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ENDOCRINOLOGY - HPsystems

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heather watson

on 19 June 2016

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Transcript of ENDOCRINOLOGY - HPsystems

POSTERIOR ANTERIOR oxytocin
ADH TSH, FSH, LH, ACTH, GH, PRL secondary
capillary
plexus primary
capillary
plexus secretory cells of
adenohypophysis storage cells of
neurohypophysis hypthalamic
hypophyseal tract oxytocin ADH Growth hormone-releasing hormone Thyrotropin-releasing hormone
& Prolactin-releasing hormone Corticotropin-releasing hormone
stimulates ACTH Gonadotropin-releasing hormone
stimulates LH & FSH Dopamine
Prolactin-inhibiting hormone SOMATOSTATIN
inhibits GH & TSH MEDIAN EMINENCE OXYTOCIN
uterine contraction
lactation let-down antidiuretic hormone
AKA vasopressin permeability to H20 in distal tubule & collecting duct of kidney = water reabsorption and excretion of concentrated urine POSTERIOR ANTERIOR oxytocin
ADH TSH, FSH, LH, ACTH, GH, PRL secondary
capillary
plexus primary
capillary
plexus secretory cells of
adenohypophysis storage cells of
neurohypophysis hypthalamic
hypophyseal tract LH, FSH TSH ACTH GH PRL oxytocin ADH preoptic ventromedial dorsomedial paraventricular acrurate GHRH Growth hormone-releasing hormone TRH Thyrotropin-releasing hormone
& Prolactin-releasing hormone CRH Corticotropin-releasing hormone
stimulates ACTH GnRH Gonadotropin-releasing hormone
stimulates LH & FSH DA Dopamine
Prolactin-inhibiting hormone SS SOMATOSTATIN
inhibits GH & TSH MEDIAN EMINENCE magnocellular neurons OXY OXYTOCIN
uterine contraction
lactation let-down antidiuretic hormone
AKA vasopressin ADH permeability to H20 in distal tubule & collecting duct of kidney = water reabsorption and excretion of concentrated urine HUMAN ENDOCRINE SYSTEM TSH iodine table salt
amioderone
kelp excess Iodine load
inhibits hormone
release:
WOLFF CHAIKOV except in setting of pre-existing
hyperthyroid, where Iodine causes
massive release of hormone:
JOD-BASEDOW TSH every thyroid gland has its own capillary supply T4 T3 TRH deficiency Causes KEY FEATURES TREATMENT Definitive Dx Cold intolerance
Amenorrhea tertiary hypothyroid TSH deficiency Causes KEY FEATURES TREATMENT Definitive Dx secondary hypothyroid T4/3 deficiency Causes KEY FEATURES TREATMENT Definitive Dx primary hypothyroid sustained, rising TSH levels. T4 TRH stim test HYPOTHYROID primary HYPERTHYROID primary stimulate thyroxin production
independently of pituitary GRAVES associated with
diabetes ovarian
failure adrenal
failure IgG autoimmune GRAVES Causes KEY FEATURES TREATMENT Definitive Dx Hashimoto Causes KEY FEATURES TREATMENT Definitive Dx acute destructive phase autonomous toxic adenoma Causes KEY FEATURES TREATMENT Definitive Dx multinodular
goitre Causes KEY FEATURES TREATMENT Definitive Dx transient postpartum Causes sub-acute iodine-induced THYROID STORM Causes KEY FEATURES TREATMENT Definitive Dx silent RARE iodine excess Causes KEY FEATURES TREATMENT Definitive Dx RAI RAI RAI RAI RAI FACTIOUS / exogenous T3 RAI < 40 thyroid stimulating IgG (TSI) diffuse goitre
proptosis proptosis aka exophthalmos OBSTRUCTION OF
SUPERIOR OPTHALMIC VEIN influx
of
water ORBITAL
ENGORGEMENT deposition of glycosaminoglycans tx symptoms artificial tears
sunglasses
elevate head prevention AVOID RAI
euthyroid TSH T4 T3 +/- ATD
propanolol
radio ablation methimazole/PTU graves in pregnancy PTU crosses placenta @ 12 fetal thyroid fxns TSI crosses placenta low dose ATDs to avoid fetal goitre fetal tachy craniosyntosis febrile neonate can progress to CHF in newborn premature fusion of cranial sutures tx: PTU, iodine, propanolol 4-12 wks anesthetics, sepsis, goitre injury, TH O.D. neuro gastro gen anxiety
seizures
coma Nausea
Vomiting
Diarrhea
Cramps
Jaundice Fever
Sweating
Anorexia
Resp distress
Fatigue > 41C wide pulse pressure clincial ABCs
rate control HR
high dose PTU
Iodine
ice packs > 40 TSH T4 T3 +/- hot nodules ATD Radio ablation most common cause of hyperthyroidism. functional adenoma > 2.5cm
follicular neoplasm - rarely progress to CA typical elderly heat intolerance
palpitations
tremor
weight loss
hyperphagic
hyperfecal weight loss
anorexia
constipation
atrial fibrillation
palpitations
CHF x5 > 40 persistant patchy uptake histology shows irregular
follicles - some distended
some small and empty ATD Radio ablation precipitated by longstanding goitre hx of iodine defish
hx of nodular dz
hx of autoimmunity amioderone
contrast
kelp Jod-Basedow failure to
initiate/escape
Wolff-Chaikov hyperthyroid hypothyroid euthyroid hyperthyroid hypothyroid hyperthyroid hypothyroid 5%
PP postpartum immune system rebound
susceptible women produce TSH-Ab's DM1 x3 self-resolves 6mos-1yr may pass undetected low energy, poor memory,
impaired concentration, carelessness,
dry skin, cold intolerance, aches & pains fatigue, irritability,
nervousness, palpitations,
and heat intolerance TBG dur preg 0 no goiter, no eye signs RAI note: patchy uptake
also in non-toxic goitre increases bone turn-over BMD osteoperosis risk CV fx: tachy, systolic HTn, a.fib GI/U fx: hyperphagic, fecal, irreg menses SNS ovarian CA

metastic follicular CA

hydatidiform mole

TSH-producing adenoma

trophoblastic disease thyroxine triiodothyronine found in the
heart
muscle
CNS
fat
thyroid
pituitary placenta DIO1 found in kidney & liver glucocorticoid
lithium
sulphonamides
sodium nitroprusside Rx inhibits T4 -> T3 inhibits secretion inhibits organification inhibits secretion ORGANIFICATION TPO thyroid peroxidase PTU
methimazole DIO1 found in kidney & liver DIT DIT DIT MIT MIT MIT MIT DIT DIO2 PTU E2 t1/2 = 1hr Early: lethargy, cold intolerance,
weight gain, menorrhagia Late: dry hair, hair, hoarse void
cramps, cold & scaly skin reduced mentation can be mistaken for demetia myxodema low TSH + low TSH + low TSH + + high TSH + high TSH + high TSH SUBCLINICAL CLINICAL rare secondary
hypothyroid N TSH T4 Hashimotos Causes KEY FEATURES TREATMENT Definitive Dx RAI profound infiltration of lymphocytes + plasma cells TSH T4 T3 +/- L-thyroxine hashimotos in pregnancy @ 12 fetal thyroid fxns TSI crosses placenta fetal tachy craniosyntosis febrile neonate can progress to CHF in newborn premature fusion of cranial sutures tx: PTU, iodine, propanolol 4-12 wks iodine-induced iodine excess Causes KEY FEATURES TREATMENT Definitive Dx RAI hx of iodine defish
hx of nodular dz
hx of autoimmunity amioderone
contrast
kelp Jod-Basedow failure to
initiate/escape
Wolff-Chaikov iatrogenic surgical Causes Medications Causes iodine-induced iodine excess Causes KEY FEATURES TREATMENT Definitive Dx RAI hx of iodine defish
hx of nodular dz
hx of autoimmunity amioderone
contrast
kelp Jod-Basedow failure to
initiate/escape
Wolff-Chaikov iodine-induced iodine excess Causes KEY FEATURES TREATMENT Definitive Dx RAI hx of iodine defish
hx of nodular dz
hx of autoimmunity amioderone
contrast
kelp Jod-Basedow failure to
initiate/escape
Wolff-Chaikov autoimmune kelp
contrast
amioderone most common thyroiditis flat cohesive sheets of Hürthle cells highly eosinophilic destruction
of follicles also associated w follicular thyroid cancer note: TSH can be N goitrogens amioderone
lithium
phenobarb RAI / surgery like the iodine found in foods such as fish, seaweed, and iodized salt, except that
RAI releases an electron, or beta particle, which creates its therapeutic action. HYPOGONADISM hypothalamic-hypogonadism hyperthalamic-hypogonadism Structural anomalies tumours
infection
KALLMANN KALLMANN Dx key features Tx failure to commence or the non-completion of puberty anosmia kallmann amenorrhea
testicular atrophy of exclusion test for anosmia even in total anosmia certain very caustic substatances such as bleach can still be detected by direct stimulation of the trigeminal nerve. R/O pituitary
R/O constitutional delay
R/O Kleinfelters/Turners PRL levels BA vs CA karyotype HRT Functional inhibition acute stress
chronic illness
anorexia (etc)
severe malnutrition Tumours
metastesis
injury PROLACTINOMA Dx key features Tx basophils in
pars distalis
produce LH
and FSH
(etc) optic chiasm posterior anterior pars distalis trauma
inflammation
ischemia > 10 mm < 10 mm most common hormone-secreting pituitary tumors lactotrophs TRH DOPAMINE libido
ED gynecomastia rare
lacation >>> rare irreg menses
infertility galactorrhea ~30% tend to present late stage testicular
atrophy R/O hypothyroid
R/O PCOS always R/O pregancy
in women w amenorrhea FIRST PRL TSH N E2
T2 N MRI PRL > 200 ng/mL only 5% progress
to macroadenomas Bromocriptine dopamine agonist SURGERY with serial MRI f/u LH
FSH
hCG BROMO & SURGERY
Periodic P4 & GnRH pump Tx HYPOTHALAMUS PITUITARY KLEINFELTERS Dx key features Tx lactotrophs TRH DOPAMINE R/O hypothyroid
R/O PCOS always R/O pregancy
in women w amenorrhea FIRST PRL TSH N E2
T2 N MRI Bromocriptine dopamine agonist SURGERY with serial MRI f/u TURNERS Dx key features Tx lactotrophs TRH DOPAMINE R/O hypothyroid
R/O PCOS always R/O pregancy
in women w amenorrhea FIRST PRL TSH N E2
T2 N MRI Bromocriptine dopamine agonist SURGERY with serial MRI f/u N karyotype LH, FSH, hCG premature ovarian failure Idiopathic
Injury
viral infxn
radiation
chemo
resistant ovary
autoimmune partial loss of FSH receptors
with normal ovary on imaging assess baseline hormones PRL
P4
E2 / T2
LH & FSH dynamic testing DIRECT:
INDIRECT: GnRH stim
measure LH TRH stim
measure TSH imaging APPROACH Precocious
Puberty thelarche < 8 GH
LH
FSH Continuous administration
LHRH and GnRH agonists Tx surgery if tumour favourable
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