endocrinology the clinical basics dr anne dornhorst

Endocrinology The Clinical Basics

Dr Anne Dornhorst

Endocrinology- The Clinical BasicsThe Endocrine System

■ What it is

■ Why is it important

■ How it works

■ How can it go wrong

■ Why it goes wrong

■ How can we diagnosis problems

■ How we can put it right

The Endocrine Systemhttp://kidshealth.org/parent/general/body_basics/endocrine.html

■ …influence almost every cell, organ, and function of our bodies. The endocrine system is instrumental in regulating mood, growth and development, tissue function, and metabolism, as well as sexual function and reproductive processes

■ ……is in charge of body processes that happen slowly, such as cell growth. Faster processes like breathing and body movement are controlled by the nervous system

■ But even though the nervous system and endocrine system are separate systems, they often work together to help the body function properly

■ The hypothalamus is the primary link between the endocrine and nervous systems.

http://kidshealth.org/parent/general/body_basics/endocrine.html

Endocrinology- The Clinical Basics

■ A gland is a group of cells that produces and secretes, or gives off, chemicals (hormones).

■ Exocrine glands, - sweat and salivary glands, release secretions locally

■ Endocrine glands, release more than 20 major hormones directly into the bloodstream to cells in other parts of the body.



Endocrinology- The Clinical BasicsThe Classic Endocrine

System-■ Hypothalamus■ Pituitary

◆ Thyroid, Adrenal, Gonads

■ Parathyroids

■ Pancreas

Endocrinology- The Clinical BasicsThe New Endocrine System-■ Adipocyte

◆ leptin, adiponectin etc■ Heart

◆ ANP (atrial natriuretic hormone)

■ Gut◆ Incretins

Adipose tissue

The New Endocrine System- The Fat Cell

Leptin

Adiponectin Resistin

Angiotensinogen

IL-6

TNF-Alfa Cortisol

Stored Triglycerides

• Fat cells are continually absorbing or releasing substances in response to the body’s energy needs

• Fat cells are better adapted to preserving calories than shedding them

Source: Underwood A, Adler J, Hand K, Ulick J. What You Don’t Know About Fat. Newsweek. 2004;144:40-47.

Fat Cell


■ What it is √

■ Why is it important √

■ How it works


■ How can we test malfunction


Endocrinology- The Clinical BasicsThe Classic Endocrine

System-■ Hypothalamus■ Pituitary

◆ Thyroid, Adrenal, Gonads

■ Parathyroids

■ Pancreas

The Endocrine System: how it works-Classically Hierarchical


how it worksIt is Hierarchical■ Brain

◆ Neurotransmitters■ Hypothalamus

◆ GHRF, CRF, TRH■ Pituitary

◆ GH, ACTH, TSH, etc■ Endocrine gland

◆ Thyroid, adrenal etc■ Target tissue

◆ liver, muscle, etc


how it worksFeedback ■ Negative feedback:

◆ Circulating hormone✦ Hypothalamus✦ Pituitary


■ What it is √


■ How it works √




Endocrinology- The Clinical Basics

The Endocrine SystemHow can it go wrong■ Over - perform

■ Under-perform

■ Get too big

■ Benign adenoma◆ Malignant

Endocrinology- The Clinical BasicsThe Endocrine SystemHow can it go wrong■ Over - perform

◆ Hyperthyroidism

■ Under-perform◆ Hypothyroidism

■ Gland can get too big◆ Goitre

■ Become Adenoma◆ Carcinoma

Endocrinology- The Clinical BasicsThe Endocrine SystemHow can it go wrong■ Over - perform

◆ Cushings ✦ Syndrome✦ Disease

■ Under-perform◆ Addison's

■ Adrenal Adenoma◆ Adrenal Carcinoma


How can it go wrong■ Over - perform

◆ Acromegaly

■ Under-perform◆ Dwarfism

■ Pituitary Adenoma

■ Get too big◆ Field defects


■ What it is √


■ How it works √

■ How can it go wrong √

◆ Why does it go wrong



Endocrinology- The Clinical BasicsThe Endocrine SystemWhy does it go wrong

■ Prone to adenomas ◆ Glandular tissues

■ Prone to autoimmune disease◆ Hypothyroidism, Addison's,

diabetes

■ Gene mutationsreceptor, signaling pathway

Endocrinology- The Clinical BasicsThe Endocrine SystemHow can we diagnosis

endocrine problems■ Think about it■ Common things are

common■ Ask leading questions

◆ ? Euthyroid◆ ? Euadrenal◆ ?Eugonadal

Physical Examination■ Too tall■ Too short■ Too fat■ Too thin■ Too young looking■ Too dark■ Too pale ■ Too hairy■ Hairless

Endocrinology- The Clinical BasicsCommon problem■ Thyroid disease

■ Adrenal disease

■ Pituitary disease

Clinical ManifestationsHyperthyroidism (Graves’ Disease)

Symptoms■ Weight loss

◆ Good appetite■ Palpitations■ Anxiety

◆ Poor sleep◆ Hot and bothered

■ Bowel frequency ■ Muscle weakness■ Eye signs


History■ Family history

◆ Autoimmune ✦ Hypothyroid✦ Diabetes/ B12/Coeliac

■ Signs◆ Smooth enlarged thyroid◆ Tachycardia◆ Clammy hands◆ Brisk reflexes◆ Myopathy◆ Eye signs


Diagnosis■ Think physiology

◆ Think feedback✦ Think pathology

Diagnostic tests■ Thyroid function test

◆ T4/T3, TSH■ Immunology

◆ Thyroid antibodies✦ Thyroid peroxidase antibodies✦ TSH receptor antibodies

■ Imaging◆ Thyroid uptake scan





◆ T4/T3, ⇑◆ TSH ⇓ (suppressed)

■ Immunology◆ Thyroid antibodies

✦ Thyroid peroxidase antibodies +ve✦ TSH receptor antibodies +ve

■ Imaging◆ Thyroid uptake scan ⇑

TreatmentHyperthyroidism (Graves’ Disease)

Pills■ Thiouricils

◆ Carbimazole◆ Propylthiouricil

Radiotherapy■ RAI

◆ Ablate

Surgery

Clinical ManifestationsHypothyroidism

Symptoms

■ Weight gain■ Tiredness■ Depression■ Constipation ■ Muscle aches■ Dry skin


History■ Family history

◆ Autoimmune ✦ Hypothyroid✦ Diabetes/ B12/Coeliac

■ Signs◆ Thyroid

✦ Usually not palpable◆ Bradycardia◆ Dry skin ◆ Slow reflexes◆ Muscle stiffness◆ Puffiness

Clinical ManifestationsHyporthyroidism




◆ T4/T3, TSH■ Immunology

◆ Thyroid antibodies✦ Thyroid peroxidase antibodies✦ TSH receptor antibodies

■ Imaging◆ Not usually indicated





◆ T4/T3, ⇓◆ TSH ⇑ (increased)

■ Immunology◆ Thyroid antibodies

✦ Thyroid peroxidase antibodies +ve✦ TSH receptor antibodies (usually -ve)

TreatmentHypothyroidism

L-thyroxine for lifeT4

Clinical ManifestationsNodule/goitre

Symptoms■ Breathing■ Swallowing

■ Signs◆ Tracheal compression◆ Hoarse◆ Dilated veins

Clinical ManifestationsNodule/goitre



• Anatomy


◆ T4/T3- usually normal◆ TSH- usually normal

■ Imaging◆ MRI/CT

■ Fine needle aspirate

Clinical ManifestationsHyperadrenalism

■ Cortex◆ Zona glomerulosa

✦ Aldosterone◆ Zona fasciculata

✦ Cortisol◆ Zona reticularis

✦ Sex steroids■ Medulla

◆ sympathetic neurons✦ Noradrenaline

Clinical ManifestationsHyperadrenalism

■ Cortex◆ Zona glomerulosa

✦ Aldosterone ✦ CONN’S SYNDROME

◆ Zona fasciculata✦ Cortisol✦ CUSHINGS SYNDROME

◆ Zona reticularis✦ Sex steroids✦ VIRILIZATION SYNDROME

■ Medulla◆ sympathetic neurons

✦ Noradrenaline✦ PHEOCHROMOCYTOMA

Clinical ManifestationsHyperadrenalism (Cushing’s Syndrome)

Symptoms

■ Weight gain◆ Central obesity

■ Depression ■ Poor sleep■ Bruising ■ Proximal muscle weakness■ Purple striae■ Amenorrhea■ Diabetes / Hypertension

Clinical ManifestationsHyperadrenalism (Cushing’s Syndrome)

History■ 1-2 yrs

◆ Weight gain/ bruising ■ Signs

◆ Truncal obesity◆ Proximal myopathy◆ Purple striae

Hyperadrenalism (Cushing’s Syndrome ■ The big question

◆ Is this pituitary Cushing's?✦ Pituitary adenoma

◆ Is it Adrenal Cushing’s?✦ Adrenal adenoma

• Adrenal carcinoma

◆ Ectopic Cushing’s?✦ Tumour production of ACTH

Hyperadrenalism (Cushing’s Syndrome Diagnosis

■ Think physiology◆ Think feedback

✦ Think pathology

Diagnostic tests◆ Urinary free cortisol◆ ACTH◆ Cortisol◆ Dexamethasone suppression

tests■ Imaging

◆ MRI pituitary/adrenal■ Sampling

◆ Petrosal / adrenal

Hyperadrenalism (Cushing’s Syndrome Treatemnt

■ Pituitary◆ Pituitary surgery

◆ Bilateral adrenalectomy

■ Adrenal◆ Unilateral adrenalectomy

✦ Key hole

Clinical ManifestationsHypo-adrenalism (Addison’s)

History■ 2-5yrs

◆ Tiredness◆ Nausea◆ Pigmentation◆ Weight loss◆ Faint

■ Signs◆ Pigmentation◆ Postural hypotension

■ Diagnosis◆ ACTH /Cortisol◆ Synthactin test

■ Treatment◆ Hydrocortison◆ Mineraldcortisone

Clinical ManifestationsAcromegaly

History■ 5-10 yrs

◆ Headaches◆ Change in hand / face

■ Signs◆ Jaw increase bite

malocclusion ◆ Large nose, jaw, feet

and hands◆ Proximal myopathy◆ Visual field defect

✦ bilateral hemianopia


Bilateral hemianopiaTunnel vision




Diagnostic tests■ Growth hormone

◆ OGTT◆ OGTT suppression tests

■ Imaging◆ MRI pituitary

■ Sampling◆ Petrosal

TreatemntAcromegaly

■ Surgery

■ Dopamine agonist◆cabergaline◆bromocriptine

Prolactinoma

■ Symptoms◆ Amenorrhea◆ Loss of libido

■ Depends on size◆ Macro >10mm◆ Micro < 10mm

Prolactinoma

Treatment■ Depends on size

◆ Macro >10mm✦ Dopamine agonist✦ Surgery

◆ Micro < 10mm✦ Dopamine agonist

• cabergaline• bromocriptine

Hypopituritism■ Anterior pituitary

◆ Secondary endocrine failure

✦ Thyroid / adrenal / gonadal failure

■ Posterior pituitary◆ Diabetes insipidus (DI)

Hypopituritism■ Symptoms

◆ Hypothyroid◆ Hypoadrenal◆ Hypogodanal


Hypopituritism■ Daignosis

◆ Anterior pituitary✦ Stimulation✦ Insulin tolerance test


✦ Water deprevation

Physical Examination■ Too tall■ Too short■ Too fat■ Too thin■ Too young looking■ Too dark■ Too pale ■ Too hairy■ Hairless

Other things you should know about: Hyperparathyroidism

Hyperparathyroidism■ High calcium, low

phosphate, high PTH■ Common■ Symptoms

✦ Constipation, polyurea, polydipsia, depression

■ Treatment✦ surgery

Other things you should know:Pheochromocytoma

Pheochromocytoma Rare■ Symptoms

✦ Paraxismal✦ Anxiety✦ BP✦ Pallor / sweating

■ Diagnosis◆ Urinary catocholamines

■ Treatment◆ surgery


■ What it is

■ Why is it important

■ How it works


■ Why it goes wrong

■ How can we diagnosis problems



■ Keep it simple

■ Think of it

■ Ask leading questions

■ Think physiology and anatomy

endocrinology the clinical basics dr anne dornhorst

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