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Diabetes and Endocrinology YR3 > Hyperprolactinaemia, Acromegaly - booklet > Flashcards

Hyperprolactinaemia, Acromegaly - booklet Flashcards

1
Q

What to exclude first in hyperprolactinaemia?

A
  • Pregnancy
  • Full medication history - dopamine antagonists eg anti-emetics, antipsychotics
  • Profound hypothyroidism
  • PCOS
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2
Q

What suggests prolactinoma on test results?

A
  • Prolactin levels greater than 5,000 iU/L suggests active secretion rather than stalk effect from non-functioning adenoma
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3
Q

Microprolactinoma

A
  • Most common pituitary tumour
  • Seen more in women
  • Typically present with menstrual disturbance, galactorrhoea, infertility
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4
Q

Distinguishing PCOS from microprolactinoma

A
  • Presence of androgenic symptoms
  • Less elevated prolactin (less 1000 miU/L)
  • Absence of pituitary lesion on MRI
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5
Q

Macroprolactinoma

A
  • More than 1cm and can be very large
  • Prolactin levels typicall more than 5,000 miU/L
  • When levels extremely high, immunoassay can incorrectly give lower results (Hook effect) so it may be necessary to dilute sample to achieve accuracy
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6
Q

Treatment prolactinomas

A
  • D2 agonists - Cabergoline or Bromocriptine
  • Cabergoline once/twice weekly, better tolerated usually than bromo
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7
Q

Side effects D2 agonists

A
  • Nausea
  • Postural hypotension
  • Rarer psychiatric disturbance
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8
Q

What happens to macroprolactinomas as they shrink sometimes?

A
  • CSF leak occurs due to rapid reduction in size
  • Potential risk of meningitis
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9
Q

Problem with high cumulative dose of dopamine agonists

A
  • Cardiac valve abnormalities in Parkinsons disease
  • But this is not a concern in prolactinoma doses
  • Cardiac symptoms should be investigated though with an echo if on D2 agonists
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10
Q

What causes acromegaly?

A

GH secreting pituitary tumour

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11
Q

Risk of leaving acromegaly untreated

A

Increase risk of premature death from CV disease
Increase risk of bowel cancer

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12
Q

Clinical features acromegaly

A
  • Increase size hands and feet
  • Facial features coarser
  • Frontal bossing forehead
  • Protruding chin
  • Widely spaced teeth

Soft tissue swelling:
* Enlarged tongue and soft palete
* Sleep apnoea
* Puffiness hands +/- carpal tunnel syndrome

Whole body:
* Sweating
* Headaches
* HTN
* Diabetes mellitus

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13
Q

Test for acromegaly

A
  • OGTT - failure to suppress GH
  • IGF-1- elevated
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14
Q

Some acromegaly tumours secrete…

A
  • Prolactin sinultaenously as they share same cell origin
  • This may be elevated too
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15
Q

Imaging acromegaly

A
  • MRI pituitary gland
  • Microadenomas may need contrast to see
  • Increasing role of functional imaging
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16
Q

Management for acromegaly

A
  • Surgery
  • With micro, high chanve surgical remission (complete gone)
  • With macro, chance is only 60%
  • Medical treatment
  • Radiotherapy
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17
Q

Medical treatment for acromegaly

A
  • Somatostain analogue - Monthly injections
  • GH receptor blockers
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18
Q

Radiotherapy for acromegaly

A
  • External beam or stereotactic radiotherapy (gamma knife)
  • STRT provides targeted treatment at higher dose - BUT only suitable for lesions far away from optic chiasm
19
Q

Long term side effects radiotherapy for acromegaly

A
  • Gradual hypopituitarism
  • Cerebrovascular disease
20
Q

Monitoring acromegaly post surgery

A
  • Repeat OGTT
  • Long term follow up to ensure GH and IGF-1 controlled & exclude recurrence
  • Periodic colonoscopy screening considered due to increase bowel cancer risk
  • Assess for sleep apnoea, diabetes, CV disease and symptoms of recurrence
21
Q

Non functioning pituitary adenomas often present with…

A
  • Visual field loss
  • HEadache
  • Hypopituitarism
22
Q

Treatment for non-functioning adenoma

A
  • Surgery - transphenoidal if visual field defect or threat to vision
23
Q

Causes of hypopituitarism

A
  • Pituitary adenoma
  • Inflammatory and ilfiltrative disorders (Diabetes insipidus related)
  • Traumatic brain injury
  • Radiotherapy
24
Q

Hypopituitarism symptoms

A
  • Non specific
  • Lethargy
  • Weight gain
  • Sexual dysfunction
25
Q

Medical emergency presentations of pituitary adenoma

A
  • Hypo-adrenal crisis with
  • Hyponatraemia
  • Hypotension
26
Q

Investigation for hypopituitarism

A
  • Exclude adrenal insufficiency
27
Q

Treatment hypopituitarism

A
  • ACTH deficiency - Hydrocortisone
  • TSH deficiency - Thyroxine
  • Gonadrotrophin deficiency - Men testosterone, women oesttogen and progesterone (COCP or HRT)
  • GH - GH sc injection if clinical benefit
28
Q

Cushing disease characteristsics

A
  • Central obesity
  • Dorso-cervical fat pad
  • Increased roundness of face

Often have:
* Red face (plethora)
* Thin skin
* Easily bruising
* Proximal myopathy

29
Q

Associated diseases with Cushings

A
  • HTN
  • Premature osteoporosis
  • Diabetes mellitus
30
Q

What happens if Cushings is left untreated?

A

Significant morbidity and has 5yr mortality rate of 50%

31
Q

Investigations for Cushings

A
  • Alcoholism and severe depression can cause Cushingoid (pseudocushings) so screen for this
  • 24hr urine free cortisol
  • Low dose dexamethasone supression test
  • Overnight dexamethasone supression test
  • Late night salivary cortisol
32
Q

Results for investigations Cushings

A
  • 24hr UFC elevated
  • Failure to suppress cortisol to less than 50nmol/L after LDDST or overnight suggests Cushing syndrome
  • Late night salivary cortisol - elevated
33
Q

3 causes of Cushings

A
  • Pituitary
  • Adrenal
  • Ectopic ACTH
34
Q

What suggests ectopic ACTH?

A
  • Hypokalaemia
  • History of smoking
  • Weight loss

Lung cancer or another malignancy

35
Q

What suggests adrenal tumour?

A
  • Accelerated hirsutism (hair)
  • ACTH low - negative feedback from high cortisol levels from adrenals
36
Q

ACTH normal or high

A
  • Suggests ectopic ACTH or pituitary
37
Q

CRH response in Cushings

A
  • If give CRH:
  • Exaggerated response rise in ACTH and cortisol in pituitary lesion
  • Flat response in ectopic
38
Q

HDDST results Cushings

A
  • Suppresses pituitary Cushings disease
  • Does not suppress ectopic
39
Q

What should we do if results suggest pituitary cause?

A
  • MRI pituitary
  • If no lesion seen do inferior petrosal sinus sampling
  • Can confirm central ACTH secretion by showing clear gradient between central and peripheral ACTH levels after CRH injection
40
Q

What should we do if we suspect ectopic ACTH?

A
  • Whole body CT and PET imaging
  • Carcinoma elsewhere often in thorax
41
Q

uspect

A
  • If adrenal - laparoscopic adrenalectomy
  • Ectopic - treat underlying malignancy and medically control cortisol
  • Cushing disease - transphenoidal removal, can use Ketoconazole and Metyrapone and radiotherapy
42
Q
A
43
Q
A

Diabetes and Endocrinology YR3 (28 decks)

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