Clind #2 (adrenal Disease Pituitary – Flashcards
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What is the difference between Cushing disease and Cushing syndrome?
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Cushing disease - anterior pituitary produces too much ACTH Cushing syndrome - excess cortisol in the body that is coming from another source besides the pituitary
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What is the most important human glucocorticoid? What is the major function of cortisol?
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Cortisol It's main function is to raise blood glucose levels in the body in times of stress
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What hormone is released from the hypothalamus in order to stimulate the anterior pituitary to simulate the adrenal glands to secrete cortisol?
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CRH
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What hormone is released from the anterior pituitary in order for the adrenal cortex to secrete cortisol?
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ACTH
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What occurs to cortisol levels in Addison's disease? What occurs to aldosterone levels in Addison's disease? What occurs to ACTH levels in Addison's disease?
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Cortisol levels decrease Aldosterone levels decrease ACTH levels increase
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What etiology constitutes almost 80% of the known cases of Addison's disease? What is a possible pathological etiology for Addison's disease?
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Autoimmune TB
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What gender is most impacted by Addison's disease?
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Females
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What are three classic physical exam findings for Addison's disease?
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1. Darkening of the skin 2. Longitudinal bands on nail beds 3. Absence of axillary and pubic hair
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The diagnoses of any adrenal insufficiency of any cause depends entirely upon what?
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The demonstration of inappropriately low cortisol production
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When is the best time to measure serum cortisol concentration?
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In the morning
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Why do patients that have Addison's disease experience hyponatremia, hyperkalemia, and metabolic acidosis?
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Because less adrenal gland activity means less aldosterone, which means less sodium is reabsorbed in the nephron, and more potassium and hydrogen ions stay in the blood
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Why will patient's who have Addison's disease many times experience an increase in BUN and creatinine?
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Because the decrease in sodium will lead to hypovolemia and the kidneys will not receive as much blood
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What is the main treatment method for Addison's disease?
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Hydrocortisone
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In Addison disease patients, what must be done, in regards to the hydrocortisone treatment, when the patient has increased stress, infection, trauma, or surgery?
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The hydrocortisone dose must be increased whenever they experience one of these circumstances
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Although most patients with Addison's disease will more than likely have a normal life expectancy if they are compliant with their medications, what will they more than likely experience for the rest of their lives?
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Chronic fatigue
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What is an emergent issue that may result from an issue with the adrenal glands?
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Acute adrenal crisis
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What is the treatment for acute adrenal crisis?
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1. Dexamethasone and IV saline 2. Cover with broad spectrum abx since many times due to an infection 3. Treat and monitor hypoglycemia, electrolytes, and kidney function
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What is the disease process that is due to excessive corticosteroid production?
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Cushing syndrome
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What are three classic signs of Cushing syndrome?
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1. Violaceous adominal striae 2. Moon face 3. Buffalo hump
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What is the gold standard for the treatment of Cushing syndrome? If this test is abnormal then what is conducted?
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Overnight dexamethsone suppression test 24 hour urine for free cortisol
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What is the etiology of Cushing syndrome and Cushing disease?
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Cushing syndrome - something other than the pituary gland is causing an increase in glucocorticoids, such as prednisone Cushing disease - an issue with the pituitary gland is causing an increase of glucocorticoids
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What treamtent option is curative for virtually all patients with Cushing syndrome that is secondary to an issue with the adrenal glands, such as a tumor?
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Unilateral adrenelectomy
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What is a rare adrenal medulla catecholamine secreting tumor?
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Pheocromocytoma
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Why is it difficult to diagnose a pheocromocytoma by monitoring epinephrine and norepinephrine levels?
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Because the tumor does not secrete these catecholamines consistently
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How are most pheocromocytomas discovered?
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Incidental finding on imaging
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What is the classic triad of symptoms of patients that have symptoms from a pheochromocytoma? Half of these patients will experience what other additional symptom?
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1. Episodic cephalgia 2. Diaphoresis 3. Tachycardia HTN
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What is the standard outpatient treatment for patients that have a pheochromocytoma?
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Alpha and beta blockers
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What is the definitive treatment for patients that have a pheochromocytoma?
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Surgery
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What kind of dietary instruction are patients given before having a pheocromocytoma surgically removed?
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Patients are instructed to have a very high sodium diet to increase their blood pressure so that they do not become hypotensive following surgery
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What is a medication that has been used for the treatment of pheocromocytomas? What is the MOA of this medication?
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Metyrosine It inhibits the sythesis of catecholamines
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From what portion of the pituitary gland is growth hormone secreted?
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Anterior pituitary
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What are the cells called that synthesize growth hormone?
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Somatotropin cells
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What is the hormone from the hypothalamus that begins the production of growth hormone by the somatotropin cells in the anterior pituitary? What is the hormone that inhibits its production? Give both names. What is another hormone that is produced by the liver and is a potent growth and differentiation factor that is stimulated by GH?
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GHRH GHIH (somatostatin) IGF-1
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Although GH release is mostly pulsatile, when is the most GH released?
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At night when the body is sleeping
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What is the typical treatment of children with growth hormone insufficiency?
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Daily shots of recombinant growth hormone
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What is the most common bone dysplasia in humans?
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Achondroplasia
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Are adults that are suspected to have a growth hormone insufficiency tested and/or treated any differently from children?
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No
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What is the name of the disease in adults, as well as the associated name in children, for excess growth hormone?
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Adults - acromegaly Children - Gigantism
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What is the treatment of choice if there is excess growth hormone that is secondary to a microadenoma of the anterior pituitary?
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Surgery
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What is a medication that can be used to inhibit the production of the GH? Give both generic and brand names.
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Octreotide (somatostatin)
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What is the hormone that is secreted by the hypothalamus to the anterior pituitary for the release of TSH?
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TRH
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What organ is affected in primary thyroid issues?
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Thyroid gland
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What organ is affected in secondary thyroid issues?
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Pituitary
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What organ is affected in tertiary thyroid issues?
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Hypothalamus
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What are the cells in the anterior pituitary that produce TSH?
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Thyrotroph
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What is the least common cell type in the anterior pituitary?
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Thyrotroph
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Are pituary adenomas a common cause of hyperthyroidism?
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No
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What are four symptoms that may present in patients that have a TSH secreting pituitary adenoma?
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1. Hyperthyroid symptoms 2. Diffuse goiter 3. Visual field deficits 4. Headache
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How is the diagnoses of a TSH-secreting pituitary adenoma made?
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High TSH High T4 High T3 MRI
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What are the two treatment methods for the treamtent of TSH-secreting pituitary adenoma?
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Somatostatin analog and/or surgery
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What are the three possible etiologies of central hypothyroidism?
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1. Disorder of the pituitary gland 2. Disorder of the hypothalamus 3. Disorder of the hypothalamic-pituitary portal circulation
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What are the treatment options for central hypothyroidism?
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Surgery and/or levothyroxine
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What disease is associated with excess ACTH?
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Cushing disease
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Although ACTH insufficiency will have almost all of the same symptoms as Addison's disease, what is the the key difference?
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ACTH insufficiency will not have skin changes
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What is the name of the cell in the anterior pituitary that are responsible for the production of ACTH?
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Corticoptroph cells
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Is FSH and LH excess very clinically significant? Why or why not?
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No Because the gonadotroph adenoma is poorly differentiated and secrete hormone ineffectivly
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What is the most common pituitary macoadenoma?
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Gonadotroph adenomas
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What cells in anterior pituitary are responsible for prolactin production?
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Lactotrophs
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Why does the anterior pituitary double in size during pregnancy?
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Because the elevated estrogen levels cause the lactotrophs to proliferate
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Should surgery be considered in the treatment of hyperprolactinemia?
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No
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What treatment method should be consider for hyerprolactinemia?
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Dopamine agonists
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What is the only clinical consequence of hypoprolactinemia?
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Inability to lactate after birth
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What is the main hormone that we discussed that is synthesized in the hypothalamus, and is stored and released from the posterior pituitar?
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ADH
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What will the osmoreceptors in the hypothalamus detect that will cause the posterior pituitary to release ADH?
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It will detect an increase in osmolarity due to an increase in blood sodium levels
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Where in the nephron does ADH work and what structures will it activate in order for water to leave the urine?
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It will act on the collecting duct and will open aquaporins so that water will leave the collecting duct and enter the blood stream
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What occurs to the concentration of urine with an increase in ADH?
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The concentration of the urine will increase
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What is the condition known as when there is an abnormal, and potentially life-threatening amount of ADH?
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SIADH
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What kind of hyponatremia is associated with SIADH?
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Dilutional hyponatremia
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What are the five signs of symptoms of SIADH?
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1. Very concentrated urine 2. Cerbreal edema 3. Irritability 4. Seizure 5. Coma
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What is a common cause of SIADH in terms of tumors?
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Small cell lung cancer
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What are the three treatment options for SIADH?
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1. Treat underlying issue 2. 3% normal saline 3. Water retention
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What is the disease process that is impaired water absorption due to failure in the ADH axis?
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Diabetes insipidus
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What are three typical signs of diabetes insipidus?
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1. Polyuria 2. Polydipsia 3. Nocturia
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How much dilute polyuria must be present in order to help confirm the presence of DI?
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> 3 L/day
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How is the diagnosis of DI made?
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Deprive fluids for 8 hours If >3% body weight lost and serum osmolarity > 300mOsm/kg, then you have DI
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What are the two different types of DI?
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Central Nephrogenic
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When testing to see if the patient has DI, what can be done to determine if DI is central or nephrogenic?
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Give ADH injection If urine osmolarity increases to > 600 mOsm/kg then we know that DI is central
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Will central (neurogenic) DI respond to ADH treatment?
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Yes
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Will nephrogenic DI respond to DH treatment?
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No
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What is another name for ADH?
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Vasopressin
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What is the most common type of DI?
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Central (neurogenic)
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What is the fraction of thyroid nodules are clincally identified are malignant?
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1/20
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What should be done with any nodule that is over 1 cm in size per ultrasound?
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Bx
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Does nodule size predict malignancy?
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No
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In which gender are thyroid nodules more common?
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Females
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If the thyroid nodule has a halo appearance does this indicate many times that the nodule is most likely malignant or benign?
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Benign
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What are two ultrasound findings that often indicate that a thyroid nodule is malignant?
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Microcalcifications and hypervascularity
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Does the amount of thyroid nodules that are present raise the risk of possible malignancy over just having a solitary nodule?
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No
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Which type of nodules are more likely to be cancerous; cystic or solid?
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Solid
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What is the usual way to have a thyroid nodule biopsied?
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FNA
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How many classification parameters are part of the Bethesda Classification System for thyroid diagnosis?
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Six
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What do Bethesda 1 and Bethesda 2 classifications mean in regards to thyroid nodules?
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Nondiagnostic and benign
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What does the Bethesda Classification note about Bethesda 3?
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AUS (atypical undetermined significance)
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What does the Bethesda Classification note about Bethesda 4?
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Folllicular neoplasm
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What do Bethesda Classification note about Bethesda 5 and 6?
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Suspicion of malignancy and cancer
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Which Bethesda Classification are considered indeterminate?
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Bethesda 3 and 4
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What two types of cancers are looked at in the Bethesda Classification System?
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Papillary and follicular thyroid cancers
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What is the nerve that innervates the vocal cords and could be damaged during thyroid surgery?
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Recurrent laryngeal nerve
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Under what age is there very little mortality from thyroid cancer?
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Under the age of 45
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After how many months should radioioddine scanning be performed status post a radioactive iodine ablation?
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6-12 months
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What protein can be routinely monitored once a thyroidectomy has occurred in order to ensure that there is no new thyroid cancer?
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Thyroglobulin
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What possible malignancy may be present if the patient feels like their thyroid is enlarging, but there are no nodules noted?
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Thyroid lymphoma
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What is a rare calcitonin producing thyroid cancer that involves the parafollicular C cells of the thyroid gland?
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Medullary
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While most thyroid cancers are not aggressive, what is the most aggressive thyroid cancer, and is also the most aggressive of all cancers?
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Anaplastic
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In what age group does anaplastic thyroid cancer impact the most?
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The elderly
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Why are two anti-thyroid medications that can be used to treat hyperthyroidism and issues like Graves' disease?
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Methimazole Propylthiouracil (PTU)
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Between the two anti-thyroid medications that we studied for the treatment of hyperthyroidism, which is not considered to be first line?
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PTU
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Although anti-thyroid medications are shown to be effective at treating hyperthyroidism, what is the preferred treatment in the US for hyperthyroidism?
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Radioactive iodine
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How is hyperparathyroidism diagnosed, and how it is not diagnosed?
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Hyperparathyroidism is diagnosed by biochemistry, and it is not diagnosed by way of imaging
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What is the most common complaint secondary to hyperparathyroidism?
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Fatigue / lethargy
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What pathology is responsible for 85% of the cases of hyperparathyroidism? What are the other two parathyroid pathologies that constitute the rest of the parathyroid issues that we discused in class?
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Parathyroid adenoma Parathyroid hyperplasia Parathyroid cancer
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What is a nuclear medicine test that is used to help diagnose the location of a parathyroid adenoma?
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Sestamibi parathryoid scintigraphy
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Which of the thyroid pathologies that we discussed is the most common cause of recurrent hypercalemia?
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Parathyroid hyperplasia
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What is the considered the gold standard for the treatment of hyperparathyroidism?
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Surgery
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Define primary and secondary hyperparathyroidism and state what makes them different.
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Primary - parathyroid gland(s) secrete too much PTH d/t abnormal growth of the gland Secondary - parathyroid gland(s) secrete too much PTH d/t low serum calcium levels cause by another pathological issue
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What is a gross deformity that can accompany patients that have soft tissue calcification due to secondary hyperparathyroidism?
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Soft tissue calcification
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What is an adrenal incidentaloma?
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An adrenal mass that is found while looking for something else on imaging
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What percentage of adrenal nodules are metastatic disease if an extra adrenal malignancy is present?
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Approximately 75%
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Why does primary hyperaldosteronism cause cardiovascular complications?
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Because the increased amount of aldosterone will cause increased fluid reabsoption and vasoconstriction, which is will increase the workload of the heart and lead to CV disease
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What occurs to renin levels during primary hyperaldosteronism?
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Renin levels decrease
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What is the procedure that can be performed in order to measure aldosterone and cortisol levels in the blood?
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Selective venous sampling
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What is usually noted in the blood work of a patient that has a pheochromocytoma?
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Free metanephrines
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In order of the most common to the least common, list the four types of thyroid cancers.
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Papillary Follicular Medullary Anaplastic
