BIOS222 Pathology and Clinical Science 2 & 3

Transcription

1 BIOS222 Pathology and Clinical Science 2 & 3 Session 15 Endocrine system disorders 2 Bioscience Department

2 Session Learning Outcomes At the end of the session, you should be able to: o Describe the function and role of the adrenal glands o Describe the presentation, diagnosis and treatment of cortical hypofunction o Describe the presentation, diagnosis and treatment of cortical and medullary hyperfunction o Describe the clinical presentation of adrenal tumours o Outline the aetiology, clinical presentation, diagnosis and treatment of hypopituitarism o Detail the presentation and management of pituitary tumours, diabetes insipidus, acromegaly and hyperprolactinaemia Endeavour College of Natural Health 2

3 Session Plan o Adrenal disease: Overview of the adrenal glands Cortical Hypofunction: Adrenocortical insufficiency : Addison s disease Congenital adrenal hyperplasia Cortical Hyperfunction: Cushing s syndrome Primary Hyperaldosteronism Medullary Hyperfunction: Phaeochromocytoma Tumours of the Medulla Incidental adrenal mass Endeavour College of Natural Health 3

4 Session Plan o Hypothalamic and pituitary disease: Overview of the hypothalamus and pituitary gland Hypopituitarism Pituitary tumour Hyperprolactinaemia Acromegaly Diabetes insipidus Endeavour College of Natural Health 4

5 Overview of the Adrenal Glands Endeavour College of Natural Health 5

6 Adrenal Gland o Situated on the upper pole of each kidney o Cortex: Glucocorticoids Mineralocorticoids Androgens o Medulla: Adrenaline Noradrenaline Tortora, GJ & Derrickson, B 2014, Principles of anatomy and physiology, 14th edn, John Wiley & Sons, Hoboken, NJ. Endeavour College of Natural Health 6

7 Adrenal Gland: Structure and Function Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22 nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 7

8 Adrenal Diseases Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22 nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 8

9 Cortical Hypofunction: Endeavour College of Natural Health 9

10 Adrenocortical Insufficiency o Definition: It is an adrenal cortex hypo function resulting mainly due to inadequate secretion of cortisol and/or aldosterone. o Aetiology: Secondary ( ACTH) Withdrawal of suppressive glucocorticoid therapy Hypothalamic or pituitary disease Primary ( ACTH) Addison s disease Corticosteroid biosynthetic enzyme defects Congenital adrenal hyperplasias Drugs Endeavour College of Natural Health 10

11 Addison s disease o Definition: It is a primary adrenocortical insufficiency resulting from partial destruction of the adrenal cortex, leading to adrenal cortex hormone deficiencies. o Aetiology: Common causes: Autoimmune Tuberculosis HIV/AIDS Metastatic carcinoma Bilateral adrenalectomy Rare causes: o Lymphoma o Intra-adrenal haemorrhage o Amyloidosis o Haemochromatosis Endeavour College of Natural Health 11

12 Addison s disease Clinical Features: Glucocorticoid insufficiency Mineralocorticoid insufficiency ACTH excess Adrenal androgen insufficiency Weight loss, anorexia Malaise, weakness Nausea, vomiting Diarrhoea or constipation Postural hypotension Shock Hypoglycaemia Hyponatraemia (dilutional) Hypercalcaemia Hypotension Shock Hyponatraemia (depletional) Hyperkalaemia Pigmentation of: Sun-exposed areas Pressure areas (e.g. elbows, knees) Palmar creases, knuckles Mucous membranes Conjunctivae Recent scars Decreased body hair and loss of libido, especially in female Endeavour College of Natural Health 12

13 Addison s disease Grossman SC & Porth CM 2014, Porth s Pathophysiology- Concepts of Altered Health States, 9th edn. Wolters Kluwer Health - Lippincott, Williams & Wilkins Endeavour College of Natural Health 13

14 o Diagnosis: Addison s disease Random hormone assessment: Plasma cortisol, renin, aldosterone Short ACTH stimulation test Electrolyte measurements: Na+, K+ Adrenal autoantibodies Imaging of the adrenal glands HIV test Endeavour College of Natural Health 14

15 Addison s disease o Management: Glucocorticoid replacement therapy Mineralocorticoid therapy (not always) Adrenal androgen replacement (in women) Regular schedule for meals and exercise Medical alert bracelet o Complications: Adrenal crisis Vitiligo Endeavour College of Natural Health 15

16 Adrenal crisis o Definition: It is a life-threatening situation arising upon exposure to even a minor illness or stress if Addison s disease is the underlying problem in a person. o Clinical features: Nausea Vomiting Muscular weakness Hypotension Dehydration Vascular collapse Endeavour College of Natural Health 16

17 Adrenal crisis o Management: The five Ss of management: Salt replacement Sugar (dextrose) replacement Steroid replacement Support of physiologic functioning Search for and treat the underlying cause Glucocorticoid replacement Mineralocorticoid therapy Endeavour College of Natural Health 17

18 Congenital Adrenal Hyperplasia o Definition: It is a congenital disorder caused by an autosomal recessive trait leading to a deficiency of any of the enzymes necessary for the synthesis of cortisol. o Clinical features: Features of glucocorticoid and mineralocorticoid deficiency and androgen excess Features of cortisol insufficiency and/or ACTH and androgen excess o Management: Glucocorticoid replacement Anti-androgen therapy Endeavour College of Natural Health 18

19 Cortical Hyperfunction Endeavour College of Natural Health 19

20 Cushing s Syndrome o Definition: It refers to the manifestations of hypercortisolism from any cause. Aetiology: ACTH dependent Pituitary adenoma secreting ACTH Ectopic ACTH syndrome ACTH therapy Non-ACTH dependent Adrenal adenoma or carcinoma Iatrogenic (excess glucocorticoid therapy) Pseudo-Cushing s syndrome Alcohol excess Primary obesity Major depressive illness Endeavour College of Natural Health 20

21 Cushing s Syndrome o Clinical features: Moon face Thinning of hair Truncal obesity Acne Facial plethora Buffalo hump Hirsutism or thinning hair Blue-red striae Menstrual irregularities Poor wound healing Osteoporosis Hyperglycaemia Muscle wasting Bruising Psychosis Hyperpigmentation Fluid retention Endeavour College of Natural Health 21

22 Cushing s Syndrome Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22 nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 22

23 Cushing s Syndrome o Diagnosis: To establish Cushing s syndrome 24 hours urinary free cortisol low-dose/overnight dexamethasone suppression test Late-night salivary cortisol To define its cause Plasma ACTH Adrenal imaging with CT Pituitary MRI Corticotrophin-releasing hormone test high-dose dexamethasone suppression test CT/MRI thorax and abdomen Endeavour College of Natural Health 23

24 Cushing s Syndrome o Management: Transsphenoidal removal of a pituitary adenoma or a hemihypophysectomy Cortisol replacement therapy Pituitary radiation therapy Unilateral or bilateral adrenalectomy Surgical removal of ectopic ACTH-producing tumors Pharmacologic agents that block steroid synthesis Endeavour College of Natural Health 24

25 Primary Hyperaldosteronism o Definition: It is an intrinsic abnormality of adrenal glands resulting in aldosterone excess. o Aetiology: Adrenal adenoma secreting aldosterone (Conn s syndrome) Idiopathic bilateral adrenal hyperplasia Glucocorticoidsuppressible hyperaldosteronism (rare) o Clinical features: Usually asymptomatic Na+ retention or K+ loss Oedema Muscle weakness Polyuria Occasional tetany Endeavour College of Natural Health 25

26 Primary Hyperaldosteronism o Diagnosis: Random blood biochemistry: serum K+, Na+ Plasma renin and aldosterone Imaging: CT/MRI Adrenal adenoma: The tumour is canary yellow because of intracellular lipid accumulation. o Management: Mineralocorticoid receptor antagonists Unilateral adrenalectomy Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22 nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 26

27 Medullary Hyperfunction Endeavour College of Natural Health 27

28 Phaeochromocytoma o Definition: It is a Rare neuro-endocrine tumour that secrete catecholamines (adrenaline, noradrenaline). o Clinical features: Hypertension Paroxysms of: Pallor Palpitations, sweating Headache Anxiety Abdominal pain, vomiting Constipation Weight loss Glucose intolerance Endeavour College of Natural Health 28

29 Phaeochromocytoma o Diagnosis: Urinary catecholamines CT/MRI abdomen o Management: Surgery Radio/chemo therapy Endeavour College of Natural Health 29

30 Tumours of the Medulla Incidental adrenal mass Endeavour College of Natural Health 30

31 Neuroblastoma o Definition: It is a malignant tumour derived from the neruoblasts. It secretes dopamine and catecholamines. o Clinical features: Hutchinson s syndrome- bone metastasis with anaemia, limping and irritability due to bone pain Pepper s syndrome- liver with hepatomegaly Rapid enlargement of the abdomen Fatigue Loss of appetite Fever Joint pain o Management: Surgery Endeavour College of Natural Health 31

32 Incidental Adrenal Mass o Definition: It is a mass lesion found unexpectedly in an adrenal gland by an imaging procedure done for other reasons. o Clinical features: Most are asymptomatic Clinical signs and symptoms of Glucocorticoid excess Mineralcorticoid excess- Conn s syndrome Catecholamine excess Androgen excess in women o Diagnosis: MRI and CT scan o Management: Surgery Endeavour College of Natural Health 32

33 Overview of the Hypothalamus and Pituitary Gland Endeavour College of Natural Health 33

34 Pituitary Gland o Secretes many hormones: Human Growth hormone (hgh) Prolactin (PL) Adrenocorticotrophic hormone (ACTH) Thyroid-stimulating hormone (TSH) Follicle-stimulating hormone (FSH) Luteinizing hormone (LH) Melanocyte-stimulating hormone (MSH) Oxytocin (OT) from Posterior Pituitary Antidiuretic hormone (ADH) from Posterior Pituitary Tortora, GJ & Derrickson, B 2014, Principles of anatomy and physiology, 14th edn, John Wiley & Sons, Hoboken, NJ. Endeavour College of Natural Health 34

35 Hypothalamic - Pituitary Axis Anterior Pituitary cells Hormone from pituitary Regulatory hormone from hypothalamus Target organ Effect Somatotrophs hgh GHRH, GHIH Bones, muscles, liver, body Growth and development Lactotrophs PRL PRH, PIH Mammary Glands Thyrotrophs TSH TRH Thyroid Gland Corticotrophs MSH CRH Skin Pigmentation ACTH CRH Adrenal cortex Production of milk and lactation Release of thyroid hormones T3/T4 Release of corticoids Gonadotrophs FSH GnRH Gonads M: Sperm production and LH GnRH Gonads release of testosterone F: follicular development and release of oestrogen/ progesterone Endeavour College of Natural Health 35

36 Pituitary Diseases Endeavour College of Natural Health 36

37 Hypopituitarism o Definition: It describes combined deficiency of any of the anterior pituitary hormones. o Aetiology: Structural: Pituitary tumours Meningiomas Inflammatory: Sarcoidosis Haemochromatosis TB Congenital deficiencies: GNRH GHRH TRH CRH Functional: Chronic illness Excessive exercise. Endeavour College of Natural Health 37

38 Hypopituitarism o Clinical features: Growth hormone Lethargy Gonadotrophins Lethargy Loss of libido Hair loss Amenorrhoea ACTH Lethargy Postural hypotension Pallor Hair loss TSH Lethargy Vasopressin (ADH) (usually post-surgical) Thirst and polyuria Endeavour College of Natural Health 38

39 Hypopituitarism o Diagnosis: Tests to identify Pituitary hormone deficiency MRI or CT scan of brain Further investigations to exclude infectious or infiltrative causes Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22 nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 39

40 Hypopituitarism o Management: Acutely ill patients: Similar to adrenocortical insufficiency Chronic condition: Chronic hormone replacement Specific treatment for the underlying causes Endeavour College of Natural Health 40

41 Pituitary Tumours o Definition: Mass lesions found in or around the pituitary gland. o Clinical features: Headache Visual field defects Optic atrophy Acute-onset hypopituitarism Endeavour College of Natural Health 41

42 o Diagnosis: MRI and CT scan Biopsy Pituitary Tumours o Management: Surgery Radiotherapy Treat associated hypopituitarism Endeavour College of Natural Health 42

43 Hyperprolactinaemia o Definition: Hyperprolactinaemia is a common abnormality which usually presents with hypogonadism and/or galactorrhoea. o Aetiology: Physiological: Stress, Pregnancy, Exercise, A baby crying Drugs: Antipsychotics, Antidepressants, Dopamine depleting drugs Pathological: Primary hypothyroidsim, Pituritary tumours, Renal failure Endeavour College of Natural Health 43

44 o Clinical features: Women Hyperprolactinaemia Secondary amenorrhoea Anovulation Infertility Men Decreased libido Reduced shaving Lethargy Endeavour College of Natural Health 44

45 Hyperprolactinaemia o Diagnosis: Prolactin levels Gonad function tests T 4 and TSH levels o Management: Treat underlying cause Dopamine agonist therapy Endeavour College of Natural Health 45

46 Acromegaly o Definition: Acromegaly is caused by growth hormone (GH) secretion after the epiphyseal closure in adults from a pituitary tumour, usually a macroadenoma, and carries an approximate two-fold excess mortality when untreated. o Clinical features: Headache Sweating Features of pituitary tumours Coarse facial features Thick skin Enlarged organs Hypertension Cardiomyopathy Excessive sweating Endeavour College of Natural Health 46

47 Acromegaly Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22 nd edn, Churchill Livingstone Elsevier, Edinburgh Endeavour College of Natural Health 47

48 Acromegaly Images from: Tortora, GJ & Derrickson, B 2014, Principles of anatomy and physiology, 14th edn, John Wiley & Sons, Hoboken, NJ. Endeavour College of Natural Health 48

49 Acromegaly o Diagnosis: GH levels during oral glucose test Pituitary function tests Prolactin levels Colonoscopy for colonic neoplasms screening o Management: Surgery Radiotherapy Drugs to lower GH secretion Endeavour College of Natural Health 49

50 Diabetes Insipidus o Definition: It is characterised by the persistent excretion of excessive quantities of dilute urine and by thirst due to deficient or unresponsive ADH. o Classification: Cranial diabetes insipidus: There is deficient production of ADH by the hypothalamus Nephrogenic diabetes insipidus: the renal tubules are unresponsive to ADH. Endeavour College of Natural Health 50

51 Diabetes Insipidus o Aetiology: Cranial Structural hypothalamic or high stalk lesion Idiopathic Genetic defect of enzymes for biosynthesis of ADH Nephrogenic Genetic defect for ADH receptors Metabolic abnormality Drug therapy Poisoning Chronic kidney disease Endeavour College of Natural Health 51

52 Diabetes Insipidus o Clinical features: Polydipsia Polyuria (5 20 L or more of urine in 24 hours) Conscious patients with intact thirst mechanism: Maintain adequate fluid intake Unconscious patients/ with damage to the hypothalamic thirst centre: Diabetes insipidus is potentially lethal. Endeavour College of Natural Health 52

53 Diabetes Insipidus o Diagnosis: Water deprivation test o Management: Demopressin Thyozide diuretics, amiloride NSAIDs Endeavour College of Natural Health 53

54 Reading and Resources o o o o o o o Crowley LV, 2012, An Introduction to Human Diseases Pathology and Pathophysiology Correlations, 9th edn, Jones and Bartlett Learning Grossman SC & Porth CM 2014, Porth s Pathophysiology- Concepts of Altered Health States, 9th edn. Wolters Kluwer Health - Lippincott, Williams & Wilkins Hinson, J, Raven, P & Chew, S 2010, The endocrine system: basic science and clinical conditions, 2nd edn, Churchill Livingstone Elsevier, Edinburgh Jamison, JR 2006, Differential diagnosis for primary care: a handbook for health care practitioners, 2nd edn, Churchill Livingstone Elsevier, Edinburgh. Jarvis, C, 2012 Physical Examination & Health Assessment, 6th ed., Elsevier Saunders, Philadelphia. Kumar, P & Clark, M 2012, Kumar and Clark s clinical medicine, 8th edn, Saunders Elsevier, Edinburgh. Kumar, V, Abbas, AK & Aster, JC 2015, Robbins & Cotran pathologic basis of disease, 9th edn, Elsevier Saunders, Philadelphia. Endeavour College of Natural Health 54

55 o o o o o o Reading and Resources Lee, G & Bishop, P 2009, Microbiology and infection control for health professionals, 4th edn, Pearson Education, Frenchs Forest, NSW. McCance, KL, Heuther, SE, & Brashers, VL 2014, Pathophysiology: the biologic basis for disease in adults and children, 7th edn, Elsevier. Michael-Titus, A, Revest, P & Shortland, P 2010, The nervous system: basic science and clinical conditions, 2nd edn, Churchill Livingstone Elsevier, Edinburgh Mosby s dictionary of medicine, nursing and health professions 2013, 9th edn, Elsevier, St. Louis, MO. Tortora, GJ & Derrickson, B 2014, Principles of anatomy and physiology, 14th edn, John Wiley & Sons, Hoboken, NJ. VanMeter, KC & Hubert, RJ 2014, Gould's pathophysiology for the health professions, 5th edn, Elsevier, St Louis, MO. o Walker, BR, Colledge, NR, Ralston, SH, & Penman, ID (eds) 2014, Davidson s principles and practice of medicine, 22nd edn, Churchill Livingstone Elsevier, Edinburgh. Endeavour College of Natural Health 55

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