TBL Endocrine

Question 1

In what ways do secondary forms of hypertension, which are endocrine in origin differ from essential hypertension in which an etiology can be identified?

Answer 1

abrupt onset
greater severity
no positive family history of HTN
no specific age criterion

Question 2

List 3 endocrine diseases that can cause secondary HTN

Answer 2

primary hyperaldosteronism
Cushing’s disease
pheochromocytoma

Question 3

Explain the concept of pseudoresisitance

Answer 3

when medications cause tachycardia, volume expansion, and/or RAAS activation –> plasma volume expansion

can occur with alpha & beta blockers or direct vasodilators

Question 4

What is a pheochromocytoma?

Answer 4

a tumor of chromaffin cells of the adrenal medulla –> excess secretion of catecholamines –> increased BP & other symptoms

Question 5

When are most pheochromocytomas detected?

Answer 5

during surgery or abdominal imaging

or during autopsy

Question 6

Pheochromocytoma can be associated with this disease

Answer 6

neurofibromatosis

**pts with neurofibromatosis should be screened for pheo

Question 7

What is the triad of symptoms of a pheochromocytoma?

Answer 7

headache
excessive/generalized sweating
palpitations

**other symptoms: pallor, weight loss, feelings of panic & anxiety

Question 8

What types of blood pressure patterns can emerge with a pheochromocytoma?

Answer 8

sustained HTN without BP spikes
persistent HTN state w spikes reaching crisis level
normotensive state with brief & sudden spikes in BP

Question 9

(blank) is seen in more than 50% of pts with pheochromocytoma

Answer 9

orthostatic hypotension

Question 10

What are the symptoms of a pheochromocytoma-related hypertensive crisis?

Answer 10

dizziness
flushing
visual disturbances
panic/anxiety
nausea
vomiting
epileptic aura

Question 11

What are some diseases that can present like pheochromocytoma?

Answer 11

paroxysmal vasodilating headaches
autonomic dysfunction
anxiety or panic disorder
acute hypoglycemia
CAS
cocaine use

Question 12

What is necessary for the diagnosis of pheochromocytoma?

Answer 12

evidence of excess catecholamine production

Question 13

What tests do you use to diagnose pheo?

Answer 13

measure urine & plasma catecholamines

urine metanephrines & vanillylmandelic acid

Question 14

The best approach for pheochromocytoma screening

Answer 14

looking at catecholamines & their metabolites in timed urinary samples

Question 15

The most sensitive test for pheochromocytoma

Answer 15

plasma free metanephrines

**O-methylated metabolites of catecholamines are continuously seeping from chromaffin tumors

Question 16

T/F: Measurements of fractionated metanephrines are better than total metanephrines

Answer 16

True

Question 17

What can you do if catecholamine levels are elevated but not that much?

Answer 17

give a clonidine suppression test –> if pheochromocytoma, clonidine would not suppress catecholamine release

**failure to suppress plasma catecholamines after clonidine therapy –> pheo

Question 18

What kinds of imaging can be used for pheo?

Answer 18

MRI & CT

I-metaiodobenzylgaunidine (for more specificity)

Question 19

The only effective therapy approach for pheo?

Answer 19

surgical treatment

Question 20

This is essential during surgical removal of pheo…

Answer 20

alpha & beta blockers

Question 21

This should be considered in any patient with spontaneous hypokalemia, moderately severe hypokalemia after using normal doses of diuretics, or refractory HTN

Answer 21

primary hyperaldosteronism

Question 22

Does primary aldosteronism cause edema?

Answer 22

no, because of aldosterone escape

Question 23

Patients with primary hyperaldosteronism often develop this comorbid condition

Answer 23

left ventricular hypertrophy –> heart failure

Question 24

What other diseases present like primary hyperaldosteronism?

Answer 24

SIADH
Liddle’s syndrome
licorice ingestion

Question 25

(blank) ingestion increases access of cortisol to its receptor and causes Na+ retension & K+ loss

Answer 25

licorice

Question 26

How to diagnose primary hyperaldosteronism?

Answer 26

low K+ in serum abnormally high K+ in urine reduced renin activity elevated plasma/urine aldosterone

Question 27

How to treat hyperaldosteronism?

Answer 27

remove an adenoma medical therapy with spironolactone in pts with bilateral adrenal hyperplasia or high operative risk Eplerenone is a newer option

Question 28

What's Cushing's syndrome?

Answer 28

excess cortisol production

Question 29

Two types of Cushing's syndrome

Answer 29

ACTH-dependent & ACTH independent

Question 30

What causes 80% of ACTH dependent Cushings syndome?

Answer 30

ACTH secreting adenoma can also be caused by an ACTH secreting small cell carcinoma of the lung

Question 31

What causes the ACTH independent forms of Cushings syndrome?

Answer 31

adrenal adenoma or carcinoma

Question 32

Signs & symptoms of Cushing's disease

Answer 32

``` buffalo hump hypertension (increased beta receptors on blood vessels --> increased tone of vasculature) moon face proximal weakness hirtuism emo distubances skin abnormalities insulin resistance osteoporosis loss of libido ```

Question 33

Increased (blank) risk in Cushings patients

Answer 33

cardiovascular

Question 34

How do pts with ectopic ACTH secretion differ from pts with Cushings caused by increased cortisol secretion?

Answer 34

may not have typical symptoms of cortisol excess instead, skin hyperpigmentation due to MSH overproduction severe hypertension hypokalemic alkalosis

Question 35

Most common cause of Cushing's syndrome?

Answer 35

exogenous steroid administration

Question 36

Things that present like Cushings...

Answer 36

fat people with metabolic syndrome & cushingoid appearance | chronic alcohol excess

Question 37

Best test for diagnosing Cushing's syndrome?

Answer 37

24 hr free cortisol **amount of free cortisol in urine can be decreased by renal disease

Question 38

Test widely used to screen for Cushing's syndrome

Answer 38

dexamethasone suppression test --> exogenous dexamethasone should reduce plasma cortisol values to less than 2 in normal patients **measure urinary free cortisol as a confirmation test

Question 39

How to treat Cushing's syndrome?

Answer 39

excise the pituitary adenoma can do adrenalectomy if adrenal adenoma or carcinoma medical management with ketoconazole if all else fails

Question 40

Other causes of Cushing's disease

Answer 40

insulin resistance sleep apnea **both contribute to HTN

Question 41

T/F: Hypertension generally remits with corrective surgery of Cushing's syndrome unless exposure to excess cortisol has been sufficiently prolonged

Answer 41

True

Question 42

(blank) should be avoided in pts with Cushing's syndrome since they increase Ca++ excretion which can exacerbate the negative Ca++ balance state in Cushing's

Answer 42

loop diuretics