Endocrinology Flashcards

Question

Secondary hypothyroidism (rare)

Answer 1

1. From pituitary failure 2. Other associated conditions * Down's syndrome * Turner's syndrome * Coeliac disease

Answer 2

* Initial starting dose of levothyroxine should be lower in elderly patients and those with ischemic heart disease (e.g. 25–50 mcg/day). * Following a change in thyroxine dose thyroid function tests should be checked after 6-8 weeks * The therapeutic goal is 'normalisation' of the thyroid stimulating hormone (TSH) level. As the majority unaffected people have a TSH value 0.5–2.5 mu/l it is now thought preferable to aim for a TSH in this range. Dosage changes should of course also take account of symptoms * There is no evidence to support combination therapy with levothyroxine and liothyronine

Answer 3

* Hyperthyroidism: due to over treatment * ↓ bone mineral density * Worsening of angina * Atrial fibrillation

Answer 4

TSH low T4 high In T3 thyrotoxicosis, T4 will be normal

Answer 5

TSH high T3/4 low

Answer 6

TSH low T3/4 low Steroid therapy is required prior to thyroxine

Answer 7

TSH low T3/4 low

Answer 8

TSH high T3/4 normal - high

Answer 9

TSH Low T3/4 normal

Answer 10

Autosomal recessive disorder of defective iodine uptake Features: * Sensorineural deafness * Goitre * Euthyroid or mild hypothyroidism

Answer 11

Pretibial myxedema: erythematous, edematous lesions above the lateral malleoli * Thyroid acropachy: clubbing * Scalp hair thinning * ↑ sweating

Answer 12

Dry (anhydrosis), cold, yellowish skin * Non-pitting edema (e.g. Hands, face) * Dry, coarse scalp hair, loss of lateral aspect of eyebrows * Eczema * Xanthomata

Answer 13

antithyroid drug of choice in pregnancy. This approach was supported by the 2007 Endocrine Society consensus guidelines. It also has the advantage of being excreted to a lesser extent than carbimazole in breast milk.

Answer 14

pregnancy there is ↑ in the levels of thyroxine-binding globulin (TBG). This causes ↑ in the levels of total thyroxine but does not affect the free thyroxine level

Answer 15

ntreated thyrotoxicosis ↑ the risk of fetal loss, maternal heart failure and premature labour * Graves' disease is the most common cause of thyrotoxicosis in pregnancy. It is also recognised that activation of the TSH receptor by HCG may also occur - often termed transient gestational hyperthyroidism. HCG levels will fall in second and third trimester

Answer 16

* Thyroxine is safe during pregnancy * Serum thyroid stimulating hormone measured in each trimester and 6-8 weeks post-partum * Some women require an ↑ dose of thyroxine during pregnancy * Breast feeding is safe whilst on thyroxine

Answer 17

Papillary 70% Follicular 20% Medullary 5% Anaplastic 1% L ymphoma Rare

Answer 18

Often young ♀s - excellent prognosis (associated with FAP)

Answer 19

Spreads through blood vessels

Answer 20

Cancer of parafollicular cells, secrete calcitonin, part of MEN-2

Answer 21

Associated with Hashimoto's and other autoimmune disorders

Answer 22

* Total thyroidectomy * Followed by radioiodine (I-131) to kill residual cells * Yearly thyroglobulin levels to detect early recurrent disease (only after total thyroid ablation)

Answer 23

elderly ♀s with an unquenchable thirst and an inappropriately normal or raised parathyroid hormone level. It is most commonly due to a solitary adenoma

Answer 24

Causes of primary hyperparathyroidism * 80%: solitary adenoma * 15%: hyperplasia * 4%: multiple adenoma * 1%: carcinoma

Answer 25

Features: 'Bones, stones, abdominal groans and psychic moans' * Polydipsia, polyuria * Peptic ulceration/constipation/pancreatitis * Bone pain/fracture * Renal stones * Depression * Hypertension

Answer 26

Associations * Hypertension * Multiple endocrine neoplasia: MEN I and II

Answer 27

nvestigations * Raised calcium, low phosphate * PTH may be raised or normal * Technetium-MIBI subtraction scan

Answer 28

IV Fluids * Total parathyroidectomy * Bisphosphonates

Answer 29

↓ PTH secretion * E.g. Secondary to thyroid surgery * Low calcium, high phosphate * Treat with alfacalcidol

Answer 30

Target cells being insensitive to PTH * In type I pseudohypoparathyroidism there is a complete receptor defect whereas in type II the cell receptor is intact. * Due to abnormality in a G protein * Autosomal dominant fashion* * Associated with low IQ, short stature, shortened 4th and 5th metacarpals * Low calcium, high phosphate, high PTH * Diagnosis is made by measuring urinary cAMP and phosphate levels following an infusion of PTH. In hypoparathyroidism this will cause ↑ in both cAMP and phosphate levels. In pseudohypoparathyroidism type I neither cAMP nor phosphate levels are ↑ whilst in pseudohypoparathyroidism type II only cAMP rises.

Answer 31

Similar phenotype to pseudohypoparathyroidism but normal biochemistr

Answer 32

* Idiopathic * Post head injury * Pituitary surgery * Craniopharyngiomas * Histiocytosis X

Answer 33

association of cranial Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness (also known as Wolfram's syndrome)

Answer 34

* Genetic (primary) * Electrolytes: hypercalcemia, Hypokalemia * Drugs: demeclocycline, lithium * Tubulo-interstitial disease: obstruction, sickle-cell, pyelonephritis

Answer 35

High plasma osmolarity, low urine osmolarity * Water deprivation test

Answer 36

starting os Normal (275-299) Final urine os > 600 HIGH Urine os post DDVAVP - > 600 HIGH

Answer 37

starting os LOW Final urine os > 400 Urine post DDAVP >400

Answer 38

starting os HIGH Final urine os <300 LOW Urine post DDAVP <600 HIGH

Answer 39

starting os HIGH Final urine os <300 LOW Urine post DDAVP <300 LOW

Answer 40

f the patient is symptomatic: * Fasting glucose ≥7.0 mmol/l * Random glucose ≥11.1 mmol/l (or after 75g oral glucose tolerance test) If the patient is asymptomatic the above criteria apply but must be demonstrated on two separate occasions.

Answer 41

fasting glucose 6.1 - 7.0 mmol/l implies impaired fasting glucose

Answer 42

fasting plasma glucose < 7.0 and OGTT 2-hour 7.8 - 11.1

Answer 43

increasing pancreatic insulin secretion (B cells must be present)

Answer 44

Hypoglycaemic episodes (more common with long acting preparations such as chlorpropamide) * ↑ appetite and weight gain Sulfonylureas should be avoided in breast feeding and pregnancy

Answer 45

Chronic kidney disease: NICE recommend reviewing metformin if the creatinine is > 130 μmol/l and stopping metformin if > 150 μmol/l * Do not use during suspected episodes of tissue hypoxia (e.g. Recent MI, sepsis) * Alcohol abuse is a relative contraindication * Stop 2 days before general anaesthetic, restart when renal function normal * Stop prior to IV contrast e.g. Angiography, restart when renal function norm

Answer 46

Adverse effects * Gastrointestinal upsets are common (nausea, anorexia, diarrhea), intolerable in 20% * ↓ vitamin B12 absorption - rarely a clinical problem * Lactic acidosis* with severe liver disease or renal failure * High dose (>2gm) interferes with enterohepatic circulation of bile salt → diarrhea.

Answer 47

Mechanism of action * ↑ Insulin sensitivity * ↓ hepatic gluconeogenesis * May also ↓ gastrointestinal absorption of carbohydrates

Answer 48

They are agonists to the PPAR-gamma receptor and ↓ peripheral insulin resistance Peroxisome Proliferator-Activated Receptor Gamma (PPAR-gamma receptor) is an intracellular nuclear receptor. Its natural ligands are free fatty acids and it is thought to control adipocyte differentiation and function

Answer 49

Adverse effects * Weight gain * Liver impairment: monitor LFTs * Fluid retention - therefore contraindicated in heart failure. The risk of fluid retention is ↑ if the patient also takes insulin * Recent studies have indicated an ↑ risk of fractures * Rosiglitazone is not recommended for use in patients with ischemic heart disease or peripheral arterial disease. The risk of complications may be ↑ if rosiglitazone is combined with insulin

Answer 50

Only continue if there is a reduction of > 0.5 percentage points in HbA1c in 6 months

Answer 51

hormone released by the small intestine in response to an oral glucose load In normal physiology an oral glucose load results in a greater release of insulin than if the same load is given intravenously - this known as the incretin effect. This effect is largely mediated by GLP-1 and is known to be ↓ in T2DM.

Answer 52

↑ insulin secretion and inhibit glucagon secretion * Licensed for use in T2DM * Must be given by subcutaneous injection within 60 minutes before the morning and evening meals. It should not be given after a meal * May be combined with metformin, a sulfonylurea or a thiazolidinedion

Answer 53

Typically results in weight loss * Major adverse effect is nausea and vomiting * The Medicines and Healthcare products Regulatory Agency has issued specific warnings on the use of exenatide: o increased risk of severe pancreatitis o increased risk of renal impairment

Answer 54

Should be used only when insulin would otherwise be started, obesity is a problem (BMI > 35 kg/m2) and the need for high dose insulin is likely * Continue only if beneficial response occurs and is maintained (> 1.0 percentage point HbA1c reduction and weight loss > 3% in 6 months)

Answer 55

* Continue DPP-4 inhibitor only if there is ↓ of > 0.5 percentage points in HbA1c in 6 months * NICE suggest that a DPP-4 inhibitor might be preferable to a thiazolidinedione if further weight gain would cause significant problems, a thiazolidinedione is contraindicated or the person has had a poor response to a thiazolidinedione

Answer 56

Encourage high fibre, low glycaemic index sources of carbohydrates * Include low-fat dairy products and oily fish * Control the intake of foods containing saturated fats and trans fatty acids * Limited substitution of sucrose-containing foods for other carbohydrates is allowable, but care should be taken to avoid excess energy intake * Discourage use of foods marketed specifically at people with diabetes * Initial target weight loss in an overweight person is 5-10%

Answer 57

* The general target for patients is 6.5%. HbA1c levels below 6.5% should not be pursued * However, individual targets should be agreed with patients to encourage motivation * HbA1c should be checked every 2-6 months until stable, then 6 monthly

Answer 58

Target is < 140/80 mmHg (or < 130/80 mmHg if end-organ damage is present) * ACE inhibitors are first-line

Answer 59

) then a DPP-4 inhibitor or thiazolidinedione should be considered rather than a sulfonylurea

Answer 60

hould be considered for patients with an erratic lifestyle

Answer 61

consider human insulin Metformin treatment should be continued after starting insulin

Answer 62

Usually commenced if HbA1c > 7.5% * NICE recommend starting with human NPH insulin (isophane, intermediate acting) taken at bed-time or twice daily according to need

Answer 63

* Aspirin to all patients > 50 years and to younger patients with other significant risk factors * The management of blood lipids in T2DM has changed slightly. Previously all patients with T2DM > 40-years-old were prescribed statins. Now patients > 40-years-old who have no obvious cardiovascular risk (e.g. Non-smoker, not obese, normotensive etc) and have a cardiovascular risk < 20%/10 years do not need to be given a statin. * If serum cholesterol target is not reached consider increasing simvastatin to 80mg HS. * If target still not reached consider using a more effective statin (e.g. Atorvastatin) or adding ezetimibe * Target total cholesterol is < 4.0 mmol/l * If serum triglyceride levels are > 4.5 mmol/l prescribe fenofibrate

Answer 64

First-line: oral duloxetine. Oral amitriptyline if duloxetine is contraindicated. * Second-line treatment: if first-line treatment was with duloxetine, switch to amitriptyline or pregabalin, or combine with pregabalin. If first-line treatment was with amitriptyline, switch to or combine with pregabalin * Other options: pain management clinic, tramadol (not other strong opioids), topical lidocaine for localised pain if patients unable to take oral medication * Consider capsaicin ointment (red pepper extract) local application

Answer 65

Causes * Insulinoma - ↑ ratio of proinsulin to insulin * Self-administration of insulin/sulphonylureas * Liver failure * Addison's disease * Alcohol Other possible causes in children * Nesidioblastosis - β cell hyperplasia

Answer 66

Red blood cell lifespan * Average blood glucose concentration As HbA1c is produced by the glycosylation of hemoglobin at a rate proportional to the glucose concentration.

Answer 67

1. Glucose > 33.3 mmol/l 2. pH > 7.30 3. Serum bicarbonate > 15 mmol/l 4. Serum osmolality > 320 mosmol/kg 5. Traces of ketones may be present in urines

Answer 68

The low-insulin condition in DKA stimulate → lipolysis → production of ketone bodies, β- hydroxybutyrate and acetoacetate , which can be used as metabolic fuel

Answer 69

Blood glucose >13.8 mmol/l * pH < 7.30 * Serum bicarbonate <18 mmol/l * Anion gap > 10 * Ketonemia

Answer 70

Fluid replacement: most patients are depleted ≈ 5-8 litres. 0.9% saline is used initially * Insulin: an intravenous infusion should be started at 6U/hour. Once blood glucose is < 15 mmol/l an infusion of 5% dextrose should be started * Correction of Hypokalemia * LMWH to prevent DVT

Answer 71

* Gastric stasis * Cerebral edema * Thromboembolism * Acute respiratory distress syndrome * Acute renal failure

Answer 72

* BMI of > 30 kg/m2 * Previous macrosomic baby weighing 4.5 kg or above. * Previous gestational diabetes * First-degree relative with diabetes * Family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)

Answer 73

If a women has had gestational diabetes previously an oral glucose tolerance test (OGTT) should be performed at 16-18 weeks and at 28 weeks if the first test is normal * Women with any of the other risk factors should be offered an OGTT at 24–28 weeks

Answer 74

Weight loss for women with BMI of > 27 kg/m2 * Stop oral hypoglycaemic agents, apart from metformin*, and commence insulin * Folic acid 5 mg/day from pre-conception to 12 weeks gestation * Detailed anomaly scan at 18-20 weeks including 4-chamber view of the heart and outflow tracts * Tight glycaemic control ↓ complication rates * Treat retinopathy as can worsen during pregnancy

Answer 75

Adhesive capsulitis (frozen shoulder) is strongly associated diabetes type-I with as many as 40% of patients developing this problem at some stage

Answer 76

destruction of the β-cells of the pancreas. Identical twins show a genetic concordance of 40%. It is associated with HLA-DR3 and DR4. It is inherited in a polygenic fashion

Answer 77

relative deficiency of insulin and the phenomenon of insulin resistance. Age, obesity and ethnicity are important aetiological factors. There is almost 100% concordance in identical twins and no HLA associations.

Answer 78

* Autoimmune disease * Antibodies against β cells of pancreas * HLA DR4 > HLA DR3 * Various antibodies such as islet-associated antigen (IAA) antibody and glutamic acid decarboxylase (GAD) antibody are detected in patients who later go on to develop type 1 DM - their prognostic significance is not yet clear

Answer 79

the development of type 2 diabetes mellitus in patients < 25 years old. It is typically inherited as an autosomal dominant condition. Over six different genetic mutations have so far been identified as leading to MODY. Ketosis is not a feature at presentation. Usually there is a strong family history

Answer 80

60% of cases * Due to a defect in the HNF-1 α gene (Hepatocyte Nuclear Factor).

Answer 81

* 20% of cases * Due to a defect in the glucokinase gene

Answer 82

<10% * Due to defect in HNF-4 α gene.

Answer 83

Basics * Most common pancreatic endocrine tumour * 10% malignant, 10% multiple * Of patients with multiple tumours, 50% have MEN-1 Features * Of hypoglycemia: typically early in morning or just before meal, e.g. Diplopia, weakness etc * Rapid weight gain may be seen * High insulin, raised proinsulin:insulin ratio * High C-peptide Diagnosis * Supervised, prolonged fasting (up to 72 hours) * CT pancrea

Answer 84

Basics * Used in investigation of hypopituitarism * IV insulin given, GH and cortisol levels measured * With normal pituitary function GH and cortisol should rise Contraindications * Epilepsy * Ischemic heart disease * Adrenal insufficiency

Answer 85

CTH dependent causes * Cushing's disease (80%): pituitary tumour secreting ACTH producing adrenal hyperplasia * Ectopic ACTH production (5-10%): e.g. Small cell lung cancer CTH independent causes * Iatrogenic: steroids * Adrenal adenoma (5-10%) * Adrenal carcinoma (rare) * Carney complex: syndrome including cardiac myxoma * Micronodular adrenal dysplasia (very rare)

Answer 86

1. hypokalaemic metabolic alkalosis may be seen, along with impaired glucose tolerance. Tests to confirm Cushing's syndrome: * Overnight dexamethasone suppression test (most sensitive) * 24 hr urinary free Cortisol Localisation tests: the first-line localisation is 9am and midnight plasma ACTH (and cortisol) levels.

Answer 87

If pituitary source then cortisol suppressed * If ectopic/adrenal then no change in cortisol

Answer 88

ff pituitary source then cortisol rises * If ectopic/adrenal then no change in cortisol

Answer 89

Hypokalemia + Hypertension iddle's Syndrome is an autosomal dominant disorder that mimics hyperaldosteronism, resulting in Hypokalemia associated with hypertension. It is thought to be caused by disordered sodium channels in the distal tubules leading to increased reabsorption of sodium, leading to hypokalemia and alkalosis.

Answer 90

defect in the thiazide-sensitive Na+ Cl- transporter in the distal convoluted tubule Features * Hypokalemia * Hypomagnesemia * Hypocalciuria * Metabolic alkalosis * Normotension

Answer 91

inherited cause (usually autosomal recessive) of severe Hypokalemia due to defective chloride absorption at the Na+ K+ 2Cl- cotransporter in the ascending loop of Henle eatures: * Usually presents in childhood, e.g. Failure to thrive * Polyuria, polydipsia * Renal stones, nephrocalcinosis is commom * W eakness Nomotension MG normal

Answer 92

Features * Hypertension * Hypokalemia (e.g. Muscle weakness) * Alkalosis * Hypernatremia * Not related to posture

Answer 93

enin:Aldosterone Ratio * High serum aldosterone * Low serum renin * High-resolution CT abdomen

Answer 94

Primary Hyperaldosteronism Management * Na+ restriction * Adrenal adenoma: surgery * Bilateral adrenocortical hyperplasia: aldosterone antagonist e.g. Spironolactone

Answer 95

autoimmune destruction of the adrenal glands is the commonest cause of hypoadrenalism in the UK, accounting for 80% of cases Features * Lethargy, weakness, anorexia, nausea & vomiting, weight loss * Hyperpigmentation, vitiligo, loss of pubic hair in women * Crisis: collapse, shock, pyrexia

Answer 96

most abundant circulating adrenal steroid. Adrenal glands are the main source of DHEA in ♀s - loss of functioning adrenal tissue as in Addison's disease may result in symptoms secondary to androgen deficiency, such as loss of libido. Research is ongoing as to whether routine replacement of DHEA is beneficial

Answer 97

in a patient with lethargy is highly suggestive of Addison's

Answer 98

with suspected Addison's disease the definite investigation is a short ACTH test. Plasma cortisol is measured before and 30 minutes after giving Synacthen 250ug IM. Adrenal autoantibodies such as anti-21-hydroxylase may also be demonstrated

Answer 99

Hyperkalemia * Hyper-Renin * Hypo-Aldosterone * Hyponatremia * Hypoglycemia * Metabolic acidosis (Hypo pH)

Answer 100

Normal Renal, Normal Adrenal and Normal Thyorid * Hyponatremia <135 mEq/L * Hypotonic plasma - POsm <270 mOsm/kg. * Inappropriately ↑ urine osmolality * Urine sodium >20 mEq/L (inappropriate natriuresis)

Answer 101

Causes: 1. Malignancy * Especially small cell lung cancer * Also: pancreas, prostate 2. Neurological * Stroke * Subarachnoid hemorrhage * Subdural hemorrhage * Meningitis/encephalitis/abscess 3. Infections * TB * Pneumonia 4. Drugs * Sulfonylureas * SSRIs, tricyclics * Carbamazepine * Vincristine * Cyclophosphamide 5. Other causes * Positive end-expiratory pressure (PEEP) * Porphyrias

Answer 102

are catecholamine secreting neuroendocrine tumor of the medulla of the adrenal glands (originating in the chromaffin cells), or extra-adrenal chromaffin tissue. It secretes excessive amounts of catecholamines, usually adrenaline if in the adrenal gland (not extra-adrenal) and noradrenaline. Extra-adrenal paragangliomas (extra-adrenal pheochromocytomas) are closely related, though less common. About 10% are familial and may be associated with MEN type II, neurofibromatosis and Von Hippel-Lindau syndrome.

Answer 103

24hr urinary collection of catecholamines is preferred to one of vanillylmandelic acid as it has a higher sensitivity. Three 24 hour collections are needed as some patients have intermittently raised levels Surgery is the definitive management.

Answer 104

give PHEnoxybenzamine before beta-blockers

Answer 105

Zona Glomerulosa (on outside): mineralocorticoids, mainly Aldosterone * Zona Fasciculata (middle): glucocorticoids, mainly Cortisol * Zona Reticularis (on inside): androgens, mainly Dehydroepiandrosterone

Answer 106

A normal dynamic pituitary function test has the following characteristics: * GH level rises > 20mu/l * Cortisol level rises > 550 mmol/l * TSH level rises by > 2 mu/l from baseline level * LH and FSH should double

Answer 107

anabolic hormone secreted by the somatotroph cells of the anterior lobe of the pituitary gland. Mechanism of action * Acts on a transmembrane receptor for growth * Binding of GH to the receptor leads to receptor dimerization * Acts directly on tissues and also indirectly via insulin-like growth factor 1 (IGF-1), primarily secreted by the liver

Answer 108

there is excess growth hormone secondary to a pituitary adenoma in over 95% of cases. A minority of cases are caused by ectopic GHRH or GH production by tumours e.g. pancreatic.

Answer 109

* Coarse, oily skin , large tongue, prognathism, interdental spaces * Spade-like hands, ↑ in shoe size * Sweating due to sweat gland hypertrophy * Features of pituitary tumour: hypopituitarism, headaches, bitemporal hemianopia * Raised prolactin in 1/3 of cases → galactorrhoea * 6% of patients have MEN-1

Answer 110

Growth hormone (GH) levels vary during the day and are therefore not diagnostic. The definitive test is the oral glucose tolerance (OGTT) with serial GH measurements. Serum IGF-1 may also be used as a screening test and is sometimes used to monitor disease

Answer 111

Overnight Dexamethasone Test

Answer 112

Insulin Stress Test

Answer 113

Short Synacthen Test

Answer 114

24H Urinary Catecholamines

Answer 115

Oral Glucose Tolerance Test

Answer 116

For example bromocriptine. * The first effective medical treatment for acromegaly, however now superseded by somatostatin analogues * Effective only in a minority of patient

Answer 117

* For example octreotide * Effective in 50-70% of patients * May be used as an adjunct as it helps to control cardiometabolic risk factors prior to surgery.

Answer 118

secreted by the anterior pituitary gland with release being controlled by a wide variety of physiological factors. Dopamine acts as the primary prolactin releasing inhibitor and hence dopamine agonists such as bromocriptine may be used to control galactorrhoea. It is important to differentiate the causes of galactorrhoea (due to the actions of prolactin on breast tissue) from those of gynaecomastia

Answer 119

* Men: impotence, loss of libido, galactorrhoea * Women: amenorrhoea, galactorrhoea

Answer 120

Prolactinoma * Pregnancy * Estrogens * Physiological: stress, exercise, sleep * Acromegaly: 1/3 of patients * Polycystic ovarian syndrome PRIMARY HYPOTHYROIDISM (due to thyrotrophin releasing hormone (TRH) stimulating prolactin release)

Answer 121

Metoclopramide, domperidone * Phenothiazines * Haloperidol * Very rare: SSRIs, opioids

Answer 122

* Physiological: normal in puberty * Syndromes with androgen deficiency: kallman's, klinefelter's * Testicular failure: e.g. Mumps * Testicular cancer e.g. Seminoma secreting HCG * Liver disease * Ectopic tumour secretion * HYPERTHYROIDISM NOT HYPOTHYROIDISM * Hemodialysi

Answer 123

Spironolactone (most common drug cause) * Cimetidine * Digoxin * Cannabis * Finasteride * Estrogens, anabolic steroids

Answer 124

* Elevated waist circumference: men > 102 cm, women > 88 cm * Elevated triglycerides: > 1.7 mmol/l * ↓ HDL: < 1.03 mmol/l in ♂s and < 1.29 mmol/l in ♀s * Raised blood pressure: > 130/85 mmHg, or active treatment of hypertension * Raised fasting plasma glucose > 5.6 mmol/l, or previously diagnosed type 2 diabetes

Answer 125

The management of obesity consists of a step-wise approach: * Conservative: diet, exercise * Medical * Surgical

Answer 126

pancreatic lipase inhibitor used in the management of obesity. Adverse effects include faecal urgency/incontinence and flatulence. A lower dose version is now available without prescription ('Alli').

Answer 127

* BMI of 28 kg/m2 or more with associated risk factors, or * BMI of 30 kg/ m2 or more * Continued weight loss e.g. 5% at 3 months * Orlistat is normally used for < 1 year

Answer 128

* They have a BMI of 40 kg/m2 or more, or between 35 kg/ m2 and 40 kg/ m2 and other significant disease (e.g T2DM, hypertension) that could be improved if lost weight. * All appropriate non-surgical measures have failed to achieve or maintain adequate clinically beneficial weight loss for at least 6 months * They are receiving or will receive intensive specialist management * They are generally fit for anaesthesia and surgery * They commit to the need for long-term follow-up * Consider surgery as a first-line option for adults with a BMI of more than 50 kg/ m2 in whom surgical intervention is considered appropriate. * Consider orlistat before surgery if the waiting time is long

Answer 129

Primarily restrictive: laparoscopic-adjustable gastric banding (LAGB) or sleeve gastrectomy * Primarily malabsorptive: classic biliopancreatic diversion (BPD) has now largely been replaced by biliopancreatic diversion with duodenal switch * Mixed: Roux-en-Y gastric bypass surgery

Answer 130

Leptin ↓ appetite * Ghrelin ↑ appetit

Answer 131

hought to play a key role in the regulation of body weight. It is produced by adipose tissue and acts on satiety centres in the hypothalamus to ↓ appetite. More adipose tissue (e.g. in obesity) results in high leptin levels. Leptin stimulates the release of melanocyte-stimulating hormone (MSH) and corticotrophin-releasing hormone (CRH). Low levels of leptin stimulates the release of neuropeptide Y (NPY)

Answer 132

Where as leptin induces satiety, ghrelin stimulates hunger. It is produced mainly by the fundus of the stomach and the pancreas. Ghrelin levels ↑ before meals and ↓ after meals

Answer 133

Rare cause of mixed hyperlipidemia (raised cholesterol and triglyceride levels) * Also known as Fredrickson type III hyperlipidemia, broad-β disease and dysbetalipoproteinemia * Associated with APO-E2 homozygosity * High incidence of ischemic heart disease and peripheral vascular disease * Thought to be caused by impaired removal of intermediate density lipoprotein from the circulation by the liver

Answer 134

Familial hypercholesterolemia (FH) is an autosomal dominant condition that is thought to affect around 1 in 500 people. It results in high levels of LDL-cholesterol which, if untreated, may cause early cardiovascular disease (CVD). FH is caused by mutations in the hepatic proteins involved in clearance of LDL-cholesterol from the circulation

Answer 135

10-year risk of 20% is cut-off First-degree relative with a history of premature coronary heart disease (defined as < 55 years in ♂s and < 65 years in ♀s) - ↑ risk by 1.5 times if one relative affected or up to 2.0 times if more than one relative affected * South asian ethnicity - ↑ risk by 1.4 times

Answer 136

Simvastatin 40mg on is the first line treatment * There is no target level for total or LDL cholesterol for primary prevention * Liver function tests should be check at baseline, within 3 months and at 12 months but not again unless clinically indicated

Answer 137

↑ serum cholesterol, moderate ↑ in triglyceride, serum is not lipaemic, ↓ HDL levels. Clinical features include: palmar xanthomas; tuberous xanthomas (particularly on extensor surfaces); tendinous xanthomas are rare. Xanthomas usually only occur if cholestasis has persisted for more than 3 months sometimes fat deposits may involve bone and peripheral nerves.

Answer 138

Remnant hyperlipidemia * May less commonly be seen in familial hypercholesterolemia

Answer 139

Eruptive xanthoma are due to high triglyceride levels and present as multiple red/yellow vesicles on the extensor surfaces (e.g. elbows, knees) * Familial hypertriglyceridemia * Lipoprotein lipase deficiency

Answer 140

carcinoid with liver mets diagnosis: urinary 5-HIAA

Answer 141

* Usually occurs when metastases are present in the liver and release serotonin into the systemic circulation * May also occur with lung carcinoid as mediators are not 'cleared' by the liver Hypo- not hypertension is seen in carcinoid syndrome secondary to serotonin release

Answer 142

ype 1 autoimmune POLYendocrinopathy syndrome. While (MEN) → hyperparathyroidism is a common finding

Answer 143

Addison's disease (autoimmune hypoadrenalism) is associated with other endocrine deficiencies in approximately 10% of patients. There are two distinct types of autoimmune polyendocrinopathy syndrome (APS), with type 2 (sometimes referred to as Schmidt's syndrome) being much more common. polygenic inheritance and is linked to HLA DR3/DR4. Patients have Addison's disease plus either: * Type 1 diabetes mellitus * Autoimmune thyroid disease (Hypothyroid)

Answer 144

Chronic mucocutaneous candidiasis (typically first feature as young child) * Addison's disease * Primary hypoparathyroidism

Answer 145

Mnemonic 'three P's': * Parathyroid (95%): hyperparathyroidism due to parathyroid hyperplasia * Pituitary (70%) * Pancreas (50%, e.g gastrinoma) * Also: adrenal and thyroid

Answer 146

* Pheochromocytoma 95% * Medullary thyroid CA 70% * Parathyroid (60%)

Answer 147

Medullary thyroid cancer * PHEOCHROMOCYTOMA * Marfanoid body habitus * Neuromas * Intestinal polyps histologically ganglioneromas usually asymptomatic)

Endocrinology Flashcards

(173 cards)