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Endocrine / adrenal Flashcards

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1
Q

Briefly describe the anatomy of the adrenal gland

A

Nebenniere

Cortex 3 zones
Z. Glomerulosa- mineralcorticoids
Z. Fasiculata - glucocorticoids
Z. Reticularis - sex steroids

Medulla
Produces adrenaline and Noradrenaline

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2
Q

Which specific cells does the medulla of the adrenal gland contain?

And what is their function?

A

Chromaffin cells

Release Adrenalin and noradrenalin

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3
Q

All corticoids are produced from?

A

Cholesterol

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4
Q

Name the actions of cortisol

A

Gluconeogenesis ( anabolic)
Lipolysis, protein breakdown (catabolic )
CNS altered perception
Immunosuppressive
Anti-inflammatory
Vasoconstriction , maintains blood volume

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5
Q

Name the actions of adrenaline and noradrenaline

A 
Increased heart rate and contractility 
Increase respiratory rate and promotes bronchodilation
Gluconeogenesis
Lipolysis 
Alertness 
Sweating 
Pupil dilation
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6
Q

What is Addison?

A

Primary adrenal sufficiency

  • lack of mineralcorticoids
    Glucocorticoids, Sex steroids
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7
Q

Name the commonest cause of addisons ? What are other causes?

A

Autoimmune adrenalitis

CMV 
TB
HIV
Waterhouse Friedrichsen ( adrenal haemorrhage ) 
Tumour 
Congenital adrenal hyperplasia
21-alpha hydroxylase deficiency
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8
Q

How to differentiate between primary and secondary adrenal insufficiency ?

Name a cause for secondary adrenal insufficiency

A

In primary, all corticoids are low in secondary mineralcorticoid secretion remains intact
High ACTH in primary , low ACTH in secondary

In Secondary adrenal insufficiency there is lack of ACTH secretion resulting from hypopituritarism ( tumour , irradiation )
Or eg sudden withdrawal from prolonged corticoid therapy

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9
Q

Addisons presents with lots of unspecific features . Name some and the most common signs .

A 
Postural hypotension 
Hyperpigmentation ( palmar creases )
Weight loss 
Wasting 
Lethargy 
Depressed mood 
Unexplained abdominal pain, nausea , vomiting

Hyponatraemia
Hyperkalaemia
Hypoglycaemia

Loss of libido
Hair loss ( axillary and Pubic hair )
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10
Q

What causes skin hyperpigmentation in addisons ?

A

High ACTH levels

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11
Q

What tests could you perform to diagnose addisons ?

A

ACTH stimulation test
- give synacthen , failure to increase cortisol

Measure ACTH - high - screen for autoantibodies

Single cortisol measurement unreliable as varies during day

Electrolyte disturbances
Low Na
High K
Low glucose

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12
Q

What other conditions can Addison be associated with ?

A

Diabetes mellitus 1
Hashimoto
Pernicious anaemia

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13
Q

Treatment of addisons

A

Steroid replacement
Hydrocortisone 15-25mg

Replace mineralcorticoids
Eg fludricortisone

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14
Q

What can trigger an adrenal crisis and how does it present?

A

Triggered by stress , sepsis , sudden stop of cortison

Fever, vomiting, diarrhoea 
Abdominal pain
Hypoglycaemia 
Hyperkalaemia 
Huponatraemia 
Metabolic acidosis 
Shock

-> give IV or IM hydrocortisone

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15
Q

What is Conn Syndrome ?

A

Primary hyperaldosteronism

Leading to excess aldosterone due to overproduction

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16
Q

Name two conditions that can cause conn syndrome

A

Idiopathic adrenal hyperplasia

Aldosteronoma (aldosteroneproducing adenoma )

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17
Q

What are the clinical signs of Conn’s?

A

Hypertension
Hypokalaemia
Metabolic alkalosis
Diabetes insipidus

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18
Q

A young patient presents with treatment resistant hypertension . His blood tests reveal hypokalaemia . What is a possible diagnosis ?

A

Conns syndrome

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19
Q

Which investigations would you perform in a patient with conns sydrome ?

A

Plasma aldosterone concentration to plasma renin activity (PAC:PRA) Ratio ( >20 ng/dl)

Oral Saline or Saline Infusion test would both slow normal suppression of RAAS

CT

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20
Q

Why is there no Oedema and only

Mild hypernatraemia in conns syndrome ?

A

Aldosterone escape

Volume expansion causes ADH secretion which leads to compensatory diuresis

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21
Q

Treatment of conns

A

Spironolactone ( SE gynaecomastia, loss of libido )

Surgery if only one adrenal gland affected

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22
Q

What is a phaeochromozytoma and what is it associated with ?

What’s the most
Common location?

A

Catecholamine secreting tumour from chromaffin cells , most commonly adrenal medulla (10% sympathetic ganglion )

Neurofirbomatosis 1
Von hippel Landau disease
Multiple endocrine neoplasia 2

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23
Q

How may a patient with phaeochromocytoma present with?

A 
Hypertension 
Hyperglycaemia 
Throbbing headache 
Palpitations 
Tachycardia 
Sweating
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24
Q

Name 2 tests performed in patients with phaeochromocytoma .

A

Metanephrine in Plasma

24h urine test for metanephrine and catecholamines / vanillymandelic acid

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25
How would you manage a patient with phaeochromocytoma ?
Selective alpha blocker Labetalol Fluid replacement Surgical removal
26
What is Cushing syndrome? What are it's causes ?
Increased levels of cortisol Exogenous: prolonged glucocortico steroid Endogenous Primary : ACTH independent : adrenal adenoma Secondary : ACTH dependant Increased ACTH production from pituitary gland = cushings disease Or ACTH from ectopic production e.g paraneoplastic syndrome
27
Name the features of Cushing's syndrome
Skin: Bruising , thinning , striae, delayed wound healing, flushed face , hirsutism , acne ``` Neuropsychological Lethargy Depression Sleep disturbance Psychosis ``` Muskulosceletal Muscle wasting , weakness Osteoporosis ``` Endocrine / metabolic Hyperglycaemia , Diabetes Central obesity Moon face Buffalo hump ``` Increased risk of infection Hypertension Amenorrhea
28
How to investigate a patient with signs of high cortisol levels ?
Dexamethasone suppression test | 24 h cortisol urine
29
How would you differentiate the causes of high cholesterol regarding their location on the pituitary - adrenal axis ?
ACTH measurement If low - adrenal tumour If high - cushings disease or ectopic Dexamethasone high dose In ectopic no change in cortisol levels CRH stimulation If in pituitary - cortisol rises If ectopic - no change
30
Give the features of ACTH, cortisol and CRH in Pituitary Tumor Adrenal Tumour Ectopic cortisol production
Pituitary Tumor - high cortisol - high ACTH Adrenal Tumour - low ACTH - high Cortisol - low CRH Ectopic Doesn't respond High Cortisol High ACTH from ectopic source possible
31
What electrolyte changes would you find in Cushing's syndrome?
Hypernatraemia Hypokalaemia Metabolic acidosis Hyperglycaemia
32
How to treat an exogenous Cushing syndrome , how an endogenous ?
Exo: reduce dose ! Don't just withdraw -> adrenal crisis ``` Endo Surgery + replacement Or Cortisol suppression Fluconazole Mitotane ```
33
Name the 2 commonest cause of hypercalacaemia .
Primary hyperparathyroidism Malignancy
34
What is SIADH What does it result in?
Syndrome of inappropriate ADH secretion - excessive ADH secretion resulting in hyponatraemia ( due to water retention ) There is no hypovolaemia and no oedema
35
What findings would you expect in SIADH?
Hyponatraemia - plasma hypoosmolality Concentrated urine - hyper osmolality
36
What das ADH do?
Inserts aqua poring causing water reabsorption | In response to hypotension or hyperosmolality in plasma
37
# Define Hyponatraemia What are symptoms ?
``` < 135 mmol/l Asymptomatic Nausea vomiting = mild Confusion ( neuro signs ) = moderate Seizures , coma = severe ```
38
What are the causes of hyponatraemia ?
``` Hypovolaemic Urine sodium >20 - diuretics - Diabetes mellitus ( osmotic diuresis ) - Addison's disease Urine sodium <20 -Vomiting -Diarrhoea -Fistula , Burns ``` Hypervolaemic Nephrotic syndrome Cardiac failure renal failure Euvolaemic SIAD Stress Hypothyroidism
39
What is the danger of sodium replacement in hyponatraemia ?
If too quickly | Central pontine myelinolysis
40
Define hypernatraemia . | What is it always associated with?
> 145 mmol/l Water loss
41
Causes of hypernatraemia
``` Hypovolaemic ( low sodium but greater water loss ) Diuretics Sweating Burns Diarrhoea Fistula ``` Euvolaemic ( normal Saline but water loss ) Diabetes insipidus Hypervolaemic ( increased total sodium ) Overuse of IV saline fluids
42
How to correct hypernatraemia ?
``` Hypovolaemic give Saline Euvolaemic give glucose 5% Hypervolaemic give diuretics Not too quickly otherwise Cerebral oedema ```
43
# Define hypercalcaemia and name it's 2 most common causes . What's the initial management ?
>2.6 mmol/L Primary hyperparathyroidism Malignancy Rehydration with saline
44
How are calcium levels in the body regulated ?
Low calcium stimulates PTH ( from parathyroid gland ) which Promotes ca reabsorbtion from kidney ( and phosphate excretion ) increased vitamin D production ( 1-alpha hydroxylase -> calcitriol ) And release from Ca from bones ( activation of osteoclasts )
45
Define hypocalcaemia | And give 4 causes
< 2.0 mmol/L ``` VIt D deficiency Chronic renal failure Hypoparathyroidism Hyperphosphataemia Loop Diuretics Multiple transfusions ```
46
What are symptoms of hypocalcaemia?
``` Muscle spasm Tetany Carpopedal sign Trousseu's sign ( spasm after inflation BP cuff ) Totsage de Point arrhythmia Abdominal cramps Seizures ```
47
Name the two most common causes for hypocalcaemia . How to differentiate between them ?
Hypoparathyroidism (Low PTH) Vitamin D deficiency - malabsorption , CKD ( high PTH )
48
What causes Hypoparathyroidism ?
Post Op Autoimmune Congenital - Di-George -syndrome Destruction by metastasis etc
49
How do acute and chronic hypoparathyroidism present ?
``` Acute : Signs of Hypocalcaemia Muscle spasm Tetany Carpopedal spasm Trousseu's sign Seizures Chvostek's sign ``` Chronic : Extrapyramidal signs Increased bone mineral density Cataract
50
In hypoparathyroidism , which blood results would you expect ?
Hypocalcaemia Low PTH Hyperphosphatameia
51
Name the 3 types | Of hyperparathyroidism and it's causes.
Primary Adenoma of parathyroid gland ``` Secondary CKD Malnutrition Vit D deficiency Cholestasis ``` Tertiary Longstanding secondary HPTH in CKD
52
What is the main feature of primary hyperparathyroidism and it's symptoms ?
Hypercalcaemia ``` Kidney stones Bone pain Abdominal pain Paeudohout Salt-and-pepper- skull Psychiatric disorders ```
53
What happens in secondary hyperparathyroidism ?
Conditions lead to Hypocalcaemia resulting in excessive PTH production Can lead to risk of fractures
54
How to treat primary hyperparathyroidism ?
Surgery | Calcimimetics
55
What is Paget's disease ?
A disease of the bone with increased and uncontrolled bone turnover ( disease of osteoclasts )
56
Which classical features are seen in Paget's disease ?
Deformities Bossy Skull Bowing of tibia Diffuse , increased bone density Bone pain Fractures - osteoporosis circumscripta
57
How to treat Paget's?
Bisphosphonate Oral risedronate IV zoledronate
58
How to differentiate between primary and secondary hypothyroidism ?
Primary TSh high, T3, 4 low Secondary TSH low, t3,t4 low
59
What are possible causes of a goitre ?
Diffuse: Graves , hashimoto , subacute viral, physiological Nodular Multinodular Adenoma Carcinoma
60
Name 6 causes of hypothyroidism
Atrophic ( antithyroid antibodies causing atrophy and fibrosis but no goitre) Hashimoto (goitre) Postpartum thyroiditis (lymphocytic ) Iodine deficiency Drug induced : amiodarine, Lithium Post thyroidectomy and radioiodine treatment
61
What effect does amiodarone have on thyroid hormones ?
Decrease conversation of T4 to T3
62
Name 7 symptoms of hypothyroidism
``` Lethargy Depression, low mood Cold intolerance Constipation Bradycardia Loss of libido Impaired Menstruation Weight gain Hair loss Hyporeflexia ```
63
How would you investigate a patient with suspected thyroid disease?
``` USS Autoantibodies Biopsy Scintigraphy Isotope scan in hyperthyroidism (hot and cold nodules ) ```
64
How to treat hypothyroidism ? Side effects ?
Levothyroxine 0-100mcg , review after 3 months or when change or dose than yearly control S/E Hyperthyroidism Reduced bone mineral density AF
65
What are rare complications of untreated hypothyroidism ?
Myoedemcoma Hypothermia Hypoventilation Loss of consciousness
66
How to differentiate between primary and secondary hyperthyroidism ?
Primary High T3,T4, low TSH Secondary high T3,T4, high TSH
67
What are causes of hyperthyroidism?
Exogenous- l-thyroxin , iod, contrast media Graves ``` Toxic multinodular goitre Single toxic goitre Viral thyroiditis (de Quervain) Drug induced : amiodarone Post Parfum thyroiditis TSH pituitary adenoma Hashitoxicosis Ectopic thyroid tissue (thyroid cancer ovarian teratoma) Marine Leihart syndrome ```
68
Explain Graves' disease and give its typical presentation.
``` IgG antibodies stimulation TSH receptor , causing excess production and diffuse gland enlargement Goitre Exophthalmos + opthalmoplegia Thyroid acropathy Pretibial myxoedema ```
69
Give 7 symptoms of hyperthyroidism
``` Weight loss Diarrhoea Hyperreflexia Hair loss Palpitations Tachycardia Tremor Anxiety Osteoporosis Sleep disturbance Sweating Moist warm skin ```
70
What's the treatment of hyperthyroidism ? Give each S/E
Carbimazole Thyroid antagonism Block and replace or reduce by titration 20-40mg S/E Agranulocytosis Infection, sore throats Teratogenicity in pregnancy PTU: propylthiouracil S/E liver failure , expensive , used in pregnancy Surgery S/E laryngeal nerve palsy, parathyroid gland damage Radioactive iodine Takes 6-12 weeks - keep away from baby this time due to radiation B-blocker like propanolol
71
What's a complication of hyperthyroidism?
Thyrotoxic crisis | Tachycardia , sweating, distress , delirium, mause vomiting
72
Define hyperkalaemia | And give it's causes
K > 5.0 mmol/L Metabolic acidosis Haemolysis Massive blood transfusion Excess K therapy Renal failure Ace inhibitors Addisons Amiloride & spironolactone ( k sparring diuretics )
73
Symptoms and signs of hyperkalaemia
Fast irregular pulse , palpitations , tachycardia , light headed , chest pain Asymptomatic ``` ECG changes Tall rented p waves Broad QRS Small P Waves Leading to Ventricular fibrillation and systole ```
74
Treatment of hyperkalaemia
``` Non urgent Calcium resonium - oral Emergency 1. Calcium chloride / gluconate 2. IV Insulin+Glucose 3. Salbutamol 4. Dialysis ```
75
Define hypokalaemia | What are the causes ?
< 3.5 ``` Prolonged fasting Insulin , salbutamol Diuretics : loop and thiazides Conns Cushing's Steroid use Vomiting Diarrhoea ```
76
Symptoms and ECG changes of hypokalaemia ?
Weakness , lethargy, hypotonia, hyporeflexia, cramps, constipation Flat T waves U waves Tachyarrhythmia eg torsade de pointes
77
Explain the hypothalamus - pituitary axis .
Hypothalamus stimulates anterior pituitary via different hormones to release : Growth hormone ACTH -> cortisol, aldosterone and sex steroid release from adrenal gland TSH - thyroid gland FSH and LH - ovaries , cycle and oestrogen / Progesteron production Prolactin - mammary glands milk production Hypothalamus also stimulates posterior pituitary via nerves to release oxytocin and ADH
78
What is Kallmans syndrome?
Isolated gonadotropin releasing hormone deficiency + ansomnia + colour blindness Results in low fsh and lh
79
What type of tumours are pituitary tumours ? Between which types can you differentiate ?
Mostly benign adenomas Chromophobe - nom secretory - prolactinomaa - ACTH release leading to Cushing's - GH release leading to acromegaly Acidophils - can Release GH and Prolactin Basophils Only release ACTH Don't show local compression signs
80
What are local compression signs of a pituitary adenoma ?
Headache Bitemporal heminopia CN palsy 3,4,6
81
What is a craniopharyngioma?
A tumour in rathkes pouch ( btw pituitary and 3rs ventricle ) It's the most common intracranial tumour in childhood Presents with growth failure Rare
82
What is pituitary apoplexy?
Rapid pituitary enlargement due to bleed in tumour , | Presents with rapid acute onset of neurolog. Signs
83
What hormone levels would you suspect in hyperprolactaemia ?
High prolactin Low FSH, LH Low testosterone and oestrogen
84
Causes of hyperprolactaemia Including physiological causes
Prolactinoma Craniopharyngioma Pituitary adenomas compressing pituitary stalk Dopamine antagonist- metoclopramid Haloperidol MDMA Oestrogen ``` Physiological Pregnancy Breast feeding Post orgasm Stress ```
85
Symptoms | Of hyperprolactaemia ?
Female Infertility Amenorrhea Galactorrhea ``` Men Erectile dysfunction Hair loss Galactorrhea Both : loss of libido, osteoporosis ```
86
Which test would you perform in a young female presenting with hyperprolactaemia ?
Pregnancy test
87
How to treat a prolactinoma?
Bromocriptine | =dopamine agonist
88
What is Sheehan syndrome ?
Hypopituitarism | After childbirth causes by post partum haemorrhage ( hypovolaemic shock ) -> ischaemia of anterior pituitary
89
What is Acromegaly and what is it caused by?
Excess growth hormone and insulin like growth factor 1 due to pituitary adenoma
90
How does acromegaly / gigantism present in adults and children?
``` Children = gigantism Longitudinal growth -> Tall stature Long hand , feet fingers, toes Coarsening of face ``` ``` Adults = acromegaly Epiphyseal plate closed no change in stature Big hand and feet , enlarged nose , jaw Teeth spacing Painful joints Cardiomyopathy ``` + effects of tumour Bitemporal hemianopia Headache CN palsy
91
How to investigate a patient that complains of an increase in shoe , ring and glove size ?
Acromegaly Measure IGF1 If high perform oral glucose tolerance test with GH If growth hormone not suppressed - indicative for acromegaly
92
A patient was diagnosed with acromegaly , what's the treatment ?
Transphenoidal adenomectomy

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