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Abdominal Distension & Weight Gain Rebaz Karim 10/12/24Use code CBOSCECREW24 at checkout on geekyquiz.com for 10% off OSCE flashcards, OSCE stations and knowledge bundles. Learning Objectives ● To identify common symptoms and signs of key endocrine conditions. ● To be able to take focused endocrine related history ● To structure explanations of endocrine conditions clearly and effectively for patients. Abdominal distention Weight gain What are the potential endocrine causes? What are the potential endocrine causes? ● Cushing's Syndrome ● Cushing's Syndrome ● Hypothyroidism / Hyperthyroidism ● Hypothyroidism ● Addison's Disease ● Insulin resistance ● Diabetes Mellitus (especially Type 1 or poorly controlled Type 2) ○ Diabetes ● Polycystic OvarySyndrome (PCOS) ○ PCOS ● Acromegaly ○ Metabolic Syndrome Abdominal distention Weight gain What are other potential causes? What are otherpotential causes? ● APKD ● Lifestyle ● Irritable bowel syndrome (IBS) ○ Excessive Caloric Intake ● IBD - Crohn’s disease / ulcerative colitis○ Emotional or Stress-Related Eating ● Diverticulitis ○ Sleep Deprivation ● Celiac disease ● Flatus (Aerophagia, Small intestinal ○ Aging bacterial overgrowth (SIBO) ) ● Medication-Related Causes ● Obstruction ○ Small or large bowel obstruction (e.g., adhesions,ants + Antipsychotics hernias, tumors). ○ Steroids ○ Large bowel obstruction (Mass, Intussusception) ● Ascites (Fluid): ○ Antiepileptics ○ Liver disease ○ Insulin or Sulfonylureas ○ Infection ○ Malignancy ● Fluid overload ● Gastroparesis ● Gynaecological Causes ○ Heart Failure ○ Pregnancy ○ Liver orKidneyDisease ○ Ovarian cysts / malignancies ○ Endometriosis Cushing’s syndrome Syndrome? • a collection ofsigns,symptoms, and other clinical findings that consistently occur together and characterize a particular condition or disease. • Can Have Multiple Causes! Cushing’s syndrome • Refer to the signs and symptoms that develop after prolonged abnormal elevation of cortisol • Mechanism – Increase lipogenesis and fat deposition + Insulin resistance -> promote fat storage Causes: • Exogenous steroids (in patients on long term high dose steroid medications) – Most common cause! • Cushing’s Disease (a pituitary adenoma releasing excessive ACTH) • Adrenal Adenoma (a hormone secreting adrenal tumour) • Paraneoplastic Cushing’s – SCLCHypothyroidism / Hyperthyroidism Most common causeof hyperthyroidismis Gravesdisease, keyfeatures: • Diffuse goitre (without nodules) • Graves eye disease • Bilateral exophthalmos • Pretibial myxoedema Toxic Multinodular Goitre (second most common - Goitre with firm nodules, age >50) Mostcommon cause for hypo- Hashimoto's disease: General signsandsymptoms forall causes: • Menorrhagia or irregular periods • Hair loss • Decreased deep tendon reflexes Important to be aware of the extreme spectrum of each – medical emergencies: • Thyroid Storm (can present with septic like picture) • Myxedema coma– Abdominal distention commonAddison’s disease • Also known as Primary Adrenal Insufficiency = Where adrenal glands become damaged = do not produce enough steroid hormones, particularly cortisol and aldosterone • Autoimmune cause == 80% Symptoms? Signs: • Lethargy + weakness • Hyperpigmentation (hand • Reduced libido creases) • Syncope • Hypotension (particularly • GI symptoms postural hypotension) • Nausea • Hypoglycaemia • Cramps • Vitiligo • Abdominal pain • Loss of pubic hair in women • anorexia • “salt-craving”Addison’s disease Beware of Addisonian Crisis! Signs and symptoms? • Reduced consciousness • Hypotension • Hypoglycaemia, hyponatraemia, hyperkalaemia • Patients can be very unwell ! Can be first presentation of Addisons Disease Life threatening – immediate management required – Do not wait for investigations! APKD APKD is a genetic condition characterized by thedevelopment ofnumerous fluid-filled cysts in the kidneys,leading to kidney enlargement and progressivekidney dysfunction Renal Symptoms: • Hypertension: Often the first sign, even before reduced kidney function. • Flank or abdominal pain: Due to cyst rupture, bleeding, or stretching of the kidney capsule. • Hematuria: Blood in urine, often from ruptured cysts. • Progressive kidney failure: Leading to uraemia in advanced stages. Extra-Renal Manifestations: • Liver cysts: Seen in ~80% of patients but rarely cause liver failure. • Cerebral aneurysms: Increased risk of subarachnoid haemorrhage • Mitral valve prolapse and other valvular disorders. • Diverticulosis in the colon. Complications: • Urinary tract infections (UTIs): Especially cyst infections. • Nephrolithiasis (Kidney stones). • Chronic pain syndromes.Acromegaly A condition resulting from excessive growth hormone secretion, usually due to a secreting pituitary adenoma. This adenoma can be microscopic or a significantly sized tumour that causes compression of local structures.Polycystic Ovary syndrome (PCOS) A common ovarian disorder, characterized by a combination of symptoms related to ovarian dysfunction, hormonal imbalances, and the presence of multiple small cysts in the ovaries. 36 year old female presents with Abdominal distention and weight loss What are we going to ask in the history? 36year old female presents with Abdominaldistention and weight loss 1. Open questions 4. ICE 2. History of presenting complaints • Onset:Gradual vs. sudden? 5. PMH + PSH • Duration:Howlong have the symptomsbeen • Ask specifically for autoimmune conditions: CeliacDisease, thyroid problems etc • Progression:Stable, worsening, or intermittent? • Any surgical history (especially if suspectingAddison's diseaseor small bowel obstruction ) 1. - 3. Systems review 6. MH • Any allergies? GI • Ask specifically for steroid use • Bowel movements, howregular, when was the last time? - ( hyper/hypo thyroidism, IBS, IBD, obstructions ) • Mucus or blood in stools - (IBD, diverticulitis, Colon cancer ) • Abdominal pain – SOCRATES 7. FH • Nausea and Vomiting- content, colour, hematemesis • Specifically ask if any autoimmune conditions run in the • DietaryChanges (coeliac, dietaryintolerance, metabolicdisease) family Endocrine • Fatigue - Common in hypothyroidism, diabetes, and Addison’s disease 8. Social history • Menstrual Irregularities –hypothyroidism, PCOS • Lifestyle – How active are they • Any hair loss – Hypothyroidism • Work • Skin Changes–Cushing’s, Addison's, hypo/hyperthyroidism • Heat orColdSensitivity - hypo/hyperthyroidism • Living situation • Thirst andUrination –Addison's, Diabetes, Cushing’s Syndrome • Smoking, alcohol and recreational drugs Systemic • Fever 9. Close consultation – summary + plan • Weight Changes: Gain: Hypothyroidism, Cushing’s syndrome, insulin resistance. Loss: Hyperthyroidism, diabetes, Addison’s disease. Examinations and further investigations? 1. Bedside 2. Laboratory testing 3. Imaging 4. Special testsExaminations and further investigations? Examinations and further investigations? Bedside: • General Observations: Cachexia,obesity,or moon face (Cushing’s) Further bedside tests: • Vital Signs • Urinalysis (glucose, protein) - Temperature (fever for systemic or inflammatory causes - Blood pressure (hypotension in Addison’s, hypertension in Cushing’s) • Capillary Blood Glucose - Heart rate (tachycardia in hyperthyroidism, bradycardia in • ECG • Pregnancy Test hypothyroidism). • BMI (Obesity, Monitoring ) • Abdominal Examination - visible masses, striae (Cushing’s), or surgical scars. - Organomegaly, palpablebilateral flank masses (APKD) - Bowel sounds (absent in obstruction, hyperactivein IBS or hyperthyroidism). • Thyroid Examination - Inspect for goiter, scars, or signs of hypothyroidism(e.g.,dry skin,coarse hair). - Palpate for thyroid size, nodules, and tenderness. - Graves' disease: auscultate for bruit, check for proptosis/exophthalmos, lid lag, pretibial myxedema • Skin and Nails - Hyperpigmentation – most obvious at Skin folds: palms and soles (Addison’s). - Thin skin or bruising (Cushing’s) - Dry skin (hypothyroidism). Examinations and further investigations? Laboratory testing Autoimmunescreen Thyroid Function Tests (TFTs) - anti-tTG(Coeliac Screen) - Elevated TSH + low T4 (hypothyroidism). - Anti TSH (Graves'Disease) - Suppressed TSH + high T4 (hyperthyroidism) - Anti TPO (Hashimoto’sThyroiditis /graves) Cortisol and ACTH Levels - Low cortisol (Addison’s) Full BloodCount (FBC) - High cortisol (Cushing’s syndrome). - WCC (steroid use, infection) - RBC /Hb (Anaemia) Blood Glucose & HbA1c - Diabetes screening Urea andElectrolytes (U&Es) Inflammatory Markers (CRP/ESR) - Hyperkalaemia + Hyponatremia (Addison’s) - Raised in IBDor infections. Liver FunctionTests(LFTs) - Ascites duetoliverdisease? Examinations and further investigations? Imaging Special Tests 1. Abdominal Ultrasound 1.Dexamethasone Suppression Test • For organomegaly, ascites, or masses. 1. For Cushing’s syndrome. 2. CT Abdomen and Pelvis • Detailed evaluation for masses, obstruction, 2.Short Synacthen Test or malignancy. 3. Thyroid Ultrasound 1. To diagnose Addison’s disease. • If nodules or goiter are detected. 3.Endoscopy/Colonoscopy 1. If GI bleeding or malignancy is suspected. 4.CXR 4.Laparoscopy • To rule out malignancy or secondary 1. If diagnostic uncertainty for abdominal endocrine causes (e.g., lung cancer and distension or chronic pain persists. Cushing’s). 5.MRI Pituitary or Adrenal Glands • If suspected hormonal imbalance or tumor.Explanation stationsExplanation stationsExplanation stations 1. Brief History (Make it brief but include all aspects! ) - “Sincethisis ourfirst time meeting, can you bring meup to dateon what’s brought you heretoday?" - Symptoms: Has it been causing you any problems? Or do Quick focused system review - PMH: Ask specific relevant conditions - MH: Allergies, specific contraindications? - Social: Smoking, alcohol, lifestyle! 2. Understanding - One direct question - What do you know already about X? 3. Concerns - “Is there anything specific you’d like to discuss or make sure we address today?” - “Are there any particular concerns or worries you have about this?” -> Need to address concerns or let them know you will come back to it later! 4. Outline Plan! - I will go through.. Normal, What X is, causes … Explaining Addison’s Normal anatomy/ physiology: • Your body hastwo adrenal glands, one sitting on top of each kidney.These glands make hormoneslike cortisol and aldosterone. • Cortisol: Helps you deal with stress, keeps your energy steady, and manages your immune system. • Aldosterone: Helps balance salt and water in your body, which affects blood pressure. What disease is: • Addison’sdisease happens when youradrenalglands become damaged and don’tmake enough of these hormones. • This is why it's also called adrenalinsufficiency. • Withoutthese hormones, your body struggles to handlestress,maintain energy, and regulate salt and water balance. -> Linkto thepatient’ssymptomsand signs Cause: Multiple potential causes: • Autoimmune disease (most common): Your immune system mistakenly attacks your adrenal glands • Infections -> Explain whatthe causein their case and why(e.g. your scans/blood tests show…) Explaining Addison’s Complications • If untreated or in stressfulsituations (likeillnessor surgery), it can lead to an Addisonian crisis, a medical emergency whereblood pressuredrops dangerously low. Thisneeds urgent treatment. Management • Hormone replacement therapy: Hydrocortisone (replaces cortisol) + Fludrocortisone (replaces aldosterone). • Preventing Addisonian crisis : You need to double your hydrocortisone dose during illness, injury, or surgery. • Regular monitoring: To make sure your hormone levels stay balanced • Emergency preparedness: Carry a steroid emergency card or medical alert bracelet and have an injection kit for emergencies. Finish • Summary + Plan • Leaflet Explaining Cushing’s Syndrome Normal anatomy/ physiology: Your body naturally produces a hormone called cortisol. It’s made by the adrenal glands, which sit on top of your kidneys. Also known as your stress hormone it helps your body: • Handle stress (like when you're anxious or sick). • Control your blood sugar and energy levels. • Keep your blood pressure stable. • Fight infections and reduce inflammation. What is Cushing's Syndrome? • Cushing's syndromeoccurs when your body has too much cortisol for a long time. This excess cortisol can causechanges to how your body looks and works. • Weight gain: You may notice weight gain, especially around your belly, face (moon face), and neck (buffalo hump). • Skin changes: Your skin may become thin, bruise easily, or develop purple stretch marks. • Muscle weakness: You might feel weaker in your arms and legs. • Fatigue: Feeling very tired or worn out. • High blood pressure: You may have higher-than-normal blood pressure. • Mood changes: You could feel more anxious, depressed, or irritable. • Bone problems: Long-term excess cortisol can weaken your bones, making them easier to break. ➔ Link to patient’s symptoms and signs you have gathered frombriefhistory Causes: Therearedifferent reasons your body might havetoo much cortisol: • Taking steroids: Some medications (like prednisone for asthma or arthritis) can increase cortisol levels. • Adrenal Tumor: A tumor in the adrenal glands can also produce excess cortisol. • Other Tumors: Sometimes, tumors elsewhere in the body can causethe problem, too. ➔Explain what cause is specifically for the patient Explaining Cushing’s Syndrome Complications: If left untreated, Cushing's syndrome can cause serious health problems: • Heart disease and high blood pressure. • Osteoporosis: Weak bones that break more easily. • Type 2 diabetes: Because cortisol can raise blood sugar levels. • Increased infections: Because high cortisol weakens your immune system. • Mental health issues: Anxiety, depression, and trouble concentrating. Treatment and Management: Therearethings we can do for you and thing you can do • What You Can Do: - Eating healthy and exercising– help reduce blood pressure and keep bone strong • What we can Do: - Medications: We can prescribe medications to help reduce the amount of cortisol your body makes - Surgery: If there’s a tumor causing the problem, we may recommend surgery to remove it.