Endocrine and Hepatobiliary Flashcards by Michael McMahan

_____ system
• Maintain metabolic equilibrium (homeostasis)
• Secrete chemical messengers (hormones)
• Regulate activity of various organs
• Process of feedback inhibition
• Increased activity of target tissue, typically down-
regulates activity of gland secreting stimulating
hormone
•diseases
a. diseases of under/over-production of hormones
b. diseases associated with development of mass
lesions

Endocrine System

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• Base of brain-sella turcica
• Connected to hypothalamus 
a.  stalk composed of axons
b.  venous plexus
• Central role in regulation of other endocrine 
glands
• Two components
a. anterior lobe (adenohypophysis)
b. posterior lobe (neurohypophysis)
• Diseases divided according to lobe mainly 
affected

Pituitary gland

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• Produces growth hormone

• Somatotrophs

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• Produces prolactin

• Lactotrophs

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• Produces adrenocorticotrophic hormone

• Corticotrophs

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• Produces thyroid simulating hormone

• Thyrotrophs

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• Produces follicle stimulating hormone and luteinizing

hormone

• Gonadotrophs

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Pituitary Adenomas
Radiation Treatment
Neurosurgery
Sheehan Syndrome
Ischemic necrosis of pituitary gland
Pituitary Dwarfism
Amenorrhea & Infertility
Libido & Impotence
Postpartum lactation failure
Hypothyroidism
Hypoadrenalism

Hypopituitarism

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Pituitary Adenomas
Pituitary Hyperplasia
Pituitary Carcinomas
Hypothalamic disorders
Gigantism
Acromegaly
Cushing disease

Hyperpituitarism

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• Primary tumor
• Excess growth hormone (GH)
• Adenoma of anterior 
pituitary
• 2nd most common
• Affects all “growing tissues” 
• Gigantism- before growth 
plate closure

Hyperpituitarism

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•Generalized 
overgrowth• 3 standard deviations
•Headaches
•Chronic fatigue 
•Arthritis, 
osteoporosis
• Muscle weakness
•Hypertension
•Congestive heart

Gigantism

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• Late diagnosis
• Poor vision; photophobia 
• Enlarged skull, hands, feet, ribs
• Soft tissue, viscera  
• Enlarged maxilla, mandible, nasal and frontal 
bones, maxillary sinus
• Intraoral: 
• Diastemas
• Malocclusion
• Macroglossia
• Enlarged lips
• Sleep apnea

Acromegaly

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\_\_\_\_\_\_\_ pituitary issues:
• Diabetes Insipidus (Central)
• Polyuria
• Dilute urine
• Polydipsia
• Secretions of Inappropriately High 
Levels of ADH (SIADH)
• Hyponatremia
• Cerebral edema
• Neurologic dysfuction
• Total Body Water
• Blood volume normal
• No peripheral edema

Posterior pituitary

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____ controls TSH secretion

TRH

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_____ controls T3 and T4 production

TSH

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What 3 things are responsible for thyroid function? (glands)

Hypothalamus
Pituitary
Thyroid

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What 3 things are responsible for thyroid function? (glands)

Hypothatlamus
Pituitary
Thryoid

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\_\_\_\_\_ hypothyroidism
• Intrinsic abnormality 
in the thyroid
• Surgery
• Radiotherapy
• Autoimmune

Primary

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_____ hypothyroidism

• Pituitary failure

Secondary

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Adult
Generalized fatigue
Apathy
Mental sluggishness
Listless
Cold intolerance
Overweight

Myxedema

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• Childhood
• Impaired skeletal 
development
• Severe mental 
retardation 
• Short stature
• Course facial features
• Delayed tooth 
eruption

Cretinism

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Symptoms of ______:

Cold intolerance
Fatigue, lethargy
Weight gain
Constipation
Bradycardia

Hypothyroidism

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• Autoimmune 
• Painless 
enlargement
• Symmetric & 
diffuse
• Risk of B-cell non-
Hodgkins
Lymphomas

Hashimoto thyroiditis

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Clinical signs and symptoms Goiter (small)
Exophtalmus (frequent)
Heat intolerance
Weight loss
Malabsorption and diarrhea
Tachycardia
Irritability and anxiety
Most common causes Autoimmune - Graves’ disease and 
Hashimoto’s thyroiditis
Laboratory T4 and Free T4 elevated 
T3 and Free T3 elevated
TSH and TRH suppressed

Hyperthyroidism

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Symptoms of _____: - Weight loss - Nervousness - Rapid pulse - Goiter - Muscle wasting

Hyperthyroidism

* Tachycardia * Increased appetite * Weight loss * Exophthalmos * Intolerance to heat

Graves disease

``` • Diagnosis • TSH • Primary-low • Secondary- normal to high • T4 (T3) increased • Treatment • Ablation • Significance • Thyroid storm • Caused by infection, stress, trauma • Elevated body temp. • Tachycardia • 20-40% mortality ```

Graves disease

``` • Thyroid enlargement • Impaired synthesis of thyroid hormone • Iodine deficiency • Endemic • Hyperplasia of follicles • Pituitary stimulation • Maintenance of minimal function (euthyroid) • Diffuse early on, then nodular • Diet deficient in iodine • Decreased output of T3 & T4 by thyroid • Pituitary responds by secreting TSH • Thyroid hyperplasia ```

Goiter

Derived from developing pharyngeal pouches Lie in close proximity to upper and lower poles of each thyroid lobe May be found on path of descent of pharyngeal pouches – carotid sheath, thymus, anterior mediastinum Secrete Parathormone (PTH) which, with calcitonin regulates calcium homeostasis –controlled by the level of free (ionized) calcium

Parathyroid gland

_____: Activates osteoclasts activity Increases Ca renal tubular resorption Increases conversion of Vit. D into the active dihydroxy form in the kidneys Increases urinary excretion of phosphates Increases Ca absorption by the GI tract.

PTH:

* Hypocalcemia * Tetany * Chvostek Sign * Tapping CN VII * Muscle contraction * Eye, mouth, nose * Trosseau sign * Occluding circulation of forearm * Carpal spasm

Hypoparathyroidism

_____ hyperparathyroidism Adenoma Hyperplasia Carcinoma Morphologic changes Skeletal changes - bone resorption - Formation of bone cysts and hemorrhages (osteitis fibroso –cystica) - Brown tumors -Urinary tract stones (nephrolithiasis) - Metastatic calcification Serum calcium levels, especially Ionized calcium levels are high •Hypercalcemia • Hypophosphatemia • Increased urinary excretion of both calcium and phosphate

Primary

______ hyperparathyroidism: Calcium is chronically depressed and low serum calcium levels lead to compensatory hyperactivity of the parathyroids Serum phosphate levels are elevated Causes Chronic renal failure Vitamin D deficiency Inadequate dietary calcium Steatorrhea Morphology Hyperplastic parathyroid glands Bone chages (see primary hyperparathyroidism) Metastatic calcification Not as severe as in primary hyperparathyroidism Related to symptoms secondary to chronic renal failure Bone abnormalities (renal osteodystrophy) Calciphylaxis Tertiary hyperparathyroidism

Secondary

* Osteomalacia & loss of lamina dura * Brown tumor * Nephrolithiasis * Peptic/duodenal ulcers * Mental changes

Hyperparathyroidism

• Increases serum calcium • Activates osteoclasts • Increases renal tubular reabsorption of calcium • Increases renal conversion of Vit D • Increases urinary excretion of phosphate • Increased gastric absorption of calcium

PTH

_____ portion of adrenal gland: • Aldosterone • Regulated by angiotensin II

• Zona Glomerulosa

_____ portion of adrenal gland: • Glucocorticoids (cortisol) • Regulated by ACTH (biofeedback)

• Zona Fasiculata

_____ portion of adrenal gland: • Androgens • No feedback with ACTH

• Zona Reticularis

* Destruction of adrenal cortex * Production of adrenal corticosteroid hormones * Autoimmune * Metastatic carcinoma * Infections * TB * Deep fungal * Secondary hypoadrenocorticism * Disorder of hypothalamus or pituitary gland

Addison's disease

* Clinical symptoms appear late * Weakness & Fatigue * Hypotension (postural) * GI disturbances * Nausea/ Vomiting (N/V) * Anorexia * Diarrhea * Weight Loss * Salt cravings ( K+ ↑, Na+↓,) * Hyper-pigmentation (Bronzing) * ACTH precursor stimulates melanocytes * Frictional areas * Adrenal Crisis (Acute) * Abdominal pain * Hypotension * Vascular collapse

Addison's disease

``` ______ Hypercortisolism: • Too much endogenous steroid • Females 5x • 3rd decade • Pituitary adenomas (ACTH) • 50% • Cushing disease • Adrenal hyper/neoplasia • 10-20% • Neuroendocrine tumors • Produce ACTH • Small Cell Lung Carcinoma ```

•Primary hypercortisolism

______ Hypercortisolism: ``` • Most common • Exogenous • Rule of 2s • Can become hypocortisol without taper ```

•Secondary hypercortisolism

* Presentation * Central obesity * Peripheral wasting * Buffalo hump * “Moon facies” * Abdominal striae * Hirsutism * Poor wound healing * Diabetes * Hyperglycemia * Osteoporosis * Hypertension

Cushing syndrome

``` • AD • Marfanoid body type • Medullary thyroid carcinoma • Pheochromocytomas • Adrenal medulla • Neuromas • Can be first sign • Soft painless papules • Lips, conjunctiva, tongue, palate, buccal mucosa • Sentinel neuromas ```

MEN 2B

``` _____ Pancreas • Secretes enzymes • Digestion • Inactive proenzymes • Acute pancreatitis • Chronic pancreatitis • Cancer ```

• Exocrine pancreas

``` ______ Pancreas • Secretes hormones • Glucose homeostasis • Other metabolic activities • Diabetes mellitus • Beta cells in the islets of Langerhans ```

• Endocrine pancreas

``` • Injury to acinar cells • Interstitial or edematous pancreatitis • Mild • Reversible • Acute hemorrhagic pancreatitis • Alcoholism • Chronic biliary disease Etiology: • Metabolic • Alcoholism • Hyperlipoproteineimia • Hypercalcemia • Drugs • Thiazide diuretics • Genetic ```

Acute Pancreatitis

* Destruction of pancreatic parenchyma * Intermittent “acute” attacks * Alcoholism * Obstruction of pancreatic duct * Mechanical blockage * Congenital defects * Cancer * Inspissated mucous * Chronic injury to acinar cells

Chronic pancreatitis

• Hyperglycemia • Lack of insulin (Type 1) • Resistance to insulin (Type 2) • Combination • 21 million people ( 7% of population) • Loss of insulin (anabolic) results in a catabolic state affecting glucose, fat & protein metabolism

Diabetes mellitus

``` • Archaic terminology: Insulin Dependent DM, juvenile-onset DM • Autoimmune destruction of B cells in the Islets of Langerhans (insulitis) • Absolute deficiency • Destruction of Beta cells • Only 10% diabetics • Avg. age of onset- 14 yo • Emergencies • Acute: hypoglycemia • Chronic: ketoacidosis 180 •Cause• Destruction of β-cells • Autoimmune • T cell mediated • Auto-antibodies • Genetic • 30-70% twin concordance • HLA-DR3, DR4 (90-95%) • Environmental? • Infectious •Diagnosis ( DM1 or 2) • WNL= 70-120 mg/dL • Any of these • ≥ 200 mg/dL + S/S • Fasting ≥ 126 mg/dL • OGTT ≥ 200 mg/dl (2 hrs) ```

T1Dm

• Adult onset • “Relative” lack of insulin • 80-90% of diabetics • Insulin resistance • Early Normal blood insulin level • Target tissue Resistance • β-cell dysfunction fails to compensate • Demographics are changing • Ketoacidosis (rare) • Coma due to hyperosmolarity • Archaic terminology: Non-Insulin dependent DM, adult/maturity-onset DM • Inadequate secretion of insulin from the pancreas • Reduced tissue sensitivity to insulin (liver, skeletal muscle, adipose tissue) • Initially, hyperinsulinemia may compensate for peripheral insulin resistance and normal plasma glucose is maintained • Eventually, B cell compensation becomes inadequate and there is progression to hyperglycemia

T2DM

• The fraction of glycosylated hemoglobin in circulating red blood cells • Reflects the degree of hyperglycemia during the preceding 6-8 weeks

HbA1C

___vascular disease • Retina –diabetic retinopathy • Kidneys –nephropathy • Peripheral nerves - neuropathy

Microvascular disease

``` ____ vascular disease • Heart - myocardial infarction • Brain - stroke • Peripheral vascular disease –lower extremity gangrene ```

Macrovascular disease

• A dermatosis characterized by velvety, papillomatous, brownish-black, hyperkeratotic plaques, typically of the intertriginous surfaces and neck • May be associated with insulin resistance (cutaneous marker for type 2 diabetes) • May be associated with internal malignancy

Acanthosis nigricans

* Oral Complications * Infections * Candida sp., * Mucormycosis * Bacterial * Slow healing * Gingiva * enlargement, erythema * Subjective xerostomia * Parotid gland enlargement

``` • Regenerative • Remove 60% • Minimal change in function • 4-6 weeks for almost total regeneration of mass • The key is the hepatic reticulum • Type 4 collagen • Fibrosis= Types 1 & 3 collagen ```

Liver

``` • Metabolic • Glucose homeostasis • Synthetic- plasma proteins • Albumin, VLDL, LDL, PT, Fibrinogen • Storage • Glycogen • Triglycerides • Iron, Copper • Vitamins- A, D, K • Degrades/Detoxifies • Phase 1 oxidation • -OH, -COOH • Cytochrome p450 • Phase 2 conjugation • Glucuronic acid= Soluble • Exocrine • Bile (1L/d) • Endocrine • D3 to 25-hydroxy-cholecalciferol • T4 to T3 (active) • GHRH • Insulin & glucagon degradation ```

Liver

``` Causes of ______ • One of top 10 causes of death • ETOH • Infection (HBV, HCV) • Biliary disease • Iron overload (Hemochromatosis) • Autoimmune hepatitis • 10% idiopathic ```

Cirrhosis

``` ____ characteristics • Diffuse fibrosis and conversion of normal architecture into abnormal nodules • Bridging fibrosis • Parenchymal nodules • Micro (3mm);Macro • regeneration • Entire liver architecture effaced ```

cirrhosis

``` ____ clinical consequences: • Ascites • Formation of portosystemic venous shunts • Congestive splenomegaly • Hepatic encephalopathy ```

Portal hypertension

* NON-SPECIFIC sign of liver dysfunction * Retention of bile (>2.0 mg/dL) * Hepatitis * Obstruction (cirrhosis) * Accumulation of conjugated bilirubin * Hemolytic anemias * Accumulation of un-conjugated bilirubin * Cholestasis (Lack of flow of bile) * Retention due to obstruction or hepatocyte dysfunction * Serum Alk Phos elevated

Jaundice

Is jaundice a disease?

``` Causes of ____ Disease • Alcohol related • Drug related • Infectious (HCV) • Metabolic • Neoplasms • Autoimmune ```

Liver disease

``` ETOH causes 60% of Chronic Liver Disease • ETOH accounts for 40-50% of deaths due to cirrhosis • 5th leading cause of death • Forms of liver disease • Hepatitic steatosis • Alcoholic hepatitis • Cirrhossis ```

Alcoholic liver disease

``` _____ damage • Tetracycline • Anti-neoplastic agents • Mushroom toxins • Amanita Phalloides • Carbon tetrachloride • ETOH • Microvesicular fatty change • Macrovesicular fatty change • Fibrosis/cirrhossis • Diffuse/massive necrosis • Centrilobular necrosis • Macrovesicular fatty change • Fibrosis/cirrhossis ```

Hepatocellular damage

``` ______ Hepatitis • Self limiting • No carrier state • Life long immunity • Vaccine • Epidemics • Rare fatalities (0.1%) ```

HAV

``` ______ Hepatitis • Prolonged incubation • Chronic carrier state • Increased risk of HCCa • Vaccine- Anti-HBs • 2 Billion alive today will be infected ```

HBV

``` ______ Hepatitis • Similar to HBV, but... • More cirrhosis risk • Used to be transfusion related • IV drug related • Early Tx hopeful for cure ```

HCv

``` ______ Hepatitis • Needs HBV (HBsAg) • Coinfection of B & D at same time • low chance • Super-infection of a carrier of HBV that gets a new HDV • More likely ```

HDV

``` • Excessive accumulation of Iron • WNL= 2-6 gms (only 0.5gm in liver) • Males 5-7:1 ( earlier than females) • 5th-6th decades • Iron deposition in liver, pancreas, myocardium, skin, joints ```

Hemochromatosis

* Fatty liver changes & encephalopathy in Kids (<4 yo) * Associated with viral infection * Begins as pernicious vomiting 3-5 days s/p virus * Lethargy, irritability, hepatomegaly * Mitochondrial hepatopathy (LOF)

Reye syndrome

``` • AR disorder of Copper metabolism • Chr 13 • 1:30,000 • Accumulation in Liver, brain, & eye • Normal uptake but: • Failure to enter circulation as ceruloplasmin • Inability to be excreted in bile • Unbound copper spills into circulation • Hemolysis • Diagnosis • Onset prior to age 6 • Elevated hepatic copper, low serum ceruloplasmin, high urinary copper • Acute/Chronic hepatitis • Neuropsychiatric • Behavioral changes • Parkinson-like • Pychosis • Kayser-Fleischer rings ```

Wilson disease

* Geographic distributions * Asia, Africa * 20-40 yo * 50% w/o cirrhosis * West much lower (8-30x less) * Seldom before 60 yo * 90% w/ cirrhosis * Cirrhosis (alcoholic) * HBV (200x), HCV * Aflatoxin (Aspergillus flavus)

Hepatocellular Carcinoma | Hepatoma

* Located in the upper right quadrant * Stores bile * 50mL * Releases bile * Fat digestion

Gallbladder

______ Cholecystitis • Acute inflammation • Obstruction of the neck or cystic duct • Absence of gallstones

Acute

______ Cholecystitis * Sequel to repeated bouts of acute cholecystitis * Absence of acute cholecystitis * Gallstones

• Chronic

Endocrine and Hepatobiliary Flashcards

(77 cards)