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Approach to endocrine disorders
- 2. ENDOCRINE HISTORY PRESENTING SYMPTOMS: 1.Polyuria and Polydipsia Seen in: Diabetes mellitus Diabetes insipidus: Both Cranial Diabetes insipidus and Nephrogenic Diabetes insipidus Thyrotoxicosis Hypoparathyroidism Conn’s syndrome
- 3. 2.Weight loss Hyperthyroidism Addison’s disease Anorexia nervosa Type 1 Diabetes mellitus 3.Weight gain Hypothyroidism Cushing’s syndrome Polycystic ovarian disease
- 4. 4.Muscle weakness Hyperthyroidism Cushing syndrome Osteomalacia 5.Temperature intolerence Cold intolerance:Hypothyroidism Heat intolerance:Hyperthyroididsm 6.Excessive sweating Hyperthyroidism Hypoglycemia Pheochromacytoma:Paroxysmal sweating Acromegaly:Increased size of sweat gland
- 5. 7.Tremor Hyperthyroidism Hypoglycemia 8.Ocular symptoms Exophthalmos:Grave’s disease Visual disturbance:Pituitary tumor Ptosis:Myasthenia with thyrotoxicosis Puffy eyelid:Myxoedema Periorbital oedema:Grave’s disease 9.Palpitation Thyrotoxicosis Pheochromacytoma Hypoglycemia
- 6. 10.Gynecomastia Klinefelter’s syndrome Estrogen producing tumors of testes 11.Galactorrhea Idiopathic:increased sensitivity to normal prolactin-Prolactinoma Hypothyroidism Acromegaly Premature thelarche 12.Amenorrhoea Primary:Hypothyroidism,Turner’s syndrome,Autoimmune ovarian failure Secondary:Prolactinoma,Cushing’s syndrome,PCOD
- 7. Other symptoms: Impotence: Testosterone deficieny,Diabetes mellitus Hirsuitism:PCOD,Congenital adrenal hyperplasia, Androgen secreting ovarian and adrenal tumours Paresthesia:Neuropathy of diabetes mellitus, Entrapment neuropathy of hypothyroidism and acromegaly Muscle cramps:Hypocalcemia, hypoparathyroidism
- 9. 1.Thyroid diseases The most common presentations are Thyrotoxicosis,hypothyroidism and enlargement of thyroid gland. Most common symptoms and signs of : 1.THYROTOXICOSIS Symptoms: Weight loss despite normal or increased appetite Heat intolerance Palpitations
- 10. Dyspnoea Irritability, Emotional lability Fatigue Sweating Tremor Signs: Palmar erythema Sinus tachycardia Lid retraction, Lid lag Tremor Weight loss
- 11. INVESTIGATIONS First line investigations are serum T3,T4 and TSH In most patients T3 and T4 are elevated Serum TSH is undetectable in Primary thyrotoxicosis When biochemical thyrotoxicosis is confirmed further investigations are done to identify the underlying cause, like measurement of TR Ab- elevated in Grave’s disease and isotope scanning An ECG may demonstrate Sinus tachycardia or Atrial fibrillation Radio-iodine uptake tests
- 12. MANAGEMENT Definitive treatment depends upon underlying cause Anti-thyroid drugs, Radioactive iodine or surgery A non-selective beta-blocker like Propranalol or Nadolol may alleviate but not abolish symptoms in most patients within 24-48 hrs Beta blockers should not be used for long term treatment in thyrotoxicosis
- 13. 2.HYPOTHYROIDISM Symptoms: Weight gain Cold intolerance Fatigue, Somnolence Dry skin Dry hair Hemorrhagia Signs: Weight gain
- 14. INVESTIGATIONS Primary hypothyroidism: Serum T4 is low and TSH elevated Serum T3 measurements are unhelpful since they do not discriminate between Euthyroidism and Hypothyroidism ECG:Sinus bradycardia with low voltage complexes and ST segment and T wave abnormalities MANAGEMENT Thyroxine replacement
- 15. Autoimmune thyroid diseases 1.GRAVE’S DISEASE Most commonly seen in women of 30 -50 years Other than common symptoms and signs of thyrotoxicosis other features are: ❑ Ophthalmopathy ❑ Periorbital oedema ❑ Conjuctival irritation ❑ Exophthalmos and diplopia ❑ Pretibial myxoedema
- 17. 2.HASHIMOTO’S THYROIDITIS Characterized by destructive lymphoid infiltration of thyroid, leading to a varying degree of fibrosis and thyroid enlargement Presented with: small or moderately sized diffuse goitre –which is firm or rubbery in consistency Around 25% are presented with hypothyroidism rest of which having T4 normal and TSH elevated or normal develops overt hypothyroidism in future years Antithyroid peroxidase Ab present in serum,in more than 90% cases.<20yrs ANF may also +ve. Treatment:Thyroxine therapy and also shrink an associated goitre
- 18. Transient thyroiditis Subacute thyroiditis Postpartum thyroiditis Simple and multi nodular goitres Thyroid neoplasia Toxic adenoma Differentiated carcinoma Medullary carcinoma Congenital thyroid disease Dyshormonogenesis Thyroid hormone resistance
- 19. Reproductive diseases Presenting problems: Delayed puberty Amenorrhoea Male hypogonadism Infertility Gynaecomastia Hirsuitism
- 20. POLYCYSTIC OVARIAN SYNDROME Features: MECHANISMS MANIFESTATIONS Pituitary dysfunction High serum LH High serum Prolactin Anovulatory menstrual cycles Oligomenorrhoea Secondary amenorrhoea Cystic ovaries Infertility Androgen excess Hirsuitism Acne Obesity Hyperglycemia Elevated estrogens Insulin resistance Dyslipidemia Hypertension
- 21. Management Reduce weight For menstrual irregularity and infertility: ❑ Metformin by reducing insulin resistance, may restore regular ovulatory cycles in obese women though less effective than clomifene at restoring fertility ❑ Thiazolidinediones also increase insulin sensitivity and restore menstrual regularity but C/I in pregnancy ❑ Progestogens or Progestogen-impregnated intrauterine coil
- 23. DIAGNOSIS AND TREATMENT Confirmed by karyotype analysis Short stature: Responds to high doses of Growth hormone Prophylactic gonadectomy for 45X0/46XY mosaicism due to increased risk of gonadoblastoma Pubertal development induced by estrogen therapy-but may result in fusion of epiphysis and cessation of growth Long term estrogen therapy should be monitored periodically for aortic root dilatation, hearing loss and other somatic complications
- 25. PARATHYROID DISEASES Presenting problems: Hypercalemia Hypocalcemia PRIMARY HYPERPARATHYROIDISM Caused by autonomous secretion of PTH leading to hypercalcemia Clinical features: ❑ Symptoms and signs of hypercalcemia include polyuria,polydipsia,renal colic, lethargy, anorexia, nausea, dyspepsia and peptic ulceration,constipation,depression,drowsiness and impaired cognition
- 26. ❑ Classical symptoms are described by adage bones, stones and abdominal groans. ❑ 50% are asymptomatic and many have non- specific symptoms ❑ In others symptoms are unrecognised till presented with renal calculi ❑ Hypertension is common INVESTIGATIONS: ▪ Raised PTH and hypercalcemia ▪ Ultrasound examination can be performed prior to surgery to localise adenoma
- 27. MANAGEMENT: Surgery with excision of a solitary parathyroid adenoma or hyperplastic glands Patients with vague symptoms are only to be reviewed every 6-12 months to assess symptoms, serum calcium levels and renal function, and undergo DEXA scans periodically They are encouraged to maintain high oral fluid intake to avoid renal stones When presented with severe life threatening hypercalcemia managed with IV fluids and bisphosphonates,if not effective urgent parathyroidectomy.
- 29. INVESTIGATIONS
- 30. MANAGEMENT Untreated Cushing’s syndrome has a 50% 5-year mortality Most patients are treated surgically with medical therapy given for a few weeks prior to operation. Metyrapone and Ketoconazole are used to inhibit corticosteroid biosynthesis.
- 31. ENDOCRINE PANCREAS DISEASE DIABETES MELLITUS Type 1 diabetes Immune mediated Idiopathic T cell mediated autoimmune disease involving destruction of the insulin secreting beta cells in the pancreatic islets which takes place over many years. Hyperglycaemia accompanied by classical symptoms of diabetes occurs only when 70-90% of beta cells have been destroyed.
- 32. Type 2 diabetes There is combination of resistance to the actions of insulin in the liver and muscle together with impaired pancreatic beta cell function leading to relative insulin deficiency Symptoms of Hyperglycaemia: ❑ Thirst, Dry mouth ❑ Polyuria ❑ Nocturia ❑ Tiredness,Fatigue,Lethargy
- 33. ❑ Noticeable change in weight(usually weight loss) ❑ Blurring of vision ❑ Nausea, Head ache ❑ Hyperphagia,Predilection of sweet foods ❑ Mood change,irritability,difficulty in concentrating, apathy INVESTIGATIONS Urine testing for • Glucose • Ketones • Protein
- 34. Blood testing for: ▪ Glucose ▪ Glycated haemoglobin MANAGEMENT: ▪ Dietary/life style modification ▪ Oral anti-diabetic drug ▪ Injected therapies - Insulin
- 35. HYPOTHALAMIC AND PITUITARY DISEASES CLINIAL FEATURES OF PITUITARY DISEASE
- 36. ACROMEGALY
- 37. INVESTIGATIONS: Clinical diagnosis confirmed by measuring GH levels during an oral glucose tolerance test. In 50% of patients there is paradoxical rise in GH Prolactin secretions are elevated in 30% cases. MANAGEMENT: Trans-sphenoidal surgery is usually the first line of treatment. External radiotherapy is usually second line treatment if acromegaly persists even after surgery. Medical therapy is the next choice if acromegaly persists even after surgery(Somatostatin analogues like octreotide and lanreotide).
- 38. THANK YOU