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Endocrinology 1 Flashcards

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1
Q

What is acromegaly most commonly caused by?
Other causes:

A

Excess GH secondary to pituitary adenoma

ectopic GHRH or GH production by tumours e.g pancreatic

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2
Q

Features acromegaly (6)

A

Coarse facial appearance
Spade like hands
Increased shoe size
Large tongue
Prognathism (bulging of jaw)
Excessive sweating

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3
Q

Features of pituitary tumour (3)

A

Hypopituitarism
Headaches
Bitemporal hemianopia

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4
Q

Other features of acromegaly (2)
Hint 1. MEN 2. increased in 1/3 of cases

A

MEN 1
Raised prolactin in 1/3 of cases

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5
Q

Complications of acromegaly (4)

A

HTN
Diabetes
Cardiomyopathy
Colorectal ca

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6
Q

What is Addison’s disease?
Leads to a change in which two hormones?

A

autoimmune destruction of adrenal glands leading to hypoadrenalism.

Leads to a reduction in cortisol and aldosterone.

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7
Q

Features of Addison’s (8)

A

lethargy
anorexia
N&V
weight loss
hyperpigmentation (palmar creases) (only in Addison’s)
vitiligo
loss of pubic hair
hypotension

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8
Q

Electrolyte changes in Addison’s (4) (na k+ glucose gas)

A

Hyponatramia and hyperkalaemia
Hypoglycaemia
Metabolic acidosis

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9
Q

Addison’s crisis symptoms (3)

A

Collapse
Shock
Pyrexia

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10
Q

Primary causes of hypoadrenalism (6)

A

TB
Metastases
Adrenal haemorrhage
Meningococcal
HIV
Antiphospholipid syndrome

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11
Q

Secondary causes of hypoadrenalism (3)

A

Tumours
Irradiation
Exogenous glucocorticoid therapy

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12
Q

Addison’s Ix
Definite investigation:

A

ACTH stimulation test (short synACTHen test)

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13
Q

What is an ACTH stimulation test (short synACTHen test)?

A

Measure cortisol before and 30 minutes after giving synACTHen 250ug IM

Baseline cortisol measured, given synachthen and expect cortisol to double when measured at 30 minutes and 60minutes. If still low then Addison’s

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14
Q

Addison’s - what can you do if an ACTH stimulation test is not possible?

A

Measure 9am cortisol

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15
Q

Results for a 9am cortisol

A

> 500 - unlikely Addison’s
<100 - abnormal
100-500 = do a ACTH stimulation test

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16
Q

Explain the hypothalamic pituitary axis

A

Hypothalamus releases hormones than impact both anterior and posterior pituitary as follows

Hypothalamus –> Anterior pituitary
CRH –> stimulates ACTH production
TRH –> stimulates TSH production
TRH –> stimulates prolactin
GnRH –> stimulates FSH/ LH production
Somatostatin –> inhibits GH production
Dopamine –> inhibits prolactin production

Posterior pituitary
Oxytocin
ADH

ACTH –> adrenals –> cortisol on many tissues
TSH –> thyroid –> thyroxine
FSH/LH –> gonads –> androgen or oestrogen production
GH –> liver –> insulin growth factor release (IGF) on many tissues
Prolactin –> breast –> lactation

Oxytocin –> uterine muscle
ADH –> distal convoluting tubules –> water reabsorption

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17
Q

Addison’s Mx (2)

A
  1. Hydrocortisone (20-30mg/day) (double if sick) - majority given in the first half of the day in 2-3 divided doses.
  2. Fludrocortiose (stays the same when sick)
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18
Q

What is Bartter’s syndrome?

What is the effect on BP

A

Autosomal recessive disease causing severe hypokalaemia

(defective chloride absorption at the NaKCl cotransporter in the ascending loop of Henle)

Associated with normotension

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19
Q

Features of Bartter’s (5)
Age group

A

Presents in childhood

FTT
Polyuria and polydipsia
Hypokalaemia
Normotension
Weakness

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20
Q

Mx of thyrotoxicosis

A

Carbimazole high dose for 6 weeks until pt becomes euthyroid before being reduced

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21
Q

MOA carbimazole

A

blocks thyroid peroxidase from coupling and iodinating thus reducing thyroid hormone production

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22
Q

Most common cause of thyrotoxicosis

A

Grave’s

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23
Q

Other causes of thyrotoxicosis (5)

A

Graves
Toxic nodular goitre
Acute phase of subacte thyroiditis
Acute phase of post partum thyroiditis
Amiodarone

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24
Q

DVLA rules for diabetics on insulin/ other hypoglycaemic inducing drugs such as sulfonylureas
Group 2
(5)

A
  • no severe hypoglycaemia event in last 12 months
  • full hypoglycaemic awareness
  • show adequate control by regular blood glucose monitoring (BD monitoring and at times relevant to driving) (for 3 months before applying)
  • driver must understand risks of hypoglycaemia
  • no other debarring complications of diabetes
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25
Group 2 versus Group 1 in the context of DVLA
HGV = Group 2 Car = Group 1
26
Car driver and on insulin or other hypoglycaemic inducing drugs such as sulfonylureas Group 1
Hypoglyaemic awareness No more than one episode of hypoglycaemia requiring the assistance of another person within the preceding 12 months No visual impairment Drivers are contacted by DVLA
27
If on tablets of exanatide or diet controlled do the DVLA need to be informed?
No
28
SE mineralocorticoids (2)
Fluid retention HTN
29
When to have a gradual withdrawal of systemic corticosteroids? (3)
40mg OD for more than 1 week Or if they have received any dose for more than 3 weeks Recently received repeated courses
30
SE glucocorticoids psychiatric (3) GI (2) Eyes (2)
insomnia depression psychosis Peptic ulcers Pancreatitis Glaucoma Cataracts
31
Cushings Metabolic acidosis or alkalosis
Hypokalaemic metabolic alkalosis
32
Cushings syndrome Causes ACTH dependent (2) ACTH independent (3) Pseudo (2)
ACTH dependent 1. Pituitary adenoma = Cushing's disease 2. Ectopic ACTH production e.g small cell lung cancer ACTH independent 1. Iatrogenic (steroids given to pt) 2. Adrenal carcinoma/ adenoma 3. Carney complex Pseudo-Cushings 1. ETOH excess 2. Depression
33
Cushings Investigations (3)
1. Overnight dexamethasone suppression test 2. 24 hr urinary free cortisol 3. CRH stimulation test
34
Cushings Explain what the overnight dexamethasone test is Explain its results
Split into low dose and high dose dexamethasone test 10pm give 1mg dexamethasone, 9am measure cortisol and ACTH In a pt without any issues Give 1mg dexamethasone, this acts on hypothalamus (negative feedback) and pituitary and adrenals --> therefore in the morning, you should have a low cortisol. If you have Cushing's disease (pituitary adenoma causing high cortisol) As pt is used to having lots of cortisol, having 1mg dexamethasone will not cause negative feedback system. Therefore cortisol level will be normal or raised. If low dose test is suggestive of Cushing's you will then move on to high dose. Give 8mg of dexamethasone at 10pm Morning measure cortisol and ACTH If you have Cushing's disease (pituitary adenoma), 8mg is enough to trigger negative feedback system. Therefore ACTH will decrease and cortisol will fall. If you have an adrenal gland tumour. The adrenal gland tumour cells will produce cortisol independent of ACTH. Therefore dexamethasone will work on pituitary through negative feedback system which leads to low ACTH. However as cortisol is independent of ACTH. Cortisol levels will be raised. If you have ectopic ACTH production. Then dexamethasone will cause reduction in CRH and therefore ACTH. However as ectopic ACTH production still going on. ACTH will be raised and thus cortisol will be raised. To summarise Low dose test Low cortisol = normal High cortisol = cushing's syndrome High dose test Low ACTH and low cortisol = Cushing's syndrome Low ACTH and high cortisol = Adrenal carcinoma/ adenoma High ACTH and high cortisol = ectopic
35
Explain CRH stimulation test
This is to determine between pituitary source or ectopic source In a pituitary source - CRH stimulation = increased ACTH = increased cortisol In an ectopic source - CRH stimulation = ACTH remains the same and cortisol stays the same as the ectopic ACTH acts as negative feedback to the hypothalamus.
36
TFTS interpretation What would you expect the TSH to look like in steroid therapy and secondary hypothyroidism
Steroid Low TSH, normal T4 Secondary hypothyroidism low and low
37
Sick euthyroid TFTs
low and low although sometimes TSH can be normal
38
How to prevent thyroid related eye disease? What medication can reduce the risk?
smoking cessation prednisolone
39
Mx thyroid eye disease (4)
Topical lubricants Steroids Radiotherapy Surgery
40
What is the classification of thyroid disorders?
Primary - problem with the thyroid gland Secondary - usually due to pituitary (pituitary apoplexy) Congenital - hypothyroidism
41
Name the thyroid condition: Painful goitre and raised ESR
= subacute thyroiditis (hypothyroiditis)
42
Subacute (De Quervain's) thyroiditis - hypo or hyper By what week will it return to normal?
Presents with hyperthyroidism following a viral infection but is actually hypothyroidism. Week 4
43
Name the thyroid condition: Fibrous tissue replacing the normal thyroid parenchyma Painless or painful goitre? Hypo or hyper
Riedel thyroiditis Painless Hypothyroiditis
44
Toxic multinodular goitre What is it?
benign thyroid nodules that secrete excess thyroid hormones
45
Postpartum thyroiditis Hypo or hyper?
Hyper initially then hypo
46
Most common cause of low thyroid in the developing world?
Iodine deficiency
47
Name two drugs that can cause hypo thyroid and one that can cause hyper
Lithium hypo Amiodarone both
48
Name a skin condition caused by hyperthyroidism
Pretibial myxoedema
49
Name three autoantibodies that can be tested for?
anti-TPO (Hashimotos) TSH receptor antibodies (Grave's) Thyroglobulin antibodies
50
Mx hyperthyroidism (3)
- propranolol - carbimazole - radioiodine tx
51
When do you tx subclincial hypothyroidism? (figures)
TSH >10 and <= 70yo start rx if asymptomatic with levothyroxine If >80 watch and wait
52
When do you tx subclinical hypothyroidism? 65yo
TSH 4-10 and T4 normal = subclinical hypothyroidism <65 and symptomatic - trial levothyroxine for 6 months, if no improvement then stop
53
Subclinical hypothyroidism Mx Older people (>80) Asymptomatic people
Watch and wait, observe and repeat TFTs in 6 months
54
What are the main cause of subclinical hyperthyroidism? Particularly in which group of patients? (sex and age) Mx
Multinodular goitre - particularly in elderly females If persistently low TSH then low dose carbimazole for 6 months
55
Describe Riedel's thyroiditis Describe the goitre Age group and sex Associated with which condition?
Hypothyroid characterised by dense fibrous tissue replacing the normal thyroid parenchyma hard, fixed, painless goitre middle aged women associated with retroperitoneal fibrosis
56
Describe the 4 phases of subacute thyroiditis (De Quervain's)
phase 1 (lasts 3-6 weeks): hyperthyroidism, painful goitre, raised ESR phase 2 (1-3 weeks): euthyroid phase 3 (weeks - months): hypothyroidism phase 4: thyroid structure and function goes back to normal
57
subacute thyroiditis (De Quervain's) Ix
thyroid scintigraphy: globally reduced uptake of iodine-131
58
subacute thyroiditis (De Quervain's) mx (3)
self limiting pain can be tx with NSAIDs or aspirin if severe then steroids (especially if hypothyroidism develops)
59
Examples of meflitinides When will they be used? Similar to SE (2)
Repaglinide Erratic lifestyle Similar to sulfonylureas Weight gain and hypoglycamia
60
MODY mx (2) Most common type Gene defect Increased risk of?
sensitive to sulfonylureas, insulin is not necessary MODY 3 HNF alpha 1 gene defect Increased risk of HCC
61
Metabolic syndrome criteria (5)
Atleast 3 of the following: Raised BM Raised BP Raised waist circumference Raised triglycerides Reduced HDL

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