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Flashcards in Surgery - Endocrine Deck (68):
1

acute onset N/V, ab pain, hypoglycemia, hypoTN after stressful event in steroid-dependent pt - what is happening?

Acute adrenal insufficiency

Potentially lethal post op complication

Preop steroid use is main cause

2

Panadrenal insufficiency - what are you missing?
- what will you see clinically?
- what will you see on labs
- what do you do?

Aldo (low Na, high K)
Cortisol (hypoglycemia)
Catecholamines (epi, norepi)

Will have refractory hypotension

METABOLIC ACIDOSIS
HypoNa
HyperK
Hypoglycemia

Tx: + steroids (hydrocortisone) ASAP
ACTH stimulation test to dx

3

Tx SIADH

Tx DI

SIADH
- Demeclocycline

DI
- Desmopressin

4

Sestamibi scan

Used to ID enlarged parathyroid glands
- can be minimally invasive parathyroid surgery

5

Most common location for missing inferior parathyroid gland

In thymus

6

Tertiary hyperparathyroidism

After renal transplant, parathyroids don't respond to normal renal function and continue to overproduce PTH

7

How do you lower BP in pheo?

+ a- and b- blockers

NEVER to b-blockade alone b/c unopposed a-stimulation can be fatal from teh catecholamines

8

Pheo 10% rule

MEEB

10% are:
malignant
extra-adrenal
epi producers
bilateral

9

Diagnostic tests for gastrinoma

Where is gastrinoma?

Serum gastrin measurement
Gastric ulcer analysis
Secretin stimulation test (test function of pancreas - will increase gastrin in gastrinomas BUT normally supposed to suppress gastrin)

Duodenum and head of pancreas is where most tumors are
--> find via MRI or CT

10

MEN 1 syndromes

Parathyroid
Pituitary
Pancreatic endocrine (Z-E, insulinomas, VIPomas)

11

MEN 2a syndromes

Medullary thyroid carcionma
Pheo
Parathyroid

12

MEN 2b syndromes

Medullary thyroid carcionma
Pheo
Oral/intestinal ganglioneuromatosis (marfanoid habitus)

13

Addison's disease

Adrencortical insufficiency

Hyper K
Hypo Na
Hypo glycemia
Fever
wt loss
dehydration
hyperpigmentation in chronic

14

VIPoma characteristics

Diarrhea
Hypo K
Leg crams
Decreased acid in stomach

"Pancreatic cholera" --> usually in head of pancreas

15

Thyroid diagnostics
- how do you eval?
- cold vs. hot nodule?
- what do you use to discriminate cysts from nodules?

- FNA to evaluate
- Cold nodule = 15% chance malignant
- Hot nodules = rarely cancerous
- US used to follow size or recurrence of cysts after FNA -->Good for discriminating cysts from nodules

16

Complications of thyroid surgery

Injury to recurrent laryngeal N (CN 10 = Vagus)
- Found in tracheoesophageal grooves, dive behind cricothyroid muscle
- Larynx, posterior cricoarytenoid, lateral cricoarytenoid
- Unilateral injury = hoarseness
- Bilateral injury = cord paralysis/airway obstruction and may need tracheostomy

Injury to external branch of superior laryngeal N (CN 10 = Vagus)
- Cricothyroid
- Injury = deep + quiet voice, can’t hit high notes

Injury to parathyroid --> hypocalcemia, hyperphosphatemia

17

Blood supply and drainage of thyroid

Blood supply
- Superior thyroid A (external carotid, 1st branch)
- Inferior thyroid A (thyrocervical trunk)
- Innominate artery (aorta, 5% ppl)

Blood drainage
- Superior thyroid V
- Middle thyroid V
- Inferior thyroid V

18

Lymph node around pyramidal lobe?

Delphian lymph node group

19

Connecting thyroid to trachea

Ligament of berry

20

Post-op thyroidectomy cautions

- Dyspnea: recurrent laryngeal N b/l damage OR neck hematoma
- Lateral aberrant rest of thyroid = papillary cancer of lymph node b/c mets
- Monitor Ca b/c can have parathyroid damage (b/c blood supply can be compromised)

21

Thyroid binding globulin - what does it do?
- changes in physio states?

Which TH is active?

Thyroid binding globulin binds most thyroid hormone in blood stream
- Only free T3 is active
- ↑ TBG in preggers
- ↓ TBG in hepatic failure

22

Hashimoto's

- Ab: microsomal, antithyroglobulin

- Histo: Hurthle cells, lymphocytic infiltrate

- NONtender thyroid, Low T3/T4, normal TSH

- Higher incidence of malignancy assoc w/ Hashimotos (esp papillary and lymphoma)

- Tx: TH replacement

23

Subacute (deQuervain's) hypothyroidism

- Usually follows flu-like illness (VIRAL)
- Acute is bacterial illness
- Histo: granulomatous inflammation
- TENDER thyroid
- ↑ ESR
- Tx: analgesics + aspirin, steroids if more resistant, NO surgery

24

Riedel's thyroiditis

- Thyroid replaced by fibrous tissue
- Rock hard NONpainful goiter
- Tx: surgery decompression, TH replacement, steroids/tamoxifen if refractory

25

Jod Basedow phenomenon

Iodine deficiency person given LOTS of iodine can get thyrotoxicosis

26

Grave's disease

- Thyroid stimulating Ig
- Often presents in stress; if surgery, risk HYPOthyroidism

27

Thyroid storm

- Stress induced catecholamine surge from hyperthyroidism d/o
- Can lead to arrhythmias  death

28

How do you monitor thyroid cancer recurrence?

Thyroglobulin

Will be 0 if got all the thyroid tissue

29

Papillary carcinoma of the thyroid
- age
- prognosis
- histology
- tx

- 30-40yo
- Best prognosis
- Most common, most common after radiation

- Loves mets to lungs

- Histo: Orphan annie eye nuclei, Psamomma bodies

- Prognosis based on MACIS scale = Distant mets, age at presentation, completeness of resection, extrathyroidal invasion, size of mass)

Tx:
Total thyroidectomy:
- previous head and neck radiation
- > 1.5 cm

Lobectomy:
- < 0.5 cm

Post op:
- thyroid suppression + TH + I ablation (?)

30

Follicular carcinoma of the thyroid
- characteristics
- spread
- treatment

- Capsular invasion determines if follicular adenocarcinoma vs. follicular adenoma --> FNA cannot dx!

- Hematogenous spread!
- Loves mets to Bone

Tx:
- lobectomy + ismuthectomy for microinvasive < 4cm
- total thyroidectomy for > 1 cm, microinvasive > 4cm

Hurthle cell is a variant

31

Medullary carcinoma of the thyroid
- characteristics
- testing for it
- histo
- surgery
- postop/monitoring

- Highly malignant, total thyroidectomy

- MEN 2A, 2B association
- Most (80%) are sporadic; 20% familial
- If suspected MEN2 + HTN, need to get markers for pheo --> operate on pheo 1st

- Pentagastrin stimulation test (causes increase in calcitonin)

- Histo: From parafollicular C cells  makes calcitonin
- Amyloid-like material

Tx:
- Total thyroidectomy + removal of lymph nodes in central compartment of neck

Post op:
- NO I ablation and thyroid suppression b/c tumor from C cells
- Monitor w/ calcitonin and CEA levels

32

Anaplastic carcionma of the thyroid

- Older pts, poor prognosis
- Chemo + radiation

33

Hyperthyroid pharmacology
- treatments
- side effects

- Propylthiouracil ----| peroxidase and 5’deiodinase
- GOOD FOR PREGGERS

- Methimazole ----| peroxidase

- S/E: Agranulocytosis, Aplastic anemia, Hepatotoxicity = propylthiouracil, Methimazole = teratogen

34

Imaging studies to find source of Cushings:
- pituitary
- adrenal

PItuitary = MRI

Adrenal = CT

35

Imaging to find insulinoma

CT scan

36

Whipples triad

Suggest patient's findings are 2/2 hypoglycemia or an insulinoma

1. Symptoms known or likely to be caused by hypoglycemia (diaphoresis, lightheadedness)

2. A low plasma glucose measured at the time of the symptoms

3. Relief of symptoms when the glucose is raised to normal

37

Nesidioblastosis

Devastating hypersecretion of insulin in newborn

Needs 95% pancreatectomy

38

Severe necrolytic dermatitis, resistant to all forms of therapy

Mild diabetes

Anemia

Glossitis

Stomatitis

What does the person have?
How do you dx? Locate it? Treatment?

Glucagonoma

Glucagon assay is dx

CT scan used to locate tumor

Resection is curative

Somatostatin + streptozocin to help those w/ metastatic inoperable tumors

39

How do you tell between primary hyperaldosteronism 2/2 to hyperplasia vs adenoma?

Hyperplasia = more aldo secreted when upright (will have postural changes)

Adenoma = no postural changes

40

Pheochromocytoma
- work up
- treatment

Workup:
- 24hr urinary VMA, metanephrine, or free catecholamine secretion
- CT scan adrenals

Tx:
- surgery
- prep w/ alpha blocker first! Phenoxybenzamine (irreversible)

Phentolamine is for tyramine excess (also alpha blocker)

41

2 populations you see renovascular hypertension

Young women w/ fibromuscular dysplasia

Old men w/ arteriosclerotic occlusive disease

BOTH are resistant to anti-HTN meds

42

Acromegaly workup

Somatomedin C levels

IGF-1 levels

MRI of pituitary

43

Paralysis of upward gaze
- name?
- caused by?

Parinaud syndrome

Tumor of pineal gland

44

When is thyroglobulin not an accurate marker of thyroid cancer recurrence?

If there is thyroiditis like with thyroid antibodies

45

What side is a nonrecurrent laryngeal N on? Why does it happen

Right side

Usually happens w/ the right subclavian artery arises from the left side of the aorta and crosses behind the esophagus

46

Branchial cleft cyst

congenital epithelial cyst that arises on the lateral part of the neck due to failure of obliteration of the second branchial cleft (or failure of fusion of the second and third branchial arches) in embryonic development

47

Signs of adrenal insufficiency

Skin pigmentation
Weakness
wt loss
HYPOtension
N/V/Ab pain
Hypoglycemia
Hyponatremia
Hypokalemia

48

Somatostatin actions

Inhibit most GI hormones
- insulin
- glucagon

Inhibitis
- TSH
- renin
- calcitonin

Inhibits intestinal, biliary and gastric motility

49

Thyroid:
- follicular cells
- parafollicular cells

What do they make?

Follicular - t3, t4

Parafollicular - calcitonin (inhibit osteoclasts)

50

Indications for thyroid surgery

- Malignancy / indeterminate or suspicious path

- symptomatic = compressive sx, unilobular goiter

- hyperfunctioning = toxic adenoma

51

Tx 2ndary hyperparathyroidsim

Not on dialysis
- vit D supplementation (calcitriol)

On dialysis:
- calcimimetics (cinacalcet) - increases sesnitivity of CaSR
- phosphate binders

52

If delayed sestamibi shows continued highlighting of parathyroid gland, what does this mean?

Parathyroid adenoma

Metabolically more active tissues will hold onto the dye more and this is indicative of adenoma

53

Suspected hyperparathyroidism 2/2 parathyroid adenoma.

US thyroid = normal

Sestamini scan = normal

What do you do next?

A 24-hour urinary calcium measurement should be performed to ensure that the patient has primary hyperparathyroidism.

If familial hypercalcemia hypocalciuria is ruled out with the 24-hour urinary test, then the surgeon should discuss with the patient about a bilateral four-gland operation for likely parathyroid hyperplasia versus taking no action at this time and repeating imaging tests in six months or trying a new imaging modality.

54

Hungry bone syndrome

is the constellation of hypocalcemia, hypophosphatemia, and hypomagnesemia after successful parathyroidectomy due to the sudden withdrawal of excess PTH.

Parathyroidectomy for hyperparathyroidism may result in an imbalance between osteoblast-mediated bone formation and osteoclast-mediated bone resorption that results in rapid absorption of calcium, phosphate, and magnesium into the bones.

55

Parathyromatosis

is caused by the rupture and/or spillage of hyperfunctioning parathyroid cells into the operative bed during an initial operation.

If the cells remain hyperfunctioning they cause recurrent hyperparathyroidism and present as multiple random nodules within the original operative field.

The other options are unlikely given this patient's history and physical examination findings.

56

Papillary carcinoma of thyroid tx

Total thyroidectomy:
- previous head and neck radiation
- > 1.5 cm

Lobectomy:
- < 0.5 cm

57

Follicular carcinoma of thyroid tx

Lobectomy + isthmusectomy:
- well circumscribed lesion (microinvasive)

Total thyroidectomy
- > 1 cm
- microinvasive > 4 cm

58

Medullary carcinoma of thyroid tx

Total thyroidectomy

Central neck compartment nodes removal
Lateral neck dissection if palpable nodes

59

Risk of carcinoma of solitary thyroid nodule w/ PMHx of low dose head or neck radiation?

40%

60

Electrolyte abnormalities of high PTH/hyperparathyroidism

Low phosphorus
High Cl
Mild metabolic acidosis

Cl: PO4 ratio of 33:1 is consistent w/ dx of primary hyperPTH

PTH ---| reabsorb phosphorus and bicarb
b/c more bicarb excreted, more Cl reabsorbed and Na too

61

Parathyroidectomy pts

Symptomatic pts

Asymptomatic < 50 yrs w/ 1+ following:
- Ca > 11.5
- 24 hr urine Ca > 400 mg
- Cr decreased by 30%
- bone mineral density > 2 SD below normal

62

Most common causes of hypercalcemia

HyperPTH
Malignancy

63

Hypercalcemia - dx test to perform?

Serum and urine protein electrophoresis

Can find malignancy causing bone destruction

64

Tx adrenocortical tumor

Resection
MItotane as adjuvant + glucocorticoids b/c will destroy adrenals

Poor prognosis

65

Meaning of:
- elevated testosterone + DHEAS

DHEAS is in adrenals - if have elevated testosterone + DHEAS is adrenal tumor

Elevated testosterone + normal DHEAS is ovariansource

DHEA is from ovaries and adrenals.

66

Myopathy causes

POlymyositis/dermatomyosistis

Hyper or hypothyroidism

Cushing's disease

LE syndrome, MG

Steroids

67

Signs + symptoms of thyrotoxicosis
No goiter or exophthalmos
Low TSH
High T3, T4

What is happening?
How do you dx?

Factitious thyrotoxicosis b/c ingest thyroid hormone

Dx w low serum thyroglobulin levels

68

Sick euthyroid syndrome

Thought o be due to caloric deprivation + increase in cytokine levels

Usually in ppl w/ no previous hx of thyroid disease

Any pt w/ acute severe illness may have abnormal thyroid function tests (usually fall in total adn free T3)

Can have increase in TSH when recovering from non-thyroidal illnesses

JUST DON'T DO THYROID TESTS ON SICK PTS WHOSE PROBLEMS YOU DON'T THINK RELATE TO THYROID OR THOSE RECOVERING FROM MAJOR SYSTEMIC ILLNESSES NOT RELATED TO THYROID