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Endocrinology

This revision session covers key concepts in endocrinology, including glucose regulation, diabetes mellitus, thyroid disease, and hyperthyroidism. Learn about the causes, symptoms, and management of these conditions.

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Endocrinology

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  1. Endocrinology

  2. Endocrinology Phase 2a Revision Session Rhys Watkins and David Rutherford 27/3/17 The Peer Teaching Society is not liable for false or misleading information…

  3. Glucose Range: 3.5-8 mmol/L under all conditions Liver - Stores Glycogen - Glycogenolysis - Gluconeogenesis from fat, protein, glycogen Taken into cells by GLUT receptors (comes in different varieties based on location) Insulin: GlucoseGlycogen, Glucose into cells, supppressesglycogenolysis and gluconeogenesis The Peer Teaching Society is not liable for false or misleading information…

  4. Diabetes Mellitus (Type I) • B-cell destruction in Islet of Langerhans • Aetiology: Autoimmune Acute presentation: Polyuria Polydipsia Weight loss DKA Subacute presentation: Fatigue Polyuria/dipsia Visual change Balanitis/candida The Peer Teaching Society is not liable for false or misleading information…

  5. Type II – the metabolic syndrome Central obesity Elevated cholesterol/triglycerides Raised BP The Peer Teaching Society is not liable for false or misleading information…

  6. Type II Risk: Obese, advancing age, FH, certain ethnic groups Major Immediate Complication: HHS (Previously HONK) Major Long-term Complications: Kidney, Eye, Foot, Neuropathy Everything The Peer Teaching Society is not liable for false or misleading information…

  7. Diagnosis HbA1C >48 (6.5%) -- Consider ‘pre-diabetes’ if 42-47 (6.1-6.4%) Fasting glucose >7 (>6.5 = impaired GT) Oral GTT @2hrs >7.8 (>6.1 = Impaired) The Peer Teaching Society is not liable for false or misleading information…

  8. Management Stepwise METFORMIN SULFONYLUREA (caution glibenclamide/cholropropramide in eldery/renal impairment) DPP-4 INHIBITOR PIOGLITAZONE (avoid with biggest CVD risk) Triple Therapy Insulin The Peer Teaching Society is not liable for false or misleading information…

  9. Stop this from happening, please The Peer Teaching Society is not liable for false or misleading information…

  10. DKA Features: Lethargy, polyuria, dehydration, confusion, coma, abdo pain, Kussmaul breathing Diagnose: Ketone ++, Glucose >11, venous pH <7.3, bicarb <16 First priority: Fluid balance and dehydration. 0.9% saline 500ml bolus then replacement regime, typically 100ml/kg (1L over 1hr, 2hr, 4hr, 6hr) Second: Actrapid 0,1u/kg/hr IV. Avoid SC The Peer Teaching Society is not liable for false or misleading information…

  11. Resolution: pH >7.3 Bicarb >18 Ketones <0.3 Ketones poorly discriminative The Peer Teaching Society is not liable for false or misleading information…

  12. THYROID DISEASE

  13. THYROID ANATOMY Thyroid cartilage Isthmus 4th tracheal ring The Peer Teaching Society is not liable for false or misleading information…

  14. THYROID ANATOMY The Peer Teaching Society is not liable for false or misleading information…

  15. THYROID HISTOLOGY Colloid (thyroglobulin) Cuboidal epithelial cells Follicle Basement membrane The Peer Teaching Society is not liable for false or misleading information…

  16. THYROID PHYSIOLOGY The Peer Teaching Society is not liable for false or misleading information…

  17. HYPOTHYROIDISM: CAUSES PRIMARY HYPOTHYROIDISM (↓T4) • Primary atrophic hypothyroidism • Hashimoto’s thyroiditis (anti-TSHR, anti-Tg, anti-TPO) • Iodine deficiency • Post-thyroidectomy / radioiodine / antithyroid drugs • Lithium / amiodarone SECONDARY HYPOTHYROIDISM (↓TSH) • Hypopituitarism

  18. HYPOTHYROIDISM SYMPTOMS SIGNS CVS:- RS: Hoarse voice GI: Constipation Int:Cold intolerance Endo: Weight gain UG: Menorrhagia MSK: Myalgia, weakness Neuro / Psych: Tired, low mood, dementia Bradycardic Reflexes relax slowly Ataxia (cerebellar) Dry, thin hair / skin Yawning / drowsy / coma Cold hands +/- ↓T°C Ascites Round puffy face Defeated demeanour Immobile +/- Ileus CCF

  19. HYPOTHYROIDISM ↓T3, ↓T4 = ↑TSH INVESTIGATIONS: TFT Lipids/cholesterol (c) FBC (macrocytosis)

  20. HYPOTHYROIDISM: ASSOCIATIONS AUTOIMMUNE Type 1 Diabetes Mellitus Addison’s disease Pernicious anaemia Primary biliary cirrhosis INHERITED Turner’s syndrome Down’s syndrome Cystic fibrosis

  21. HYPOTHYROIDISM: TREATMENT • Levothyroxine (T4) – review at 12 weeks, adjust 6 weekly • NB: give smaller doses if elderly as risk of angina or MI The Peer Teaching Society is not liable for false or misleading information…

  22. The Peer Teaching Society is not liable for false or misleading information…

  23. HYPERTHYROIDISM: CAUSES 1. GRAVES’ DISEASE: • IgG autoantibodies bind to and stimulate TSH receptors (triggers = infection, stress, childbirth) • Eye disease, pretibial myxoedema, thyroid acropachy • Autoimmune (vitiligo, type 1 DM, Addison’s) 2. TOXIC MULTINODULAR GOITRE 3. TOXIC ADENOMA 4. ECTOPIC THYROID TISSUE (mets / struma ovarii) 5. EXOGENOUS (Iodine / T4 excess) 6. DE QUERVAIN’S THYROIDITIS (post-viral)

  24. Pretibial Myxoedema Thyroid Acropachy

  25. HYPERTHYROIDISM SYMPTOMS SIGNS CVS:Palpitations RS: - GI: Diarrhoea Int:Heat intolerance Endo: ↓Weight, ↑appetite UG: Oligomenorrhoea +/- infertility MSK: - Neuro / Psych: Tremor, irritability, labile emotions HANDS: - Palmar erythema; warm, moist skin; fine tremor PULSE: - Tachycardia; SVT; AF FACE: Thin hair; lid lag / retraction NECK: Goitre; nodules; bruit

  26. HYPERTHYROIDISM ↑T3, ↑T4 = ↓TSH INVESTIGATIONS: (a) TFT (b) FBC (normocytic anaemia) (c) ESR (↑) (d) Calcium (↑) (e) LFT (↑) (f) Thyroid autoantibodies (g) Visual fields, acuity, eye movements

  27. HYPERTHYROIDISM: TREATMENT (i) β-blockers: - Propanolol (rapid control of symptoms) (ii) Antithyroid medication: • Titration (carbimazole: SE = AGRANULOCYTOSIS) • Block and replace (carbimazole + thyroxine) (iii) Radioiodine (131I) (iv) Thyroidectomy

  28. THYROID EYE DISEASE • 25-50% have Graves’ disease • Main risk factor = smoking • Eye and thyroid disease may not correlate SYMPTOMS: Eye discomfort, grittiness, diplopia SIGNS:Exophthalmos, proptosis, ophthalmoplegia TESTS: Clinical diagnosis +/- CT/MRI orbits MANAGEMENT:Conservative measures (stop smoking, sunglasses, Fresnel prism); IV methylprednisolone; Surgical decompression; Eyelid surgery

  29. CAUSE OF GOITRE THYROID CANCERS DIFFUSE • Physiological • Graves’ disease • Hashimoto’s thyroiditis • De Quervain’s NODULAR • Multinodular • Adenoma / cyst • Carcinoma Papillary (60%) Follicular (≤25%) Medullary (5%) Lymphoma (5%) Anaplastic EMERGENCIES 1. Myxoedema coma (↓T4) 2. Thyrotoxic storm (↑T4)

  30. ADRENAL DISORDERS

  31. ADRENAL GLANDS

  32. ADRENALS HISTOLOGY

  33. CUSHING’S SYNDROME • CHRONIC glucocorticoid excess • LOSS of normal feedback mechanisms • LOSS of circadian rhythm. • Most common cause = IATROGENIC • If due to pituitary adenoma = Cushing’s DISEASE • “Lemon on sticks” appearance The Peer Teaching Society is not liable for false or misleading information…

  34. CUSHING’S SYNDROME: CAUSES

  35. CUSHING’S SYNDROME SYMPTOMS SIGNS Int:Acne Endo: ↑ Weight UG: Gonadal dysfunction MSK:Proximal weakness Psych: Mood change • FAT DISTRIBUTION: • Central obesity • Moon face • Buffalo neck hump • Supraclavicular fat distribution • SKIN CHANGES: • Skin and muscle atrophy • Bruises • Purple abdominal striae • OTHER: • Osteoporosis • Hypertension, hyperglycaemia • Infection-prone / poor healing

  36. BASIC RULES OF ENDOCRINOLOGY: 1. EXCESS hormone – INHIBIT the gland 2. LOW hormone – STIMULATE the gland The Peer Teaching Society is not liable for false or misleading information…

  37. The Peer Teaching Society is not liable for false or misleading information…

  38. CUSHING’S SYNDROME: INVESTIGATIONS 1. Bloods (↑plasma cortisol) 2. Overnight dexamethasone suppression test • Dexamethasone 1mg PO at 00:00 • Measure serum cortisol at 08:00 • Normal <50nmol/L (no suppression in Cushing’s) 3. 48h dexamethasone suppression test -Dexamethasone given qds for 2 days • Measure cortisol at 0h and 48h • No suppression in Cushing’s

  39. LOCALISING THE LESION • If above tests +ve → PLASMA ACTH • ACTH undetectable → ADRENALTUMOUR→ CT ADRENAL GLANDS • ACTH detectable → PITUITARY vs ECTOPIC: - 48h HIGH-DOSE dexamethasone suppression test - CRH TEST (measure cortisol at 120 mins) The Peer Teaching Society is not liable for false or misleading information…

  40. CUSHING’S SYNDROME: TREATMENT • Iatrogenic – stop steroids • Cushing’s disease – trans-sphenoidal surgery or bilateral adrenalectomy (caution Nelson’s syndrome) • Adrenal adenoma – adrenalectomy • Adrenal carcinoma – adrenalectomy, RT and adrenolytics (mitotane) • Ectopic ACTH – surgery (if localised)

  41. YOU HAVE NO ADRENAL GLANDS

  42. ADDISON’S DISEASE The Peer Teaching Society is not liable for false or misleading information…

  43. ADDISON’S DISEASE • Primary adrenocortical insufficiency • Destruction of adrenal cortex • ↓Glucocorticoids and ↓Mineralocorticoids The Peer Teaching Society is not liable for false or misleading information…

  44. ADDISON’S DISEASE: CAUSES • Autoimmune (80%) – commonest in UK • TB – commonest worldwide • Adrenal metastases (lung, breast, kidney) • Lymphoma • Opportunistic infections in HIV (e.g. CMV) • Adrenal haemorrhage (e.g. SLE, APS) • Congenital adrenal hyperplasia (late-onset) The Peer Teaching Society is not liable for false or misleading information…

  45. ADDISON’S DISEASE SYMPTOMS SIGNS GI:N/V, abdo pain, constipation / diarrhoea Int: Tanned skin Endo: Lean build MSK:Weakness, flu-like arthralgias, myalgias Neuro:Dizzy, faints Psych: Tired, tearful, anorexia, depression, psychosis • SKIN: • Pigmented palmar creases and buccal mucosa • Vitiligo • CVS: • Postural hypotension • Shock (↑BP, ↓HR, coma)

  46. BASIC RULES OF ENDOCRINOLOGY: 1. EXCESS hormone – INHIBIT the gland 2. LOW hormone – STIMULATE the gland The Peer Teaching Society is not liable for false or misleading information…

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