endocrinology the clinical basics dr anne dornhorst
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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.
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.
http://kidshealth.org/parent/general/body_basics/endocrine.html
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
Endocrinology- The Clinical BasicsThe Endocrine System
■ What it is √
■ Why is it important √
■ How it works
■ How can it go wrong
■ How can we test malfunction
■ How we can put it right
Endocrinology- The Clinical BasicsThe Classic Endocrine
System-■ Hypothalamus■ Pituitary
◆ Thyroid, Adrenal, Gonads
■ Parathyroids
■ Pancreas
Endocrinology- The Clinical BasicsThe Endocrine System
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
Endocrinology- The Clinical BasicsThe Endocrine System
how it worksFeedback ■ Negative feedback:
◆ Circulating hormone✦ Hypothalamus✦ Pituitary
Endocrinology- The Clinical BasicsThe Endocrine System
how it worksFeedback ■ Negative feedback:
◆ Circulating hormone✦ Hypothalamus✦ Pituitary
Endocrinology- The Clinical BasicsThe Endocrine System
■ What it is √
■ Why is it important √
■ How it works √
■ How can it go wrong
■ How can we test malfunction
■ How we can put it right
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
Endocrinology- The Clinical BasicsThe Endocrine System
How can it go wrong■ Over - perform
◆ Acromegaly
■ Under-perform◆ Dwarfism
■ Pituitary Adenoma
■ Get too big◆ Field defects
Endocrinology- The Clinical BasicsThe Endocrine System
■ What it is √
■ Why is it important √
■ How it works √
■ How can it go wrong √
◆ Why does it go wrong
■ How can we test malfunction
■ How we can put it right
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
Clinical ManifestationsHyperthyroidism (Graves’ Disease)
History■ Family history
◆ Autoimmune ✦ Hypothyroid✦ Diabetes/ B12/Coeliac
■ Signs◆ Smooth enlarged thyroid◆ Tachycardia◆ Clammy hands◆ Brisk reflexes◆ Myopathy◆ Eye signs
Clinical ManifestationsHyperthyroidism (Graves’ Disease)
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
Clinical ManifestationsHyperthyroidism (Graves’ Disease)
Diagnosis■ Think physiology
◆ Think feedback✦ Think pathology
Diagnostic tests■ Thyroid function test
◆ 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
Clinical ManifestationsHypothyroidism
History■ Family history
◆ Autoimmune ✦ Hypothyroid✦ Diabetes/ B12/Coeliac
■ Signs◆ Thyroid
✦ Usually not palpable◆ Bradycardia◆ Dry skin ◆ Slow reflexes◆ Muscle stiffness◆ Puffiness
Clinical ManifestationsHyporthyroidism
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◆ Not usually indicated
Clinical ManifestationsHypothyroidism
Diagnosis■ Think physiology
◆ Think feedback✦ Think pathology
Diagnostic tests■ Thyroid function test
◆ T4/T3, ⇓◆ TSH ⇑ (increased)
■ Immunology◆ Thyroid antibodies
✦ Thyroid peroxidase antibodies +ve✦ TSH receptor antibodies (usually -ve)
Clinical ManifestationsNodule/goitre
Symptoms■ Breathing■ Swallowing
■ Signs◆ Tracheal compression◆ Hoarse◆ Dilated veins
Clinical ManifestationsNodule/goitre
Diagnosis■ Think physiology
◆ Think feedback✦ Think pathology
• Anatomy
Diagnostic tests■ Thyroid function test
◆ 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
Clinical ManifestationsAcromegaly
Diagnosis■ Think physiology
◆ Think feedback✦ Think pathology
Diagnostic tests■ Growth hormone
◆ OGTT◆ OGTT suppression tests
■ Imaging◆ MRI pituitary
■ Sampling◆ Petrosal
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
■ Posterior pituitary◆ Diabetes insipidus (DI)
Hypopituritism■ Daignosis
◆ Anterior pituitary✦ Stimulation✦ Insulin tolerance test
■ Posterior pituitary◆ Diabetes insipidus (DI)
✦ 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
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
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