatitis Indications for surgery • Serum calcium > 0.25 mmol/l from upper limit • Creatinine clearance < 60 ml/min • T-score < -2.5 at any site and/or previous fragility fracture at spine, hip, radius, femoral neck • 24 hour urine calcium >400mg/day (>10mmol/day) • Nephrocalcinosis or nephrolithiasis • < 50 years

Answer 38

Renal failure --> nodular hyperplasia and autonomy

Answer 39

• Intravenous fluids Normal 0.9% saline • Loop diuretic if risk of overload ONLY • Intravenous bisphosphonates e.g pamidronate, zoledronic acid (make sure PTH sample taken) • Corticosteroids e.g Vitamin D intoxication, sarcoidosis

Answer 40

PTH controls calcium balance to keep serum calcium in a narrow normal range • High or low PTH may be appropriate or inappropriate • Symptoms and causes of calcium imbalance • Think about how changes affect the feedback loop