General Endocrine Conditions Flashcards
Causes of hypercalcaemia
- Hyperparathyroidism - primary or tertiary (NOT secondary)
- Familial hypocalciuric hypercalcaemia
- Malignancy - multiple myeloma, humoral hypercalcaemia(PTHrP), bony mets
- Vitamin A or D intoxication
- CKD
- Sarcoidosis
- Hyperthyroidism
- Addisons
- Drugs eg Lithium/thiazides
- Immobilisation
What is familial hypocalciuric hypercalcaemia?
When body has problem of parathyroid detecting Ca2+ levels
What is tertiary hyperparathyroidism?
When you have had secondary hyperparathyoidism for a while and this then results in overactivity/solitary adenoma of pituitary gland
Clinical features of hypercalcaemia
- Bones - fragility fractures, bone pain
- Stones - renal calculi
- Thrones - polyuria, constipation
- Psychic moans - mood disturbance, fatigue/malaise
- Abdominal groans - abdo pain, pancreatitis
- Asymptomatic?
Complications of hypercalcaemia
- Renal calculi
- Osteoporosis
- Pancreatitis
Investigations for hypercalcaemia - steps
- Find raised Ca2+
- Check PTH
- If low - screen for cancer
- If high PTH - check urine Ca2+ creatinine clearance ratio
- If low urine Ca2+ –> FHH? Do genetic testing
- If high urine Ca2+ - suspect primary hyperparathyroidism
Other investigations for hypercalcaemia
- CXR
- FBC
- ACE - sarcoidosis
- TFTs
- Cortisol
- Vitamin D
- Myeloma screen
- Assess for end organ damage
Why do assess for end organ damage in hypercalcaemia and how?
US KUB, DEXA scan
If end organ damage - fill criteria for surgical management
Indications for surgery in primary hyperparathyroidism causing hypercalcaemia
- Very symptomatic
- End organ damage - worsening kidney function, renal stones
- Osteoporosis on DEXA
- Ca2+ more than 3
- Urine Ca2+ 10mmol/day
- Age under 50
Surgical management for primary hyperparathyroidism
- Surgical removal of adenoma or partial parathyroidectomy
Medical management for primary hyperparathyroidism
- Only indicated if not suitable for surgery (surgery 1st line)
- Cinacalcet - Ca2+ sensing agonist
- Bisphosphonates
- HRT
Medical management not first line as it will lower calcium but not affect urinary calcium
Emergency management for severe hypercalcaemia
- If renal failure - dialysis
- Aggressive IV hydration (if then overloaded use loop diuretics)
- Once volume replete consider bisphosphonates
- Calcitonin, steroids or denosumab rarely used
Causes of hypocalcaemia
- Hypoparathyroidism
- Iatrogenic - thyroid surgery
- Radiation
- Infiltration
- Autoimmune - but we don’t really do PT autoantibodies screen
- Familial/syndromic - DiGeorge, overactivity of Ca2+ sensing receptor
- Magnesium deficiency
- Drugs - PPI, Cisplatin, calcitonin, phosphate, citrate
- Pseudohypoparathyroidism
- Vit D deficiency/resistance
- CKD
- Osteoblastic mets (eg prostate Ca)
Symptoms of hypocalcaemia
- Tingling/numbness
- Cramps
- Neuropsychiatric
- Carpopedal spasm
- Seizures
Signs of hypocalcaemia
- Stridor
- Chvostek’s - tap facial nerve and face spasms
- Trousseau’s - inflate BP cuff and carpopedal spasm occurs
Syndromic vs iatrogenic hypocalcaemia
Iatrogenic hypocalcaemia behaves much more aggressively than familial/syndromic causes
Investigations for hypocalcaemia
- Serum Ca
- PTH
- Vitamin D
- Magnesium
Management of hypocalcaemia
- Calcium supplement - aim to keep calcium level just below normal range
- Vitamin D - alfacalcidol, calcitriol
- PTH not approved