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Scientific Basis of Medicine > The case of the GP under pressure > Flashcards

The case of the GP under pressure Flashcards

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1
Q

primary and secondary hypertension - what is the difference?

A

Primary - essential or idiopathic HTN
Secondary - Renal, endocrine, other (e.g. pregnancy, drugs)

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2
Q

Secondary Hypertension causes - CHAPS

A

Cushings
Hyperaldosteronism
Aortic coarctation
Pheochromocytoma
Stenosis of Renal Arteries

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3
Q

Secondary Hypertension causes - CHAPS

A

Cushings
Hyperaldosteronism
Aortic coarctation
Pheochromocytoma
Stenosis of Renal Arteries

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4
Q

Pheochromocytoma

A

Adrenal medullary tumour that secretes excess catecholamines (Adrenaline, noradrenaline and dopamine from chromaffin cells - sometimes called intra-adrenal paraganglioma)

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5
Q

Paraganglioma

A

Neuroendocrine tumours that arise from sympathetic and parasympathetic ganglia, tumours of sympathetic ganglia have the ability to secrete excess catecholamines

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6
Q

The distinction between Pheochromocytoma and …. is an important one because of implications for associated neoplasms, risk for malignancy, and genetic testing.

A

The distinction between Pheochromocytoma and Paraganglioma is an important one because of implications for associated neoplasms, risk for malignancy, and genetic testing.

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7
Q

The distinction between … and Paraganglioma is an important one because of implications for associated neoplasms, risk for malignancy, and genetic testing.

A

The distinction between Pheochromocytoma and Paraganglioma is an important one because of implications for associated neoplasms, risk for malignancy, and genetic testing.

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8
Q

What is released when you have pheochromocytoma?

A

Too much adrenaline released from the adrenal gland

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9
Q

Common Pheochromocytoma and Paraganglioma Symptoms (classic symptoms - 3)

A

Classic Symptoms in 40%

  • High BP
  • Headache
  • Sweating

Other symptoms include:
Flushing
Anxiety/panic
Palpitation
Abdo pain
Dizziness
etc

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10
Q

Case 1 - 58 YO man, developed hypertensive crisis during surgery for oral cancer
PMH: Hypertension and Ramipril
Developed anxiety and palpitation recently but put it down to recent diagnosis of oral cancer
Two nose bleeds in 10 years

A
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11
Q

Pheochromocytoma - Male vs Female

A

M=F

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12
Q

Pheochromocytoma - what decades of life?

A

3rd to 5th

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13
Q

Is pheochromocytoma rare?

A

Yes - investigate if clinically indicated

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14
Q

Pheochromocytoma: Paroxysms, ‘Spells’

A

10-60 min duration
Frequency - daily to monthly
Spontaneous
Precipitated Spells: diagnostic procedures, drugs, strenuous exercise, movement that increases intra-abdo pressure)

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15
Q

Pheochromocytoma: Hypotension

A

Hypotension occur in many patients
Mechanisms - loss of postural reflexes due to prolonged catecholamine stimulation

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16
Q

Pheochromocytoma: Features

A

N/V,
Hypercalcemia - associated MEN2, PTHrP secretetion by Pheo
Mild glucose intolerance
Lipolysis - weight loss and ketosis
Finish slide

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17
Q

Pheochromocytoma: Differentials

A

Hyperthyroidism
Arrhythmias
Hypoglycaemia
Migraine
Panic Attack
Alcohol Withdrawal
Recreational Drugs

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18
Q

Pheochromocytoma: Differentials

A

Hyperthyroidism
Arrhythmias
Hypoglycaemia
Migraine
Panic Attack
Alcohol Withdrawal
Recreational Drugs

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19
Q

Catecholamine synthesis and metabolism

A

Adrenaline - then others

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20
Q

Investigations - Pheochromocytoma

A

24hr work up
Finish slide

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21
Q

False positive - Pheochromocytoma

A

Finish slide

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22
Q

Imaging - Pheochromocytoma

A
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23
Q

What scan is this?

A

SPECT MIBG

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24
Q

blood pressure equation

A

blood pressure equation BP = CO x SVR

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25
global prevalence of hypertension …% population
global prevalence of hypertension 22% population
26
how much of hypertension is primary? around …%
how much of hypertension is primary? around 90%
27
renal causes of secondary hypertension (3)
renal artery stenosis glomerulonephritis polycystic kidney disease
28
Endocrine causes of secondary hypertension (4)
renal causes of secondary hypertension
29
drugs causing secondary hypertension (5)
COCP NSAIDs steroids cocaine antidepressants
30
contributory factors to hypertension (6)
high BMI excessive salt excess alcohol lack of exercise stress caffeine
31
risk factors for hypertension(8)
male increasing age family history ethnicity smoker hyperlipidaemia diabetes low social status
32
Where is renin produced?
juxtaglomerular apparatus
33
what triggers renin production?
decreased renal perfusion
34
what does renin do?
converts angiotensinogen to angiotensin I
35
What converts angiotensin I to angiotensin II?
Angiotensin converting enzyme (ACE)
36
Where is ACE released from?
pulmonary epithelium
37
Action of Angiotensin II(3)
Vasoconstriction Release of aldosterone increased ADH secretion from pituitary
38
Where is aldosterone produced?
zona glomerulosa of adrenal cortex
39
action of aldosterone
increased tubular retention of sodium and water. lose potassium
40
Where does aldosterone act?
distal convoluted tubule and collecting duct
41
what causes hyperaldosteronism with low renin?
conn's syndrome bilateral adrenal hyperplasia congenital adrenal hyperplasia
42
presentation of someone with high aldosterone to renin ratio …
presentation of someone with high aldosterone to renin ratio hypertension hypokalaemia normal/high sodium metabolic alkalosis
43
treating conn's syndrome or adrenal hyperplasia?
laparoscopic adrenalectomy
44
treating conn's syndrome or adrenal hyperplasia if bilateral disease
aldosterone antagonists e.g. spironolactone
45
what causes high aldosterone with high renin (4)
treating conn's syndrome or adrenal hyperplasia if bilateral disease aldosterone antagonists e.g. spironolactone
46
presentation of someone with low aldosterone to renin ratio?
hypertension high creatinine
47
treatment for someone with a low aldosterone to renin ratio (4)
medical therapy renal angioplasty stent incision surgical repair
48
causes of renal stenosis (3)
atherosclerosis autoimmune phenomena genetic causes
49
complications of hypertension
atherosclerosis, strokes, CCF, CHD, LVH, renal failure, hypertensive retinopathy
50
acute target organ damage caused by hypertension
retinal haemorrhage stroke encephalopathy pulmonary oedema MI AKI aortic dissection
51
phaeochromocytoma - what is this?
adrenal medullary tumour that secretes excess catecholamines from chromaffin cells
52
List 3 catecholamines
dopamine, norepinephrine, epinephrine
53
paraganglioma
neuroendocrine tumour arising from sympathetic or parasympathetic ganglia
54
can paragangliomas secrete catecholamines?
yes if arise from sympathetic ganglia
55
primary hypertension
high blood pressure with no known cause
56
secondary hypertension
secondary hypertension high blood pressure caused by the effects of another disease
57
classic triad of phaeo symptoms
classic triad of phaeo symptoms high blood pressure headache sweating
58
high blood pressure headache sweating = classic triad of…
Phaeochromocytoma
59
other symptoms of phaeochromocytoma (aside from sweating, headache, high BP)
Phaeochromocytoma
60
what are phaeo spells like?
symptoms appear for 10-60mins, can be spontaneous or precipitated
61
What can precipitate a spell of phaeo symptoms?
invasive procedures drugs strenuous exercise micturition
62
how can phaeos cause postural hypotension?
loss of postural reflexes due to prolonged catecholamine stimulation
63
how can phaeos cause hypercalcaemia ?
can secrete PTH related protein which acts in same way
64
phaeos impact on lipids and glucose
causes lipolysis and glucose intolerance
65
when should you investigate for phaeos?
HTN at a young age incidentaloma found resistant HTN HTN crisis
66
usual age of phaeo presentation
30-50
67
differentials for pheochromocytoma?
hyperthyroidism arrythmias hypoglycaemia panic attack alcohol withdrawal
68
zones of adrenal cortex
zona glomerulosa, zona fasciculata, zona reticularis
69
What does the zone glomerulosa secrete?
mineralocorticoids (aldosterone)
70
what does zone fasciculata secrete?
glucocorticoids (cortisol)
71
what does zona reticularis secrete?
androgens
72
how is noradrenaline converted to adrenaline?
PNMT enzyme (phenylethanolamine N-methyltransferase)
73
what does PNMT enzyme need to function?
presence of cortisol
74
why is adrenaline the only catecholamine not released by paragangliomas?
no cortisol present so PNMT can't work
75
1st investigations for PPGL
urinary and plasma metanephrines
76
what should you do if metanephrines slightly raised
repeat test if still elevated clonidine suppression test
77
Clonidine suppression test Used to test for …
pheochromocytoma Clonidine is an anti-hypertensive agent that is a central alpha-2 receptor agonist so should lower BP
78
reasons for falsely elevated metanephrines? (4)
paracetamol cocaine caffeine chocolate
79
imaging for phaeos (3)
CT MRI MIBG
80
MIBG scan
nuclear medicine scan that detects neuroendocrine tumours
81
pre-op treatment for pheochromocytoma ?
alpha adrenergic blockers beta blocker if patient tachycardic CCB
82
how long is the pre-op treatment for phaeos?
7-14 days, also high sodium diet and fluid intake
83
Familial Pheochromocytoma
Familial Pheochromocytoma hereditary cause of tumours
84
syndromes associated with phaeochromocytomas
MEN2 von-hippel-lindau NF1 mutation SDHD mutation
85
SDHD
SDHD a protein that if mutated can cause paragangliomas or phaeos
86
surgery for pheochromocytoma
surgical excision of tumour, can be partial or total adrenalectomy
87
indications for genetic screening with phaeos
bilateral tumours paraganglioma presence unilateral with family history young onset

Scientific Basis of Medicine (35 decks)

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