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Obesity Ayah ShahObesity management • 1 line: • Lifestyle management: • Dietary changes e.g. reduced calorie diet, etc. • Increased exercise • Medical management: • Treat complications • Orlistat – lipase inhibitor, given if BMI > 30 and risk factors, continue if there is > 5% weight loss after 3 months. • Surgical management: • Bariatric surgery is BMI > 40 or 35-40 with comorbidities e.g. diabetes. • The patient should have made attempts at other management but without success. Cushing’ s syndrome A group of silevels of cortisol.at develop due to abnormally highCushing’s syndrome – signs and symptoms • Zero to finals has a helpful way to remember: • Round in the middle with thin limbs: • Moon face • Central obesity • Abdominal striae (stretch marks) • Buffalo hump (fat pad on upper back) • Proximal muscle wasting in limbsComplications of high levels of cortisol • Hypertension • Cardiac hypertrophy • Hyperglycaemia (Type 2 Diabetes) • Depression • Insomnia • Osteoporosis • Easy bruising and poor skin healingCushing’s syndrome - causes • Taking steroids e.g. prednisolone long term • Cushing’s disease – a pituitary adenoma that releasesexcessACTH, therefore stimulating the adrenal glands to release cortisol • Adrenal adenoma - secretes excess cortisol • Paraneoplastic Cushing’s – When a cancer outside of the pituitary stimulates releases excess ACTH, stimulating the adrenal glands to release excess cortisol. • Does anyone know the most cause of paraneoplastic Cushing’s? • Small Cell Lung Cancer Cushing’s syndrome - diagnosis • Dexamethasone suppression test: • This is the test of choice for diagnosis. • There are two steps involved, the low dose, and then the high dose. • You give the dexamethasone at night ,and measure cortisol levels un the morning. • Starting with the low dose, if you give a patient low dose Dexamethasone (1mg): • In a normal person, this should suppress the hypothalamus and pituitary gland via negative feedback. This means reduced stimulation of the adrenal glands and therefore reduced cortisol levels. So in the morning, cortisol levels should be low. • If cortisol levels are still high, then you can diagnose Cushing’s syndrome. • Then give the patient high dose dexamethasone (8mg) to identify the cause: • Ipituitary gland producing too much ACTH, so think about it like more cortisol is needed to suppress it than normal. • If the cortisol levels are still not suppressed we then measure ACTH levels to identify the cause: • If ACTH levels are low, this means the ACTH produced by the pituitary has been suppressed so the cortisol is coming from elsewhere, i.e. the adrenal glands, so the cause is an adrenal adenoma. • If the ACTH levels are still high, then we know ACTH is coming from somewhere other than the pituitary gland because this should be suppressed, so we can diagnose ectopic ACTH release i.e. paraneoplastic Cushing’s • Give the dexamethasone at night then. Measure cortisol levels in the morning. Diagnosis • Low dose – 1mg dexamethasone • High dose – 8mg dexamethasone Cushing’s syndrome - other investigations and management • Other investigations: • FBC – raised white cell count • U&Es – if it’s an adrenal adenoma, aldosterone may also be high so you may get low potassium. • MRI brain - pituitary adenoma • CT chest – Small cell lung cancer • Abdominal CT – adrenal tumors • Management: • Treat the underlying cause by surgicallygmtour.tuHyperaldosteronism Most common cause of secondary hypertension.Primary hyperaldosteronism (Conn’s syndrome) • The adrenal gland itself has the issue, it’s producing too much aldosterone. • This can be due to various causes including: • Adrenal adenoma • Bilateral adrenal hyperplasia • Familial hyperaldosteronism type 1 and 2 (rare) • Adrenal carcinoma (rare) • Serum renin levels will be low due to negative feedback.Secondary hyperaldosteronism • There is excessive renin levels which result in excess aldosterone levels. • Causes of high renin levels occur due to low blood pressure at the kidneys, including: • Renal artery stenosis • Renal artery obstruction • Heart failure • Renal artery stenosis, is due to narrowing of renal artery which supplies the kidneys. Most often due to atherosclerosis. The narrowed vessels means less blood flow to kidneys which is perceived as low blood pressure resulting in renin release. This can be diagnosed with doppler USS, CT angiogram or magnetic angiography (MRA). • Does anyone know the rarer causes of renal artery stenosis? Fibromuscular dysplasiaHyperaldosteronism - investigations • First line test: • Renin/aldosterone ratio: • High aldosterone and low renin = primary hyperaldosteronism • High aldosterone and high renin = secondary hyperaldosteronism • Other tests include: • Blood pressure = hypertension • Serum electrolytes = hypokalemia • Blood gas analysis = alkalosis • If a high aldosterone level isfoundthen: • CT or MRI to visualize tumour • Renal doppler ultrasound, CT angiogram or MRA for renal artery stenosis Hyperaldosteronism - management • Aldosterone antagonists: • Eplerenone • Spironolactone • Treat underlying cause: • Surgical removal of tumor • Percutaneous renal artery angioplasty via femoral artery for renal artery stenosis Adrenal insufficiency Where the adrenal glands are not producing enough steroid hormones. Primary adrenal insufficiency (Addison’s Disease) • An autoimmune condition which results in damage to the adrenal glands. This results in less cortisol AND aldosterone being produced.Secondary adrenal insufficiency • Due to inadequate ACTH release, resulting in low cortisol release. Often due to damage to the pituitary gland due to various causes e.g.: • Infection • Loss of blood flow • Radiotherapy • Sheehan’s syndrome (pituitary gland necrosis following blood loss due to childbirth)Tertiary adrenal insufficiency • Due to inadequate CRH release by the hypothalamus. • This occurs when patients are taking long term exogenous steroids e.g. prednisolone. Overtime this causes suppression to the hypothalamus due to negative feedback. • When the steroids are stopped suddenly, the hypothalamus needs time to restart, so CRH isn’t produced straight away so cortisol also isn’t produced. This is why when patients are on long term steroids we like to taper them off so the hypothalamus has time to wake up.Adrenal insufficiency – signs symptoms • Symptoms: • Fatigue • Nausea • Cramps • Abdominal pain • Reduced libido • Signs: • Bronze hyperpigmentation to skin (this due to high ACTH stimulating melanocytes, therefore only occurs in primary hyperaldosteronism) • Hypotension (especially postural hypotension) Adrenal insufficiency – investigations • Short synACTHen test (ACTH stimulation test): • Ideally in the morning. • Give patient synacthen (synthetic ACTH), then measure blood cortisol levels at baseline, 30 minutes and 60 minutes) • In healthy adrenal glands, cortisol levels should at least double. • A failure to double indicates Addison's disease) • ACTH levels: • In Addison's disease (primary), ACTH is high to try and stimulate those adrenals. • In secondary adrenal failure, ACTH is low because the pituitary is the issue. • Hyponatremia and hyperkalemia can occur • Adrenal autoantibodies can be found in Addison's disease (adrenal cortex antibodies and 21-hydroxylase antibodies) • CT/MRI of the adrenals to identify tumour or hemorrhage (not needed in Addison's) • MRI pituitary if pituitary pathologyAdrenal insufficiency - management • Replacement steroids is key. • Hydrocortisone is used to replace cortisol. • Fludrocortisone is used to replacealdosterone if this is also insufficiency. • Make sure to give patients a steroid card and emergency ID tag to alert emergency services. • Patients should NEVER miss a dose. • If a patient becomes ill acutely, we double the hydrocortisone.This is because naturally, when we are ill, our cortisol levels increase, so we are trying to mimic that so the patient doesn’t go into a CRISIS. Addisonian crisis (adrenal crisis) • This is the acute presentation of severe Addison’s disease where steroids are absent, causing a life threatening condition. • Signs include: • Reduced consciousness, hypotension, • hypoglycemia • Hyponatremia and hyperkalemia • Very unwell • Sometimes this can be the first presentation of Addison's disease, pr maybe the patient was triggered due to infection, trauma and other acute illness. • It can also occur in those who suddenly stop long term steroids. • TREAT IMMEDIATELY, don’t wait for definitive investigations if you suspect it as it is life threatening. • Management includes: • Monitoring • IV steroids – IV hydrocortisone 100mg stat then 100mg every 6 hours • IV fluids resus • Correct hypoglycemia • Monitor electrolytes and fluid balancePhaeochromocytoma • A tumor of the chromaffin cells in the adrenal medulla. • This results inexcessadrenaline release which triggers the “fight or flight response” • Adrenaline is released in bursts so patients often get steeled periods and then bursts of symtpoms . • Associated with multiple endocrine neoplasia type 2 (MEN 2)Multiple endocrine neoplasiaPhaeochromocytoma prestation • Anxiety • Sweating • Headache • Hypertension • atrial fibrillationcardia and paroxysmalPhaeochromocytoma diagnosis • 24 hour urine catecholamines – unreliable because levels fluctuate therefore we measure It over 24 hours • Plasma free Metanephrines – Metanephrines are a breakdown product of adrenaline and have a longer half life and also fluctuate less so is more reliable. Phaeochromocytoma - management • Alpha blockers i.e. phenoxybenzamine • Beta blockers (once established on alpha blockers) • Adrenalectomy is definitive management but make sure they’re stabilized medically first • Occurs due to excess growth hormone production by anterior pituitary gland. Acromegaly • Most commonly due to pituitary adenoma. • Can rarely occur fie to a cancer such as lung or pancreatic cancers secreting ectopic GHRH or GH.Acromegaly - presentation Space Occupying Lesion Overgrowth of tissues GH can cause organ Symptoms suggesting dysfunction active raised GH Headaches Prominent forehead and Hypertrophic heart Development of new skin Visual field defect brow (“frontal bossing”) Hypertension tags (“bitemporal Large nose Type 2 diabetes Profuse sweating hemianopia”) Large tongue Colorectal cancer (“macroglossia”) Large hands and feet Large protruding jaw (”prognathism”) Arthritis from imbalanced growth of joints • GH itself fluctuates so measuring it isn’t useful • Insulin-like Growth Factor 1 (IGF-1) – initial screening test Acromegaly - • Oral glucose tolerance rest while measuring GH investigations (high glucose should normally suppress GH) • MRI brain for pituitary tumor • Refer to ophthalmology for formal visual field testing • Transsphenoidal resection of pituitary tumor is definitive manage if caused by pituitary adenoma. • Surgical resection of other cancer causing ectopic GHrH/GH release. Acromegaly • Medications to block GH: • Pegvisomant(GH antagonism) management • Somatostatin analogues (block GH release e.g. octreotide) • Dopamine agonists (block GH release e.g. bromocriptine) • Antidiuretic hormone (ADH), also known as ‘vasopressin’ is released by the posterior pituitary gland. ADH physiology • ADH binds to receptors in the collecting duct of the kidney causing reabsorptionof water.Syndrome of Inappropriate Ant iDiuretic Hormone (SIADH) • Excessive ADH can be due to too much ADH production by the posterior pituitary OR somewhere else e.g. small cell lung cancer • Excessive ADH means more water is reabsorbed. • More water = dilution of sodium, causing hyponatremia • There is less water excreted in the urine, so urine is more concentrated with a high urine osmolality and high sodium.SIADH - causes • Post-operative from major surgery • Infection, particularly atypical pneumonia and lung abscesses • Head injury • Medications (thiazide diuretics, carbamazepine, vincristine, cyclophosphamide, antipsychotics, SSRIs, NSAIDSs,) • Malignancy, particularly small cell lung cancer • MeningitisSIADH - diagnosis • It’s a diagnosis of exclusion because we can’t measure ADH directly. • U&E’s will show hyponatremiaand you’ll have high urine sodium and urine osmolality • Youmainly want to rule out othercausesof hyponatremiasuch as: • Adrenal insufficiency • Diuretics • Diarrhea, vomiting, burns, excessive sweating, excessive water intake • CKD • AKI • Do a chest X-ray to rule out pneumonia, lung abscesses and lung cancer.SIADH - management • Establish and treat the cause • Fluid restriction • Tolvaptan – vaptans are ADH blockersSIADH - symptoms • Very non-specific. • Headaches • Fatigue • Muscle aches and cramps • Confusion • Severe hyponatraemia can cause seizures and reduced consciousnessDiabetes insipidus Nephrogenic DI Cranial DI The collecting ducts are The hypothalamus not responding to ADH itself isn’t producing • Think of it as the opposite of SIADH Causes include: ADH. • Drugs e.g., lithium Causes include: • There is a lack of ADH, therefore, • Genetics • Idiopathic that reabsorption of water isn’t • Intrinsic kidney • Brain tumors occurring, so these patients get disease • Head injury polyuria, and polydipsia due to the • Electrolyte • Brain disturbance malformations water loss. (hypokalemia and • Brain infections hypercalcemia) • Brain surgery or radiotherapy DI - presentation • Polyuria(excessive urine production) • Polydipsia(excessive thirst) • Dehydration • Postural hypotension • HypernatremiaDI - Investigations • Low urine osmolality • High urine osmolality • Water deprivation testWater deprivation test • Also known as desmopressin stimulation test • Patient should avoid taking any fluids for 8 hours (fluid deprivation) • Then measure urine osmolality and give synthetic ADH (desmopressin) • 8 hours later, measure urine osmolality againDI - management • Treat underlying cause if possible • Mild causes don’t need intervention • under specialist supervision)ranial DI (in nephrogenic it can be given in higher dosesProgress questionsQuestion 1 A 65 year oldwoman presents to clinic with a history of weight gain, easy bruising and recently diagnosed type 2 diabetes mellitus. On clinical examination you find purple • Overnight dexamethasone is striae on her abdomen and her blood pressure is 159/85. the low dose dexamethasone Bloods tests reveal no anaemia and normal kidney and suppression test. We use this thyroid function. to rule out Cushing’s syndrome. Which of the following is the best initial test to screen for • High dose is used to identify suspected Cushing's syndrome? the cause. • 24 hour urinary free cortisolis 1. MRI-pituitary not very useful due to 2. High dose Dexamethasone suppression test fluctuations during the day. • MRI pituitary would be used 3. Lose dose dexamethasone suppression test cause.if you think it’s a pituitary 4. Oral glucose tolerance test 5. 24 hour urinary free cortisol • Oral glucose tolerance test used in acromegaly A 67 year oldmale with an extensive smoking history Question 2 presents to clinic with new chronic cough, associated with haematolysis and clubbing. He also mentions he has found it harder to rise from the sitting position as well as easy bruising • The symptoms of clubbing, with purple striae of the skin. coughing, hemoptysis, etc. as Which of the following is the most likely cause of his skin well as background smoking changes? history suggests lung cancer. 1. Hypothyroidism • The easy bruising and striaeis 2. Ectopic ACTH release suggesting Cushing's. 3. Acromegaly • So it’s suggesting ectopic ACTH release from small cell 4. Carcinoid syndrome lung cancer. 5. HypoadrenalismQuestion 3 A 59-year-old man presents with confusion. On examination, it is foundthat he is in hypovolaemic shock. His daughtertells you that he has been refusing to take his long-term steroids that he’s usually on for a chronic condition. Given the likely diagnosis of Addisonian crisis, what is the most • IV corticosteroids should be appropriate management? given patients with suspected Addisonian crisis to maintain safe blood pressure and 1. Alpha blocker glucose levels. 2. Dehydroepiandrosterone • Fludrocortisone is used to 3. IV hydrocortisone 4. Fludrocortisone treat is chronically but not in 5. Glucose acute presentationQuestion 4 A 26 year oldfemale presents to endocrinelinic for investigation of fatigue.No relevant PMH. She has been feeling 'tired all the time’, with a lack of motivation, low moods, dizziness and weight loss. On examinationshe has some pigmented skin patches and a postural • Autoimmune adrenal drop in blood pressure between lying and standing. She has a 9am insufficiency (Addison's cortisol level of 250 nmol/l and then has a shortsynacthentest disease) is the commonest which confirms the diagnosis of adreno-cortical insufficiency. What cause of adrenal insufficiency is the most likely cause of her condition? 1. Adrenoleukodystrophy 2. Adrenal malignancy 3. TB 4. Autoimmune disease 5. Congenital adrenal hyperplasiaQuestion 5 A 31 year old womanfemalewith polyuria and polydipsia. She is urinating multiple litres per day • This is the first line test for DI.nd diabetes insipidus is suspected. Which of the following is the best diagnostic test 1. Fluid deprivation test 2. 24 hour urinary free cortisol 3. Anterior pituitary profile 4. Salt loading test 5. Oral glucose tolerance testQuestion 6 A 47-year-old man is seen in clinic for suspected diabetes insipidus. The endocrinologist suspects a central causeof the diabetes insipidus. Which of the following may suggest a cause of • Lithium is a cause of nephrogenic diabetes insipidus? insipidus.c diabetes • The rest are all causes of 1. CNS infections cranial diabetes insipidus. 2. Lithium 3. Head trauma 4. Pituitary surgery 5. CraniopharyngiomaQuestion 7 A 29 year old followinga seizure and is foundto be severely hyponatraemic . He is euvolaemic and has a low plasma osmolality (<270 mOSm/kg). Which • This patient has euvolemic condition is most in keepingwith these results and hyponatremia. This occurs due to excess ADH. presentation? • The excessADH causes water retention, therefore dilution 1. Diabetes Insipidus of the sodium, resulting in 2. SIADH hyponatremia. 3. Conn’s syndrome 4. Hyperosmolar hyperglycaemicsyndrome 5. Cushing’s disease A 59-year-old man presents with weakness, Question 8 cramps, paraesthesia. He mentions he’s been increasingly thirsty for the last few months. The GP orders bloods which revealhypokalaemia . • This is used as the screening Which of the following is the most appropriate test. initial investigation for suspected primary • High aldosterone: renin ratio hyperaldosteronism? would indicate primary hyperaldosteronism 1. Waterdeprivation test 2. Aldosterone:reninratio 3. Adrenal venoussampling 4. Oral salt loading 5. CT adrenal glands Data interpretation: • Practice lots of endocrine questions on passmed, they come up loads on progress too. Explanation stations: OSCE stuff • Obesity, it’s complications and management • Look at NHS website for good tips History: • Not sure how likely this is but learn the symptoms well,e.g. Cushing’s has very specific features. Zerotofinals Geeky medics Resources NHS website Passmed Quesmed