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Yr3 - General Medicine > Endocrinology > Flashcards

Endocrinology Flashcards

1
Q

Anatomy of the thyroid gland

A

2 lobes joined by a central isthmus

Sits anteriorly to thyroid cartilage in the neck - distinguished from other neck features by its movement on swallowing

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2
Q

Vascular supply of the thyroid gland

A

Inferior and superior thyroid arteries

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3
Q

Constituents of thyroid tissue

A

Colloid - stores iodinated thyroglobulin
Follicular cells - synthesises thyroglobulin
Neuroendocrine cells (c-cells) - secrete calcitonin

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4
Q

Types of thyroid hormones

A

T4 (thyroxine) - main circulating hormone - converted peripherally to T3
T3 (triiodothyronine) - more potent and shorter acting

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5
Q

How are thyroid hormones transported?

A

Thyroxine binding blobulin (TBG)
Transthyretin
Albumin

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6
Q

Thyroid hormone receptors

A

Free hormone acts on intracellular thyroid receptors
TRα
TRβ

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7
Q

Actions of thyroid hormones

A

Increase basal metabolic rate and growth in children
Increase heart rate
Effect CNS and reproductive system

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8
Q

Interpretation of thyroid function tests

A

TRH stimulates pituitary TSH secretion

This drives T3 and T4 secretion

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9
Q

Features of primary hypothyroidism

A

Problem with thyroid gland itself - commonly autoimmune

Characterised by reduced circulating T4 and high TSH

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10
Q

Features of secondary hypothyroidism

A

Due to TSH deficiency - usually pituitary disease

Characterised by low T4 and non-elevated TSH

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11
Q

Features of hyperthyroidism

A

Characterised by increased T3/T4 with suppressed TSH

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12
Q

Things that can affect thyroid function tests

A

Acute illness
Medication - lithium and amiodarone
Pregnancy

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13
Q

Define thyrotoxicosis

A

Hyperthyroidism

Commonly affects young women

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14
Q

Causes of thyrotoxicosis

A

Autoimmune (Graves) - presence of TSH receptor stimulating antibodies
Nodular hyperthyroidism - autonomous secretion of T3/T4
Thyroiditis - inflammation of the thyroid gland causing release of thyroxine

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15
Q

Features of Graves disease

A

Hyperthyroidism
Commonly affects young women
Follows a relapsing-remitting course

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16
Q

Features of nodular hyperthyroidism

A

Typically presents at an older age

Either solitary toxic nodule or numerous nodules situated within a toxic multi-nodular goitre

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17
Q

Features of thyroiditis

A 
Follows
- viral infection
- medication - amiodarone
- childbirth
Often followed by hypothyroid phase
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18
Q

Symptoms of hyperthyroidism

A

Increased sympathetic action

  • weight loss with increased appetite
  • insomnia
  • irritability
  • anxiety
  • heat intolerance
  • palpitations
  • tremor
  • pruritus
  • increased bowel frequency and loose motions
  • menstrual disturbance and reduced fertility
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19
Q

How may hyperthyroidism present in elderly patients?

A

Reduced energy levels - apathetic thyroidtoxicosis

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20
Q

Signs of hyperthyroidism

A

Resting tachycardia - sinus rhythm or atrial fibrillation
Warm peripheries
Resting tremor
Hyperflexia
Lid lag - increased sympathetic tone of upper eyelid`

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21
Q

Clinical features of Graves disease

A

Lid retraction
Exopthalmus
Thydroid eye disease
Skin changes - pre-tibial myxoedema and thyroid acropachy

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22
Q

Investigations for hyperthyroidism

A

Elevated free T4 and T3 with undectebtable TSH
Thyroid peroxidase antibodies are unspecific markers
TSH-receptor stimulating antibodies more specific

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23
Q

Imaging for hyperthyroidism

A

Nuclear imaging - determine functionality and cause
- Graves disease - uniform uptake
- Nodular disease - increased uptake in autonomous nodules
- Thyroiditis - absent uptake
USS - nodular thyroid disease but not activity

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24
Q

Treatment for hyperthyroidism

A 
Medication
- thionamides reduce synthesis of T3+4 - carbimazole and propylthiouracil
- beta-blockers to control symptoms
Surgery
- thyroidectomy
Radioactive iodine
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25
Q

Potential side-effects of thionamides

A

Agranulocyotisis - bone marrow suppression
- unexplained sore-throat or fever
- urgent full-blood count to exclude pancytopaenia
Generalised rash - disappears after cessation

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26
Q

What does radioactive iodine therapy involve?

A

Single dose of 131I

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27
Q

Cons of radioactive iodine

A

Pregnancy
May flare up eye disease in patients with pre-exisitng ophthalmopathy
Causes hypothyroidism - requires lifelong thyroxine replacement
Patients emit small amount of radiation after administration - avoid close contact to young children and pregnant women

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28
Q

Complications of thyroid surgery

A

Bleeding
Infection
Damage to recurrent laryngeal nerve
Temporary or permanent hypocalcaemia

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29
Q

Features of thyroid surgery

A

Effective definitive treatment for those who can’t comply with radiation restriction - mothers with young children
Thyroid function should be controlled pre-op to avoid anaesthetic problems
Beta-blockers used during anaesthetic if thyroid function not optimal - prevent peri-operative atrial fibrillation

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30
Q

Causes of primary hypothyroidism

A 
Autoimmune disease
- Hashimotos thyroiditis
Pregnancy
Iodine deficiency -> cretinism
Drugs
- amiodarone
- lithium
Iatrogenic
- intentional treatment of hyperthyroidism
- inadvertent damage from radiation to head/neck
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31
Q

Causes of secondary hypothyroidism

A

TSH deficiency
- due to hypothalamic-pituitary disease
Characterised by low free T4 with non-elevated TSH

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32
Q

Clinical features of hypothyroidism

A 
Weight gain
Cold intolerance
Fatigue
Constipation
Bradycardia
Myxoedema - thickening of skin and puffiness around eyes
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33
Q

Investigations for hypothyroidism

A

Low fT4 with elevated TSH
Thyroid antibodies - auto-immune hypothyroidism
Thyroid peroxidase - Hashimotos thyroiditis

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34
Q

Treatment for hypothryoidism

A

Thyroxine replacement - dose sufficient to improve symptoms and normalise thyroid function

  • 50-100ug/day
  • elderly pts and those with IHD started on 25ug/day
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35
Q

Issues with thyroxine replacement therapy

A

Persistently elevated TSH
- under-replacement
- poor compliance
- malabsorption - coeliac disease, concurrent medication (iron, calcium or PPIs)
Suppressed or undetectable TSH
- over-replacement
- increased risk of atrial fibrillation and osteoporosis

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36
Q

Define subclinical hypothyroidism

A

Normal fT4 with elevated TSH

If pts asymptomatic treatment may not be needed

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37
Q

Features of cortisol

A

Glucocorticoid
Synthesis regulated by ACTH
Highest at 08:00 and lowest at midnight
Most bound to cortisol binding globulin (CBG) and albumin

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38
Q

Cortisol feedback loop

A

Cortisol exerts negative feedback on:

  • hypothalamus - reduce CRH and vasopressin
  • anterior pituitary - reduce ACTH
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39
Q

Features of adrenal androgens

A

Mainly controlled by ACTH
DHEA, DHEA-S and androstenedione are converted to more potent testosterone and dihydrotestosterone in peripheral tissues
Exert effects on sebaceous glands, hair follicles, prostate gland and external genitalia

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40
Q

Features of mineralcorticoids

A

Aldosterone

Regulated by renin-angiotensin system

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41
Q

Features of RAAS system

A

Renin activated in response to low circulating blood volume, hyponatreamia or hyperkalaemia
Catalyses conversion of angiotensin to angiotensin I
Converted to angiotensin II by ACE
Stimulates aldosterone release upon binding to angiotensin receptor
Aldosterone acts on renal distal convoluted tubule on its receptor to cause sodium retention and potassium loss

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42
Q

Layers of the adrenal cortex

A

Zona glomerulosa - mineralcorticoids - aldosterone
Zona fasciculata - glucocorticoids - cortisol
Zona reticularis - androgens - DHEA

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43
Q

Features of the adrenal medulla

A 
Sympathetic nervous system tissue
Secretes
- adrenaline
- noradrenaline
- dopamine
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44
Q

What is Addisons disease

A

Primary adrenal insufficiency
Destruction of adrenal gland or genetic defects in steriod synthesis
Effects all 3 zones

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45
Q

Symptoms of Addisons disease

A

Non-specific and gradual onset
Fatigue
Weakness
Anorexia
Weight-loss
Nausea
Abdo pain
Dizziness and postural hypotension - mineralocorticoid deficiency
Hypoglycaemia, increased pigmentation - glucocorticoid loss
Reduced libido and loss of axillary and pubic hair - androgen deficiency

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46
Q

Investigations for Addisons disease

A 
Biochemical hallmarks
- hyponatraemia
- hyperkalaemia
- raised urea
- hypoglycaemia
- mild anaemia
Confirmatory tests
- low 9am cortisol
- raised ACTH concentration
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47
Q

Management of Addisons diseasee

A

Lifelong glucocorticoid and mineralcorticoid replacement therapy
- hydrocortionse 1st line - double at times of illness
- fludrocortisone
Provide steriod emergency card, encourage to wear medical alert jewellery and emergency contacts for endocrine team

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48
Q

Causes of secondary adrenal insufficiency

A

ACTH deficiency

- long term steriod use - sudden cessation -> adrenal crisis

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49
Q

Define a phaeochromocytoma

A

Catecholamine-secreting tumour which arises from the adrenal medulla

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50
Q

Define a paraganglioma

A

Catecholamine-secreting tumour which arises from the extra-adrenal chromaffin tissue

51
Q

Clinical features of phaeochromocytoma

A 
Headache
Sweating
Pallor 
Palpitations
Anxiety/panic attacks
Hypertension
52
Q

Complications of untreated phaeochromocytoma

A 
Hypertensive crisis
Encephalopathy
Hyperglycaemia
Pulmonary oedema
Cardiac arrhythmias
Death
53
Q

Investigations for phaeochromocytoma

A 
Elevated catecholamines
- 24hr urinary catecholamines
- plasma metanephrines
Radiological localisation of the tumour
- CT or MIR abdo
- 123I-MIBG
- PET
54
Q

Management of phaeochromocytoma

A

Surgical excision - laparo or open
Alpha+/-beta blockers at diagnosis
- phenoxybenzamine or doxazosin

55
Q

Growth pituitary axis

A 
GH is secreted in pulsatile manner - peak during REM sleep
Acts on liver to produce IGF-1
Role in MSK growth in children
Positive control - GHRH
Negative control - somatostatin
56
Q

Adrenal pituitary axis

A

ACTH has circadian rhythm - peak in early morning and lowest at midnight
ACTH stimulates cortisol release
Positive control - CRH
Negative control - cortisol

57
Q

Gonadal pituitary axis

A

FSH leads to ovarian follicle development in women and sperm production in men
LH
- women - mid-cycle ovulation during LH surge and formation of corpus lutem
- men - testosterone secretion from the Leydig cells of testes
Positive control - GnRH
Negative control - testosterone, cortisol

58
Q

Thyroid pituitary axis

A

TSH drives thyroxine release via stimulation of TSH receptors in the thyroid gland
Positive control - TRH
Negative control - thyroxine

59
Q

Prolactin pituitary axis

A

Prolactin causes lactation
Direct inhibitory effect on LH and FSH
Negative control - dopamine

60
Q

Clinical assessment of pituitary gland

A 
Functional pituitary tumours = clinical syndromes
- acromegaly - GH
- Cushings disease - ACTH
- prolactinoma - PRL
- TSHoma - TSH
Non-functioning
- hypopituitarism
- compression of local structures
- bitemporal hemianopia
61
Q

Biochemical assessment of pituitary gland

A

Prolactin and TSH do not fluctate at time of day
LH and FSH
- women - within 1st 5 days of menstrual cycle
- men - 0900 in fasting state
Basal cortisol checked at 0900
IGF-1 maker of GH - low levels suggest GH deficiency, high levels suggest GH excess

62
Q

Dynamic tests of pituitary gland

A

Synacthen test - assess primary adrenal failure and pituitary ACTH reserve
- atrophy of adrenal cortex -> inadequate response to synacthen
- not acute
Insulin Tolerance Test - ACTH and GH reserve
- frank hypoglycaemia achieved with symptoms - ACTH and GH will rise
- not performed in pts with IHD or epilepsy due to risk of triggering coronary ischaemia and seizures

63
Q

Pituitary gland imaging

A 
MRI - injection of contrast 
- > 1cm = macro-adenomas
- < 1cm = micro-adenomas
CT if unable to have MRI
PET to determine functionality
64
Q

Differenentials for high prolactin levels

A 
Pregnancy
Medication
- dopamine antagonists - anti-emetics, anti-psychotics
Profound hypothyroidism
PCOS
65
Q

Features of a micro-prolactinoma

A 
More frequently in women than men
< 1cm
Present with 
- menstrual disturbance - hypogaonadism in men
- galactorrhoea
- infertility
66
Q

Distinguishing features of PCOS compared to prolactioma

A 
Androgenic symptoms
- hitsutism
- acne
Less elevated prolactin levels - <1000 miU/L
Absence of pituitary lesion on MRI
67
Q

Features of macro-prolactinomas

A

> 1cm
More common in men
Prolactin > 5000 miU/L

68
Q

Treatment for prolactinomas

A

Dopamine agonists (D2)

  • cabergoline - 1/2 weekly - better tolerance
  • bromocriptine - daily
69
Q

Side effects of D2 agonists

A

Nausea
Postural hypotension
Psychiatric disturbance

70
Q

Complications of treatment of macro-prolactinomas

A

CSF leak due to rapid reduction of size of lesion
- risk of meningitits
Cardiac valve abnormalites in Parkinson’s disease

71
Q

Causes of high prolactin

A 
Pituitary
- prolactinoma
- non-functioning adenoma
- infiltrative disease
Hypothalmic
- tumours
- infiltrative disease
Secondary
- renal failure
- primary hypothyroidism
- adrenal insufficiency
- PCOS
Analytical
- macroprolactin
- heterophilic antibodies
Medication
- antipsychotics
- antiemetics
- antihypertensives
- oestrogen
Physiological
- pregnancy
- breast stimulation
- stress
72
Q

Causes of acromegaly

A

GH-secreting pituitary tumour

73
Q

Complications of untreated acromegaly

A

Disfiguring features
Premature death from CVS disease
Increased risk of bowel cancer

74
Q

Clinical features of acromegaly

A

Increased size of hands and feet
Facial features become coarser - frontal bossing of forehead, protrusion of chin and widely spread teeth
Soft tissue swelling - enlargement of tongue and soft palate, sleep apnoea, puffiness of hands, carpal tunnel syndrome
Sweating
Headaches
Hypertension
Diabetes mellitus

75
Q

Investigations for acromegaly

A

Oral glucose tolerance test and IGT-1
- failure to suppress GH after OGTT and elevated IGF-1 levels
Pituitary MRI shows tumour

76
Q

Management of GH-secreting pituitary tumours

A 
Medical
- somatostatin analogues improve symptoms and control GH and IGF-1
- GH receptor blockers control IGF-1
- dopamine agonists may control GH
Radiotherapy
- external beam
- stereotactic - more targeted treatment at higher dose
Surgery - treatment of choice
77
Q

Monitoring of acromegaly

A

OGTT post-surgery to indicate if persistent disease
Long term follow up to monitor GH and IGF-1 levels and exclude recurrence
Periodic screening colonoscopy

78
Q

Define non-functioning pituitary adenomas (NFPAs)

A

Biochemically inactive tumours

79
Q

Clinical features of NFPAs

A

Visual field loss
Headache
Hypopituitarism

80
Q

Indications for surgical treatment of NFPAs

A

Visual field defect of threat to vision

Trans-sphenoidal or trans-cranial

81
Q

Causes of acquired hypopituitarism

A

Pituitary tumour
Inflammatory and infiltrative disorders
Traumatic brain injury
Radiotherapy

82
Q

Clinical features of hypopituitarism

A 
Lethary
Weight gain
Sexual dysfunction
Short stature in children
Acute hypo-adrenal crisis
- hyponatraemia
- hypotension
83
Q

Investigation for hypopituitarism

A

Exclusion of adrenal insufficiency
Secondary hypothyroidism - low T4 and non-elevated TSH
Secondary hypogonadism - low sex hormones with non-elevated LH and FSH
GH deficiency - low IGF-1 levels
MRI - empty fossa or pituitary tumour

84
Q

Treatment for hypopituitarism

A

ACTH deficiency - hydrocortisone replacement
TSH deficiency - thyroxine replacement
Gonadotropin deficiency
- men - testosterone
- women - oestrogen and progesterone
GH deficiency - GH as daily subcut injection

85
Q

Features of Cushings Disease

A 
Central obesity
Dorso-cervical fat pad
Increased roundness of face
Red face - plethora
Thick skin
Easy bruising
Proximal myopathy
86
Q

Complications of Cushings Disease

A

Hypertension
Premature osteoporosis
Diabetes mellitus

87
Q

Investigations for Cushing’s Disease

A

Screening

  • alcoholism and severe depression may cause a cushingoid look
  • 24hr urine free cortisol - elevated
  • low dose dexamethasone suppression test - failure to suppress
  • overnight dexamethasone suppression test - failure to suppress
88
Q

Differentials for Cushing’s disease

A 
Pituitary
- pituitary MRI
Adrenal
- accelerated hirsutism
- low ACTH
Ectopic ACTH due to lung cancer or another malignancy
- hypokalaemia
- smoker
- weight loss
- whole body CT or PET scan
89
Q

Management of Cushing’s disease

A

Adrenal tumour -> Laparoscopic adrenalectomy
Ectopic ACTH -> Treatment of underlying malignancy
Pituitary adenoma -> Trans-sphenoidal removal of the pituitary adenoma
Medical treatment
- Metyrapone
- Ketoconazole
- Radiotherapy

90
Q

Symptoms of hyponatraemia

A 
Early
- headache
- nausea
- vomiting
- general malaise
Late
- confusion
- agitation
- drowsiness
Acute Severe
- seizures
- respiratory depression
- coma
- death
91
Q

Investigations for hyponatraemia

A 
Full history and examination
Drug history
- thiazide diuretics
Hydration status
Biochemical investigations
- serum osmolality
- urine osmolality
- urine sodium
- thyroid function
- assessment of cortisol reserve - 09:00 cortisol or synacthen test
92
Q

Treatment of hyponatraemia

A

Acute severe
- hypertonic saline - prevent cerebral oedema
Cause-specific treatment
Appropriate fluid replacement - normal saline

93
Q

Characteristics of SIADH

A

Low plasma Na+
Low serum osmolality
High urine osmolality
High urine Na+

94
Q

Causes of SIADH

A 
Malignancy
- lung small cell
- pancreas
- prostate
- thymus
- lymphoma
CNS disorders
- meningoencephalitis
- abscess
- stroke
- subarachnoid/subdural haemorrhage
- head injury/neurosurgery
- vasculitis
Chest diease
- TB
- pneumonia
Drugs
- opiates
- psychotropics
- SSRI
- cytotoxics
95
Q

Treatment of SIADH

A

Treat cause
Restrict fluid
Consider salt + loop diuretics if severe
Vasopressin receptor antagonists

96
Q

Causes of hyponatremia

A 
Urine osmolality < 100 mOsm/kg
- primary polydipsia
- inappropriate IV fluids
- low solute intake
Urine osmolatlity > 100 mOsm/kg
- urine Na+ < 30 mmol/L
   - low effective arterial volume
     - heart failure
     - portal hypertension
     - nephrotic syndrome
     - hypoalbuminaemia
     - GI loss
- urine Na+ > 30 mmol/L
  - normal apparent circulating volume
     - SIADH
     - NSAIDs
  - low effective arterial volume
     - primary salt wasting
     - vomiting
     - hypoadrenalism
97
Q

Define Diabetes Insipidus

A

Cranial - vasopressin deficiency
Nephrogenic - vasopressin resistance
Leads to passing of large volumes of dilute urine with profound unquenchable thirst

98
Q

Biochemical hallmarks of DI

A

High serum osmolality
Low urine osmolality
High urine volume

99
Q

Complications of DI

A

Hypernatraemia
Dehydration
Death

100
Q

Cranial vs nephrogenic DI

A

Cranial usually seen in pituitary disease
Strong family history suggests genetic cause
Nephrogenic
- metabolic and electrolyte disturbance
- renal disease
- drugs affecting the kidney

101
Q

Common causes of hypercalcaemia

A

Primary hyperparathyroidism - non-suppressed PTH
Malignancy - suppresed PTH levels
TB and sarcoidosis - suppressed PTH

102
Q

Definition of hypercalcaemia

A

Serum calcium > 2.6 mmol/L

103
Q

Malignant causes of hypercalcaemia

A

Squamous cell epithelial tumours - secretion of PTH-related peptide (PTH-rP)

104
Q

Primary hyperparathyroidism causes

A

Single parathyroid adenoma

Parathyroid hyperplasia - genetic cause

105
Q

Investigations of hypercalcaemia

A 
High PTH - primary hyperparathyroidism
Low PTH - malignancy 
Low phosphate - PTH causes excretion
High ALP - increased bone turnover
Bone density reduced - distal radius
Nephrocalcinosis - renal USS
106
Q

Clinical features of hypercalcaemia

A 
Non-specific symptoms
- tiredness
- generalised aches and pains
- abdo pain
- constipation
- kidney stones
Primary hyperparathyroidism - asymptomatic 
Nephrogenic DI - polyuria and polydipisa
107
Q

Define familial hypocalciuric hypercalcaemia (FHH)

A

Genetic defect in calcium sensing receptor
Low urine calcium/creatinine ratio
Family history of mild hypercalcaemia

108
Q

Localisation of parathyroid adenoma

A

USS - 70-90%

SETAMIBI isotope scanning used alongside USS

109
Q

Treatment of hyperparathyroidism

A 
Surgery
- serum calcium > 2.85 mmol/L or symptoms debilitating
- young patients
- parathyroidectomy
Medical management
- calcimimetic drugs
Simple observation
110
Q

Acute severe hypercalcaemia

A

Medical emergency
Presentation
- profound dehydration
- renal impairment

111
Q

Define hypocalcaemia

A

Serum calcium < 1.9 mmol/L

112
Q

Causes of hypocalcaemia

A 
Post-surgical hypoparathyroidism
Post-thyroidectomy 
- usually temporary
- may be permanent due to damage or removal of parathyroid glands
Severe vitamin D deficiency
113
Q

Vitamin D deficiency presentation

A

Low phosphate - elevated PTH levels

Seizures and tetany in neonates - due to hypocalcaemia

114
Q

Features of hypomagnesaemia

A

Causes functional hypoparathyroidism - normal or low PTH

115
Q

Causes of hypomagnesaemia

A

GI loss
Alcohol
Drugs - PPIs

116
Q

Clinical features of acute severe hypocalcaemia

A

Laryngospasm
Prolonged QT interval
Seizures

117
Q

Clinical features of hypocalcaemia

A

Muscle cramps
Carpo-pedal spasm
Peri-oral and peripheral paraesthesia
Neuro-psychiatric symptoms
Positive Chvosteks sign - facial spasm when cheek gently tapped
Trousseasus sign - carpo-pedal spasm induced after inflation of sphygmomanometer

118
Q

Treatment of hypocalcaemia

A

Calcium replacement
- acute - 10ml 10% calcium gluconate IV over 30 mins
- mild - 5mmol/6h PO calcium
Reverse cause

119
Q

Treatment of vitamin D deficiency

A

Loading dose cholecalciferol
20,000 IU per week for 7 weeks
Maintenance dose of 1-2000 IU per week

120
Q

Treatment of hypoparathyroidism

A

1-alfacalcidol 0.25mcg/day or calcitriol - dose titration according to clinical and biochemial response
Oral calcium supplements - Sandocal and Adcal D3
Aim to keep calcium levels at lower end of normal - reduce risk of nephro-calcinosis

121
Q

Treatment of magnesium deficicency

A 
Acute
- precipitating drugs stopped
- IV MgSo4 24mmol/24hrs
Chronic
- GI loss or alcohol ingestion - specialist input
122
Q

Define psuedo-hypoparathyroidism

A

Mutation in G protein coupled to PTH receptor

Leads to PTH resistance

123
Q

Characteristics of pseudo-hypoparathyroidism

A

Characterised by

  • hypocalcaemia
  • high phosphate
  • high PTH
  • normal vitamin D
124
Q

Clinical features of pseudo-hypoparathyroidism

A

Short stature
Round face
Short 4th and 5th metacarpals

Yr3 - General Medicine (9 decks)

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