Flashcards in Surgery - Endocrine Deck (68):
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
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)
Catecholamines (epi, norepi)
Will have refractory hypotension
Tx: + steroids (hydrocortisone) ASAP
ACTH stimulation test to dx
Used to ID enlarged parathyroid glands
- can be minimally invasive parathyroid surgery
Most common location for missing inferior parathyroid gland
After renal transplant, parathyroids don't respond to normal renal function and continue to overproduce PTH
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
Pheo 10% rule
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
MEN 1 syndromes
Pancreatic endocrine (Z-E, insulinomas, VIPomas)
MEN 2a syndromes
Medullary thyroid carcionma
MEN 2b syndromes
Medullary thyroid carcionma
Oral/intestinal ganglioneuromatosis (marfanoid habitus)
hyperpigmentation in chronic
Decreased acid in stomach
"Pancreatic cholera" --> usually in head of pancreas
- 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
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)
- Injury = deep + quiet voice, can’t hit high notes
Injury to parathyroid --> hypocalcemia, hyperphosphatemia
Blood supply and drainage of thyroid
- Superior thyroid A (external carotid, 1st branch)
- Inferior thyroid A (thyrocervical trunk)
- Innominate artery (aorta, 5% ppl)
- Superior thyroid V
- Middle thyroid V
- Inferior thyroid V
Lymph node around pyramidal lobe?
Delphian lymph node group
Connecting thyroid to trachea
Ligament of berry
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)
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
- 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
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
- Thyroid replaced by fibrous tissue
- Rock hard NONpainful goiter
- Tx: surgery decompression, TH replacement, steroids/tamoxifen if refractory
Jod Basedow phenomenon
Iodine deficiency person given LOTS of iodine can get thyrotoxicosis
- Thyroid stimulating Ig
- Often presents in stress; if surgery, risk HYPOthyroidism
- Stress induced catecholamine surge from hyperthyroidism d/o
- Can lead to arrhythmias death
How do you monitor thyroid cancer recurrence?
Will be 0 if got all the thyroid tissue
Papillary carcinoma of the thyroid
- 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)
- previous head and neck radiation
- > 1.5 cm
- < 0.5 cm
- thyroid suppression + TH + I ablation (?)
Follicular carcinoma of the thyroid
- Capsular invasion determines if follicular adenocarcinoma vs. follicular adenoma --> FNA cannot dx!
- Hematogenous spread!
- Loves mets to Bone
- lobectomy + ismuthectomy for microinvasive < 4cm
- total thyroidectomy for > 1 cm, microinvasive > 4cm
Hurthle cell is a variant
Medullary carcinoma of the thyroid
- testing for it
- 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
- Total thyroidectomy + removal of lymph nodes in central compartment of neck
- NO I ablation and thyroid suppression b/c tumor from C cells
- Monitor w/ calcitonin and CEA levels
Anaplastic carcionma of the thyroid
- Older pts, poor prognosis
- Chemo + radiation
- side effects
- Propylthiouracil ----| peroxidase and 5’deiodinase
- GOOD FOR PREGGERS
- Methimazole ----| peroxidase
- S/E: Agranulocytosis, Aplastic anemia, Hepatotoxicity = propylthiouracil, Methimazole = teratogen
Imaging studies to find source of Cushings:
PItuitary = MRI
Adrenal = CT
Imaging to find insulinoma
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
Devastating hypersecretion of insulin in newborn
Needs 95% pancreatectomy
Severe necrolytic dermatitis, resistant to all forms of therapy
What does the person have?
How do you dx? Locate it? Treatment?
Glucagon assay is dx
CT scan used to locate tumor
Resection is curative
Somatostatin + streptozocin to help those w/ metastatic inoperable tumors
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
- work up
- 24hr urinary VMA, metanephrine, or free catecholamine secretion
- CT scan adrenals
- prep w/ alpha blocker first! Phenoxybenzamine (irreversible)
Phentolamine is for tyramine excess (also alpha blocker)
2 populations you see renovascular hypertension
Young women w/ fibromuscular dysplasia
Old men w/ arteriosclerotic occlusive disease
BOTH are resistant to anti-HTN meds
Somatomedin C levels
MRI of pituitary
Paralysis of upward gaze
- caused by?
Tumor of pineal gland
When is thyroglobulin not an accurate marker of thyroid cancer recurrence?
If there is thyroiditis like with thyroid antibodies
What side is a nonrecurrent laryngeal N on? Why does it happen
Usually happens w/ the right subclavian artery arises from the left side of the aorta and crosses behind the esophagus
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
Signs of adrenal insufficiency
Inhibit most GI hormones
Inhibits intestinal, biliary and gastric motility
- follicular cells
- parafollicular cells
What do they make?
Follicular - t3, t4
Parafollicular - calcitonin (inhibit osteoclasts)
Indications for thyroid surgery
- Malignancy / indeterminate or suspicious path
- symptomatic = compressive sx, unilobular goiter
- hyperfunctioning = toxic adenoma
Tx 2ndary hyperparathyroidsim
Not on dialysis
- vit D supplementation (calcitriol)
- calcimimetics (cinacalcet) - increases sesnitivity of CaSR
- phosphate binders
If delayed sestamibi shows continued highlighting of parathyroid gland, what does this mean?
Metabolically more active tissues will hold onto the dye more and this is indicative of adenoma
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.
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.
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.
Papillary carcinoma of thyroid tx
- previous head and neck radiation
- > 1.5 cm
- < 0.5 cm
Follicular carcinoma of thyroid tx
Lobectomy + isthmusectomy:
- well circumscribed lesion (microinvasive)
- > 1 cm
- microinvasive > 4 cm
Medullary carcinoma of thyroid tx
Central neck compartment nodes removal
Lateral neck dissection if palpable nodes
Risk of carcinoma of solitary thyroid nodule w/ PMHx of low dose head or neck radiation?
Electrolyte abnormalities of high PTH/hyperparathyroidism
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
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
Most common causes of hypercalcemia
Hypercalcemia - dx test to perform?
Serum and urine protein electrophoresis
Can find malignancy causing bone destruction
Tx adrenocortical tumor
MItotane as adjuvant + glucocorticoids b/c will destroy adrenals
- 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.
Hyper or hypothyroidism
LE syndrome, MG
Signs + symptoms of thyrotoxicosis
No goiter or exophthalmos
High T3, T4
What is happening?
How do you dx?
Factitious thyrotoxicosis b/c ingest thyroid hormone
Dx w low serum thyroglobulin levels