MED. & SURG.

THREE 03

YEAR TWO SEMESTER TWO

ENDOCRINE SYSTEM

Endocrine system is made up of several organs called glands. These glands, are
located all over body, and they create and secrete (release) hormones.

Hormones are chemicals that coordinate different functions in your body by

carrying messages through your blood to your organs, skin, muscles and other
tissues. These signals tell your body what to do and when to do it.

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What does the endocrine system do and how does it work?
The pituitary gland senses when your hormone levels rise, and tells other glands to
stop producing and releasing hormones. When hormone levels dip below a certain
point, the pituitary gland can instruct other glands to produce and release more.
This process, is called homeostasis, Hormones affect nearly every process in your
body, including:
 Metabolism (the way you break down food and get energy from nutrients).
 Growth and development.
 Emotions and mood.
 Fertility and sexual function.
 Sleep.
 Blood pressure.
The main glands that produce hormones include:

 Hypothalamus: This gland is located in your brain and controls your

endocrine system. It uses information from your nervous system to
determine when to tell other glands, including the pituitary gland, to produce
hormones. The hypothalamus controls many processes in your body,
including your mood, hunger and thirst, sleep patterns and sexual function.
 Pituitary: This little gland is only about the size of a pea, but it has a big
job. It makes hormones that control several other glands such as the thyroid
gland, adrenal glands, ovaries and testicles. The pituitary gland is in charge
of many different functions, including how your body grows. It’s located at
the base of your brain.
 Thyroid: thyroid is a butterfly-shaped gland in the front of your neck. It’s
responsible for your metabolism (how your body uses energy).

 Parathyroid: The parathyroid glands are four small, oval structures usually
arranged in pairs behind each thyroid lobe. They secrete parathyroid

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 hormone (PTH), which regulates the blood level of calcium. These four tiny
glands are no larger than a grain of rice. They control the level of calcium in
your body. For your heart, kidneys, bones and nervous system to work, you
need the right amount of calcium.

 Adrenal: one have two adrenal glands, one on top of each kidney. They
control the metabolism, blood pressure, sexual development and response to
stress.
 Pineal: This gland manages your sleep cycle by releasing melatonin, a
hormone that causes you to feel sleepy.
 Pancreas: a pancreas is part of your endocrine system, and it plays a
significant role in the digestive system too. It makes a hormone called
insulin that controls the level of sugar in your blood. Not only that, pancreas
also secretes several hormones, including glucagon.

 Glucagon increases blood glucose by stimulating glycogenolysis,

gluconeogenesis, and ketogenesis.
 Insulin is the principal regulator of the metabolism and storage of ingested
carbohydrates, fats, and proteins.

 Ovaries: In women, the ovaries release sex hormones called estrogen,

progesterone and testosterone. Women have two ovaries in their lower
abdomen, one on either side.
 Testes: In men, the testes (testicles) make sperm and release the hormone
testosterone. This hormone affects sperm production, muscle strength and
sex drive.

HORMONES: exert their effects on target tissue.

· The regulation of hormone levels in the blood depends on a highly specialized
mechanism called feedback. With negative feedback, the gland responds by
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increasing or decreasing the secretion of a hormone based on feedback from
various factors.
· The hypothalamus and pituitary gland integrate communication between the
nervous and endocrine systems.
Anterior Pituitary
· Several hormones secreted by the anterior pituitary are referred to as tropic
hormones because they control the secretion of hormones by other glands.
1- Thyroid-stimulating hormone (TSH) stimulates the thyroid gland to
secrete thyroid hormones.
2- Adrenocorticotropic hormone (ACTH) stimulates the adrenal cortex to
secrete corticosteroids.
3- Follicle-stimulating hormone (FSH) stimulates secretion of estrogen and
the development of ova in the female and sperm development in the male.
4- Luteinizing hormone (LH) stimulates ovulation in the female and secretion
of sex hormones in both the male and female.
5- Growth hormone (GH) has effects on all body tissues.
6- Antidiuretic hormone (ADH) regulates fluid volume by stimulating
reabsorption of water in the kidneys.
7- Oxytocin stimulates ejection of milk into mammary ducts and contraction of
uterine smooth muscle.
ASSESSMENT
· Hormones affect every body tissue and system, causing great diversity in the
signs and symptoms of endocrine dysfunction.
· Endocrine dysfunction may result from deficient or excessive hormone secretion,
transport abnormalities, an inability of the target tissue to respond to a hormone, or
inappropriate stimulation of the target-tissue receptor.
· Subjective data:

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  The nurse should inquire about use of hormone replacements, previous
hospitalizations, surgery, chemotherapy, and radiation therapy (especially of
the neck).
· Objective data:
 Most endocrine glands are inaccessible to direct examination.
· Physical examination:
 Clinical manifestations of endocrine function vary significantly, depending
on the gland involved.
 Assessment includes a history of growth and development, weight
distribution and changes, and comparisons of these factors with normal
findings.
 Disorders can commonly cause changes in mental and emotional status.
 The nurse should note the color and texture of the skin, hair, and nails. The
skin should be palpated for skin texture and presence of moisture.
 When inspecting the thyroid gland, observation should be made first in the
normal position (preferably with side lighting), then in slight extension, and
then as the patient swallows some water.
 The thyroid is palpated for its size, shape, symmetry, and tenderness and for
any nodules.
 The size, shape, symmetry, and general proportion of hand and feet size
should be assessed.
 The hair distribution pattern of the genitalia should be inspected.
DIAGNOSTIC STUDIES
· Laboratory tests usually involve blood and urine testing.
· Ultrasound may be used as a screening tool to localize endocrine growths such as
thyroid nodules.

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· Laboratory studies may include direct measurement of the hormone level, or
involve an indirect indication of gland function by evaluating blood or urine
components affected by the hormone (e.g., electrolytes).
· Notation of sample time on the laboratory slip and sample is important for
hormones with circadian or sleep-related secretion.
· The studies used to assess function of the anterior pituitary hormones relate to
GH, prolactin, FSH, LH, TSH, and ACTH.
· Tests to assess abnormal thyroid function include TSH (most common), total T4,
free T4, and total T3.

DIABETES
Diabetes is a serious condition where your blood glucose level is too high. It can
happen when your body doesn't produce enough insulin or the insulin it produces
isn't effective. Or, when your body can't produce any insulin at all.
Or
Diabetes mellitus (DM), (Scientific name for Diabetes) is a chronic multisystem
disorder of glucose metabolism related to absent or insufficient insulin supplies
and/or poor utilization of the insulin that is available.
GENERAL SIGNS AND SYMPTOMS

 Being really thirsty.

 Feeling more tired than usual.
 Losing weight.
 Genital itching or thrush.
 Cuts and wounds take longer to heal.
 Blurred vision.
 Going to the toilet a lot, especially at night.

TYPES OF DM:
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The two most common types of diabetes are classified as type 1 and type 2
diabetes mellitus. And others Includes; Gestational diabetes, prediabetes, and
secondary diabetes.
TYPE 1 DIABETES OR INSULIN DEPENDENT OR JUVENILE ONSET
DIABETES MELLITUS
Type 1 diabetes mellitus: most often occurs in people who are under 30 years of
age, with a peak onset between ages 11 and 13, but can occur at any age.
Type 1 diabetes is the end result of a long-standing process where the body’s own
T cells attack and destroy pancreatic beta cells, which are the source of the body’s
insulin. Because the onset of type 1 diabetes is rapid, the initial manifestations are
usually acute.
The classic symptoms are polyuria, polydipsia, and polyphagia.
The individual with type 1 diabetes requires a supply of insulin from an outside
source (exogenous insulin), such as an injection, in order to sustain life. Without
insulin, the patient will develop diabetic ketoacidosis (DKA), a life-threatening
condition resulting in metabolic acidosis.
TYPE 2 DIABETES OR NON INSULIN DEPENDENT OR MATURITY
ONSET/ADULT ONSET DIABETES MELLITUS
Type 2 diabetes mellitus is, the most common type of diabetes, accounting for over
90% of patients with diabetes.
In type 2 diabetes, the pancreas usually continues to produce some endogenous
(self-made) insulin. However, the insulin that is produced is either insufficient for
the needs of the body and/or is poorly used by the tissues.
The most important risk factors for developing type 2 diabetes are believed to be
obesity, specifically abdominal and visceral adiposity. Also, individuals with
metabolic syndrome are at an increased risk for the development of type 2
diabetes.
Some of the most common manifestations associated with type 2 diabetes include

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 1. fatigue,
2. recurrent infections,
3. recurrent vaginal yeast or monilia infections,
4. prolonged wound healing, and
5. Visual changes.
Other causes of Diabetes Mellitus include;
1. Pancreatic disorders
 Chronic pancreatitis
 Cystic fibrosis
 Cancer of the pancreas
All these impairs secretion/production of insulin by the pancreas
2. Liver disease (Liver Cirrhosis) which impairs glucose metabolism by the
liver
3. Endocrine disorders
 Cushing’s syndrome
 Acromegaly
 Thyrotoxicosis etc.
All these increase the body’s need for insulin
4. Pregnancy (gestational diabetes) pregnancy also increases the body’s need
for insulin
5. Drugs induced
 Thiazide diuretics
 Steroids
 Estrogens
6. Stress
7. Obesity
8. Hereditary. A family history of DM predisposes one to DM

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 A DIAGNOSIS OF DIABETES IS BASED ON ONE OF THE THREE
METHODS:
(1) Fasting plasma glucose level,
(2) Random plasma glucose measurement, or
(3) 2-hour oral glucose tolerance test.
THE GOALS OF DIABETES MANAGEMENT ARE:
1. to reduce symptoms,
2. promote well-being,
3. prevent acute complications of hyperglycemia, and
4. Prevent or delay the onset and progression of long-term complications.
These goals are most likely to be met when the patient is able to maintain blood
glucose levels as near to normal as possible.
INJECTABLE HYPOGLYCAEMICS. (INSULIN THERAPY)
Exogenous (injected) insulin is needed when a patient has inadequate insulin to
meet specific metabolic needs. Insulin is divided into two main categories:
 Short-acting (bolus) and
 Long-acting (basal) insulin.
Basal insulin is used to maintain a background level of insulin throughout the day
and bolus insulin is used at mealtime.
A variety of insulin regimens are recommended for patients depending on the
needs of the patient and their preference. Routine administration of insulin is most
commonly done by means of subcutaneous injection, although intravenous
administration of regular insulin can be done when immediate onset of action is
desired.
The technique for insulin injections should be taught to new insulin users and
reviewed periodically with long-term users.
The speed with which peak serum concentrations are reached varies with the
anatomic site for injection. The fastest absorption is from the abdomen.

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Continuous subcutaneous insulin infusion can be administered using an insulin
pump, a small battery-operated device that resembles a standard paging device in
size and appearance. The device is programmed to deliver a continuous infusion of
rapid-acting or short-acting insulin 24 hours a day and at mealtime, the user
programs the pump to deliver a bolus infusion of insulin.
An alternative to injectable insulin is inhaled insulin. Exubera is a rapid-acting, dry
powder form of insulin that is inhaled through the mouth into the lungs prior to
eating via a specially designed inhaler.
PROBLEMS ASSOCIATED WITH INSULIN THERAPY.
Hypoglycemia, allergic reactions, lipodystrophy, and the Somogyi effect
Lipodystrophy (atrophy of subcutaneous tissue) may occur if the same injection
sites are used frequently.
The Somogyi effect is a rebound effect in which an overdose of insulin induces
hypoglycemia. The Somogyi effect produces a decline in blood glucose level in
response to too much insulin.
ORAL AGENTS (ORAL HYPOGLYCAEMICS)
Oral agents (OAs) are not insulin, but they work to improve the mechanisms by
which insulin and glucose are produced and used by the body. OAs work on the
three defects of type 2 diabetes, including
(1) Insulin resistance,
(2) Decreased insulin production, and
(3) Increased hepatic glucose production.
Sulfonylureas e.g. Tolbutamide and Gilbenclamide are frequently the drugs of
choice in treating type 2 diabetes due to the decreased chance of prolonged
hypoglycemia. The primary action of the sulfonylureas is to increase insulin
production from the pancreas.
Metformin is a biguanide glucose-lowering agent. The primary action of
metformin is to reduce glucose production by the liver.

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α-Glucosidase inhibitors, also known as “starch blockers,” these drugs work by
slowing down the absorption of carbohydrate in the small intestine.

NNUTRITIONAL THERAPY AND EXERCISE

The overall goal of nutritional therapy is to assist people with diabetes in making
healthy nutritional choices, eating a varied diet, and maintaining exercise habits
that will lead to improved metabolic control.
For those with type 1 diabetes, day-to-day consistency in timing and amount of
food eaten is important for those individuals using conventional, fixed insulin
regimens.
Patients using rapid-acting insulin can make adjustments in dosage before the meal
based on the current blood glucose level and the carbohydrate content of the meal.
The emphasis for nutritional therapy in type 2 diabetes should be placed on
achieving glucose, lipid, and blood pressure goals.
The nutritional energy intake should be constantly balanced with the energy output
of the individual, taking into account exercise and metabolic body work.
In a general diabetic meal plan, carbohydrates and monounsaturated fat should
provide 45% to 65% of the total energy intake each day. Fats should compose no
more than 25% to 30% of the meal plan’s total calories, with less than 7% of
calories from saturated fats, and protein should contribute less than 10% of the
total energy consumed.
Alcohol is high in calories, has no nutritive value, and promotes
hypertriglyceridemia.
Patients should be cautioned to take alcohol, its use can make blood glucose more
difficult to control.

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Regular, consistent exercise is considered an essential part of diabetes and
prediabetes management. Exercise increases insulin receptor sites in the tissue and
can have a direct effect on lowering the blood glucose levels.
MONITORING BLOOD GLUCOSE
Self-monitoring of blood glucose (SMBG) is a cornerstone of diabetes
management. By providing a current blood glucose reading.
The frequency of monitoring depends on several factors, including the patient’s
glycemic goals, the type of diabetes that the patient has, the patient’s ability to
perform the test, independently, and the patient’s willingness to test.
PANCREAS TRANSPLANTATION
Pancreas transplantation can be used as a treatment option for patients with type 1
diabetes mellitus.
NURSING MANAGEMENT
Nursing responsibilities for the patient receiving insulin include
Proper administration, and assessment of the patient’s response to insulin therapy,
Education of the patient regarding administration, adjustment to, and side effects of
insulin.
Proper administration, assessment of the patient’s use of and response to the OA,
and education of the patient and the family about OAs are all part of the nurse’s
function.
General hygiene of the patient should be properly taken care of, for example
trimming of finger nails.
ACUTE COMPLICATIONS OF DIABETES MELLITUS
Diabetic ketoacidosis (DKA), also referred to as diabetic acidosis and diabetic
coma, is caused by a profound deficiency of insulin and is characterized by
hyperglycemia, ketosis, acidosis, and dehydration. It is most likely to occur in
people with type 1 diabetes.
DKA is a serious condition that proceeds rapidly and must be treated promptly.

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Because fluid imbalance is potentially life threatening, the initial goal of therapy is
to establish intravenous access and begin fluid and electrolyte replacement.
Hyperosmolar hyperglycemic syndrome (HHS) is a life-threatening syndrome
that can occur in the patient with diabetes who is able to produce enough insulin to
prevent DKA, but not enough to prevent severe hyperglycemia, osmotic diuresis,
and extracellular fluid depletion.
Hypoglycemia, or low blood glucose, occurs when there is too much insulin in
proportion to available glucose in the blood. Causes of hypoglycemia are often
related to a mismatch in the timing of food intake and the peak action of insulin or
oral hypoglycemic agents that increase endogenous insulin secretion.
CHRONIC COMPLICATIONS OF DIABETES MELLITUS
Chronic complications of diabetes are primarily those of end-organ disease from
damage to blood vessels secondary to chronic hyperglycemia. These chronic blood
vessel dysfunctions are divided into two categories: macro-vascular complications
and micro-vascular complications.
Macro-vascular complications are diseases of the large and medium-sized blood
vessels that occur with greater frequency and with an earlier onset in people with
diabetes.
Micro-vascular complications result from thickening of the vessel membranes in
the capillaries and arterioles in response to conditions of chronic hyperglycemia.
Diabetic retinopathy refers to the process of micro-vascular damage to the retina
as a result of chronic hyperglycemia in patients with diabetes.
Diabetic nephropathy is a micro-vascular complication associated with damage to
the small blood vessels that supply the glomeruli of the kidney.
Diabetic neuropathy is nerve damage that occurs because of the metabolic
derangements or imbalances associated with diabetes mellitus. The two major
categories of diabetic neuropathy are sensory neuropathy, which affects the
peripheral nervous system, and autonomic neuropathy.

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The most common form of sensory neuropathy is distal symmetric neuropathy,
which affects the hands and/or feet bilaterally. This is sometimes referred to as
“stocking-glove neuropathy.”
Autonomic neuropathy can affect nearly all body systems and lead to
hypoglycemic unawareness, bowel incontinence and diarrhea, and urinary
retention.
COMPLICATIONS OF THE FEET AND LOWER EXTREMITIES
Foot complications are the most common cause of hospitalization in the person
with diabetes.
Sensory neuropathy is a major risk factor for lower extremity amputation in the
person with diabetes. Loss of protective sensation often prevents the patient from
becoming aware that a foot injury has occurred.
Proper care of a diabetic foot ulcer is critical to prevention of infections.
GOOD LUCK

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 PANCREATITIS

WHAT IS PANCREATITIS?

Pancreatitis is the redness and swelling (inflammation) of the pancreas. This

happens when digestive juices or enzymes attack the pancreas.

The pancreas lies behind your stomach on the left side of your belly. It is close to
the first part of your small intestine (the duodenum).

The pancreas is a gland. It does 2 main things:

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  It makes enzymes and sends them into your small intestine. These enzymes
help break down food.
 It makes the hormones insulin and glucagon and sends them into your
bloodstream. These hormones control your body’s blood sugar level.

Pancreatitis may be sudden (acute) or ongoing (chronic).

Acute pancreatitis

 Is a sudden inflammation
 Lasts for a short time
 Let’s the pancreas return to normal afterward
 May cause serious problems or be deadly in severe cases

Chronic pancreatitis

 Is a long-lasting inflammation that comes and goes over time

 Causes permanent damage to the pancreas
 Often causes scarring of pancreatic tissue
 May cause the pancreas to stop making enzymes and insulin in severe cases

What causes pancreatitis?

The most common causes of pancreatitis include:

 Alcohol abuse
 Lumps of solid material (gallstones) found in the gallbladder. Gallstones
block the pancreatic duct so the enzymes can’t get out of the pancreas.

Other causes of pancreatitis include:

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  Belly injury or surgery
 High levels of fat particles (triglycerides) in the blood
 Very high levels of calcium in the blood
 Certain medicines, such as estrogens, steroids, and thiazide diuretics
 Infections, such as mumps, hepatitis A or B, or salmonella
 Cystic fibrosis
 A tumor
 Certain genetic defects
 Congenital abnormalities in the pancreas
 Trauma to the pancreas
 Cigarette smoking

What are the symptoms of pancreatitis?

Each person’s symptoms may vary. Symptoms may include:

 Severe belly pain that may spread to your back or chest (it may feel worse
after you eat)
 Nausea
 Vomiting
 Rapid heart rate
 Fever
 Swelling and feeling sore or tender in your upper belly
 Fluid buildup in your belly
 Lowered blood pressure
 Yellowing of the skin and eyes (jaundice)

The symptoms of pancreatitis may look like other health problems. Always see
your healthcare provider to be sure.

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How is pancreatitis diagnosed?

Your healthcare provider will look at your past health. He or she will give you a
physical exam.

You may have some blood tests done. You may also have some imaging tests
including:

 Belly X-ray. Makes images of internal tissues, bones, and organs.

 Ultrasound (also called sonography). Uses sound waves to see the internal
organs of the belly. It also checks how blood is flowing through different
blood vessels.
 EUS (endoscopic ultrasound). This is an internal type of ultrasound done
through a flexible tube (endoscope) inserted through the mouth while you
are sleeping.
 ERCP or endoscopic retrograde cholangiopancreatography. This is used
to find and treat problems in your liver, gallbladder, bile ducts, and pancreas.
It uses X-ray and a long, flexible tube with a light and camera at one end (an
endoscope). The tube is put into your mouth and throat. It goes down your
food pipe (esophagus), through your stomach, and into the first part of your
small intestine (duodenum). A dye is put your bile ducts through the tube.
The dye lets the bile ducts be seen clearly on X-rays.
 CT scan (computed tomography scan). This imaging test shows detailed
images of any part of the body such as the bones, muscles, fat, and organs.
CT scans are more detailed than regular X-rays.
 MRCP (magnetic resonance cholangiopancreatography). This uses MRI
(magnetic resonance imaging) to make detailed images of your pancreas,
gallbladder, and pancreatic and bile ducts. A dye is shot (injected) into your
vein so that the images can be seen more clearly.

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How is pancreatitis treated?

The treatment goal is to rest the pancreas and let it heal.

In most cases, you:

 Will be in the hospital for a few days

 Will be given IV (intravenous) fluids
 Will be given pain medicine and medicines that fight bacterial infections
(antibiotics)
 If mild, you may be able to eat clear liquids or a low-fat diet. However, if
severe, you may not be able to eat or drink for a few days to let your
pancreas rest. A feeding tube may need to be used in some situations.

Pancreatitis often gets better in a few days.

If any problems happen, treatment may include:

 NG tube (nasogastric tube). This is a thin tube passed down your nose and
into your stomach. It is used if vomiting is a problem. The tube can be used
for a few weeks. It can be used to remove fluid and air and give your
pancreas more time to heal. It can also be used to put liquid food into your
stomach as you heal.
 ERCP (endoscopic retrograde cholangiopancreatography). This is used
to find and treat problems in your liver, gallbladder, bile ducts, and pancreas.
It uses X-ray and a long, flexible, lighted tube (an endoscope). The tube is
put into your mouth and throat. It goes down your food pipe (esophagus),
through your stomach, and into the first part of your small intestine
(duodenum). A dye is injected into the bile ducts through the tube. The dye
lets the bile ducts be seen clearly on X-rays. The tube has tools in it. The

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 tools can remove fluid and blockages and take out gallstones. They can also
put stents (firm tubes) in the ducts to keep them open.
 Surgery to remove gallstones or your gallbladder. This is done if
gallstones or your gallbladder are causing pancreatitis.

If you have chronic pancreatitis you may also:

 Have to avoid alcohol (if your pancreatitis is caused by alcohol abuse)

 Have to stop smoking
 Need enzyme supplements to help digest your food
 Need insulin (if you get diabetes)
 Need to eat small high-protein, low-fat meals
 Need surgery to remove the permanently damaged part of your pancreas. In
advanced situations, a special transplant called islet cell transplant is done.
 Need medicine for chronic pain

What are the complications of pancreatitis?

Acute pancreatitis usually gets better on its own over time. Most people recover
without any problems. A small number of cases end up with fluid collections
around the pancreas that require drainage.

Chronic pancreatitis may also get better on its own. But that can take longer, after a
few attacks. Chronic pancreatitis has a greater risk of long-term problems such as:

 Diabetes
 Chronic pain
 Diarrhea
 Weight loss
 Low vitamin levels from malabsorption

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  A collection of fluid (pseudocyst) around the pancreas
 Bile duct blockages
 Permanent pancreas damage
 Pancreatic cancer

GOOD LUCK

ACROMEGALY
Presentation outline
1. Definition
2. Causes
3. Signs and symptoms
4. Complications
5. Investigations
6. Treatment
Definition
Acromegaly is the clinical condition resulting from excess growth hormone
production.
Causes
More than 99% are due to pituitary adenomas.
Signs and symptoms
1. Increase sweating
2. Headache
3. Lethargy (Lack of energy)
4. Joint pain
5. Tight shoes or ring
6. Deep voice

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 7. Tongue enlargement
8. Osteoarthritis and generalized muscle pain
9. Carpel tunnel syndrome
10.Goiter
Complications
1. DM
2. Upper airway obstruction, leading to disturbed sleep and snoring.
3. Heart failure
4. Visual field defects
5. Hypertension
Investigations
1. Skull X-ray may show enlargement of the pituitary fossa, there may be
enlargement of frontal air sinuses and separation of teeth
2. Specialized neuroimaging studies are required and referred to a specialist
advice.
Treatment
1. Surgery
2. Radiotherapy
3. Drug treatment: like octreotide, causes suppression of GH secretion,
Bromocriptine is also used
4. Nursing care
5. Referral to a specialized physician

WISH U ALL THE BEST.

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 DIABETES INSIPIDUS

Diabetes insipidus, is a condition in which your body produces too much urine and
isn’t able to properly retain water. Diabetes insipidus can be chronic (life-long) or
temporary and mild or severe depending on the cause.

Diabetes insipidus is mostly caused by an issue with a hormone called antidiuretic

hormone (ADH, or vasopressin), either your body doesn’t make enough of ADH or
your kidneys don’t use it properly. People with diabetes insipidus passes large
volumes of urine several times a day and drink large amounts of water because
they feel constantly thirsty.

WHAT IS THE DIFFERENCE BETWEEN DIABETES INSIPIDUS AND

DIABETES MELLITUS?

 Diabetes insipidus and diabetes mellitus are two distinct conditions with
different causes and treatments. They only share the name “diabetes”
because they both cause increased thirst and frequent urination.
 Diabetes mellitus, most commonly known as Type 1 diabetes, Type 2
diabetes or gestational diabetes, happens when your pancreas doesn’t make
any or enough insulin or your body doesn’t use the insulin it makes properly.
Your body needs insulin to transform the food you eat into energy.

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  Diabetes insipidus happens when your body doesn’t make enough
antidiuretic hormone (ADH) or your kidneys don’t use it properly. Your
body needs ADH to retain appropriate amounts of water. Without ADH,
your body loses water through urine.
 Diabetes mellitus is much more common than diabetes insipidus.

WHAT ARE THE TYPES OF DIABETES INSIPIDUS?

There are four types of diabetes insipidus, including:

 Central diabetes insipidus: This is the most common type of diabetes
insipidus. It happens when your body doesn’t have enough antidiuretic
hormone (ADH, or vasopressin). One can get central diabetes insipidus if
your pituitary gland or hypothalamus is damaged.
 Nephrogenic diabetes insipidus: This type of diabetes insipidus happens
when your pituitary gland releases enough ADH, but your kidneys don’t
respond to it properly and can’t retain water.
 Dipsogenic diabetes insipidus: In this type of diabetes insipidus, an issue
with your hypothalamus unrelated to ADH production causes you to feel
thirsty and drink more liquids. Because of this, you may need to pass urine
often.
 Gestational diabetes insipidus: This is a rare, temporary condition that can
develop during pregnancy. Gestational diabetes insipidus happens or occurs
when your placenta, a temporary organ that provides nourishment to your
baby, makes too much of an enzyme that breaks down your ADH. People
who are pregnant with more than one baby are more likely to develop the
condition because they have more placental tissue. Gestational diabetes
insipidus usually goes away shortly after the pregnancy is over. It’s not to be

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 confused with gestational diabetes, which is a type of diabetes mellitus that
can develop during pregnancy in people who don't already have diabetes
mellitus. Gestational diabetes mellitus causes high blood sugar.

WHAT ARE THE SYMPTOMS OF DIABETES INSIPIDUS?

The main symptoms of diabetes insipidus include:

 Needing to pee often, including through the night.

 Passing large amounts of light-colored or clear urine each time you pee.
 Feeling very thirsty and drinking liquids very often.

Symptoms of dehydration include:

 Feeling dizzy or lightheaded.

 Feeling tired.
 Having a dry mouth, lips and eyes.
 Difficulty performing simple mental tasks.
 Nausea.
 Fainting.

CAUSES OF DIABETES INSIPIDUS?

CAUSES OF CENTRAL DIABETES INSIPIDUS

Central diabetes insipidus happens when there’s an issue with your hypothalamus
or pituitary gland. Specific causes include:

 Damage to your hypothalamus or your pituitary gland from surgery.

 Damage to your hypothalamus or pituitary gland from a head injury,
particularly basal skull fractures.
 Inflammation (granulomas) from sarcoidosis or tuberculosis.

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  Tumors that affect your hypothalamus or pituitary gland.
 An autoimmune reaction that causes your immune system to damage healthy
cells that make an antidiuretic hormone (ADH).
 An inherited gene mutation on chromosome 20.

CAUSES OF NEPHROGENIC DIABETES INSIPIDUS

Nephrogenic diabetes insipidus happens when your kidneys don’t use antidiuretic
hormone (ADH, or vasopressin) properly. Specific causes include:

 Certain medications, such as lithium and tetracycline.

 Low levels of potassium in your blood (hypokalemia).
 High levels of calcium in your blood (hypercalcemia).
 A blocked urinary tract.
 An inherited gene mutation. The hereditary form of nephrogenic diabetes
insipidus can be caused by mutations in at least two genes.
 Chronic kidney disease (this is a rare cause).

CAUSES OF DIPSOGENIC DIABETES INSIPIDUS

Dipsogenic diabetes insipidus (also known as primary polydipsia) happens when

there’s an issue with your hypothalamus unrelated to ADH production that causes
you to feel thirsty and drink more liquids. Specific causes include:

 Damage to your hypothalamus from surgery, infection, inflammation, a

tumor or a head injury.
 Certain mental health conditions, including schizophrenia and obsessive-
compulsive disorder.

CAUSES OF GESTATIONAL DIABETES INSIPIDUS

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This affects pregnant mothers. It happens when your placenta makes too much of a
certain enzyme that breaks down your antidiuretic hormone (ADH, or
vasopressin). If pregnancy is more than one baby, one is more likely to develop
gestational diabetes insipidus because you have more placental tissue.

DIAGNOSIS AND TESTS

A water deprivation test is the simplest and most reliable method for diagnosing
diabetes insipidus. Patient is made under constant supervision during the process,
as it can cause dehydration.

A water deprivation test involves not drinking any liquid for several hours to see
how your body responds. If you have diabetes insipidus, you'll continue to pass
large amounts of watery (dilute), light-colored urine when normally you'd only
pass a small amount of concentrated, dark yellow urine.

Other tests to help diagnose diabetes insipidus or rule out other conditions include:

 Blood test to check antidiuretic hormone (ADH, or vasopressin) levels.

 Blood test to check glucose levels to rule out diabetes mellitus.
 Urinalysis to check osmolality (the concentration of your urine) and/or to
check for ketones, which could indicate diabetes mellitus.
 Imaging tests, such as an MRI, to see if issues with your pituitary gland or
hypothalamus are causing your diabetes insipidus.

TREATMENT

Treatment for diabetes insipidus depends on the type.

Treatment for central diabetes insipidus and gestational diabetes insipidus

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Desmopressin is the first-line treatment for central diabetes insipidus. It’s a
medication that works like an antidiuretic hormone (ADH, or vasopressin).
desmopressin would be injection (shot), a pill or in a nasal spray form.

Treatment for nephrogenic diabetes insipidus

Use of thiazide diuretics, which reduce the amount of urine your kidneys produce.

Use of non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, to help

further reduce urine volume when they’re used in combination with thiazide
diuretics.

Treatment for dipsogenic diabetes insipidus

There is no known treatment

WHAT ARE THE RISK FACTORS FOR DEVELOPING DIABETES

INSIPIDUS?

 Have a family history of diabetes insipidus.

 Had brain surgery or a major head injury.
 Take medications that can cause kidney problems.
 Have certain metabolic disorders, such as high blood calcium levels or low
blood potassium levels.

 A pregnant mother with more than one baby.

 Have a condition that affects liver function, such as preeclampsia and
HELLP syndrome.

WHAT ARE THE COMPLICATIONS OF DIABETES INSIPIDUS?

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The main complication of diabetes insipidus is dehydration, which happens when
your body loses too much fluid and electrolytes to work properly.

GOOD LUCK

THYROID HYPERFUNCTION
This can manifest in two ways:
 Thyrotoxicosis
 Goiter
THYROTOXICOSIS
This occurs when there are abnormally high blood levels of triiodothyronine (T3)
and thyroxine (T4) which are your body’s thyroid hormones. They increase ones
metabolic rate, causing symptoms such as tachycardia, weight loss, and other
complications. Thyrotoxicosis is rare, affecting around 2% of women and 0.2% of
men.
Symptoms

Whether you have mild or moderate thyrotoxicosis, the signs and symptoms are
similar.

 Unexplained weight loss despite of increased appetite.

 Irregular heartbeat Cardiac arrhythmias/cardiac failure in older patients.
 The rapid heartbeat of more than 100 beats per minute.
 Muscle weakness.
 Tremors, anxiety, and irritability.
 Heat sensitivity or Intolerance to heat.
 Menstrual change
 Sweating

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 Palpitations
 Tachycardia
 Exophthalmos
 High basal metabolic rate
 Weakness, hyperkinesia and emotional instability
 Diminished glucose tolerance
 Glycosuria
Causes

 Hyperthyroidism is the most common underlying cause of thyrotoxicosis,

and Graves’ disease is the leading cause of hyperthyroidism. You may
develop hyperthyroidism and/or thyrotoxicosis if you have one or more
nodules in your thyroid.
 Thyroiditis occurs when your thyroid is inflamed, releasing thyroid
hormones into your bloodstream. Medications such as lithium and
interferon, immunity problems, fungal and bacterial infections, or childbirth
may cause inflammation.
 Excessive thyroid medication for hypothyroidism. You may accidentally
take too much thyroid medication, or the doctor may intentionally prescribe
excess thyroid medication to suppress the production of thyroid-stimulating
hormone (TSH) to prevent or decrease the growth of lumps in your thyroid.
 Excessive thyroid hormone consumption from eating beef contaminated
with thyroid tissue from the cow neck leads to rare “hamburger thyroiditis.”
DIAGNOSIS
 The doctor will perform a physical exam to check if

o You have a heart palpitation.

o You have swollen, or bulging eyes.
o You have a bumpy, tender, or enlarged thyroid.

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 o You have hand tremors.
o You sweat more than usual.
 Blood tests to check the level of thyroid hormones. If you have
thyrotoxicosis, the T3 and T4 levels will be high, while the thyroid-
stimulating hormone (TSH) levels will be low.
 Imaging tests
o The radioactive iodine uptake test checks how well your thyroid
absorbs the radioactive iodine. The high radioactive iodine uptake
means excessive production of T4. You may develop thyroid nodules
and Graves’ disease. The low radioactive iodine uptake means there is
a leakage of T4 into your bloodstream from thyroiditis.
o Thyroid scan to look for inflammation, nodules, goiter, and thyroid
cancer by injecting radiotracer or radioactive liquid into your veins
before taking your thyroid images for a proper diagnosis.
o Thyroid ultrasound to determine if you have nodules on the thyroid.
Treatment

Your doctor will determine the cause of thyrotoxicosis to plan suitable treatment
options.

 Anti-thyroid drugs such as methimazole and propylthiouracil (PTU) help

reduce the production of thyroid hormones.
 Radioactive iodine can shrink the thyroid cells to lower the release of
thyroid hormone. However, your thyroid cells can be permanently damaged,
leading to hypothyroidism. You may need to take thyroid hormone
medications for the rest of your life.
 Thyroidectomy to remove the thyroid gland for the treatment of
hyperthyroidism. Like radioactive iodine, you may need to take thyroid

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 hormones to maintain the level of thyroid hormones. Otherwise, you can
develop hypothyroidism.
 Beta-blockers can relieve symptoms of thyrotoxicosis, including tremors
and rapid heart rate.
 Glucocorticoids can help reduce the pain of thyroiditis.

Some summary of Management

a. Management of anxiety
Give anxiolytic e.g. phenobabitone
b. Reduction on sympathetic over activity
Give an alpha-adrenoreceptor e.g. propranolol
c. Reduction on production of thyroxine
Give carbimazole which blocks iodination of thyroxine
d. Partial thyroidectomy
e. Radioactive treatment
Risk factors

 Age: The risk of thyrotoxicosis increases with age. Older adults over 60
years old are at higher risk.
 Gender: Females are more likely to be affected by thyrotoxicosis than males.
 Medical condition: An autoimmune disease, Type 1 diabetes, pernicious
anemia, and family history of Addison disease: You have a direct family
member with thyroid disease or Graves’ disease.
 Childbirth: If you recently gave birth to a child, your hormonal change can
lead to thyrotoxicosis.
Prevention

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Thyrotoxicosis is not preventable. But if your condition results from the overuse of
thyroid medication, reducing the dosage can prevent the risk of developing
thyrotoxicosis.

 Hyperthyroidism
 Thyrotoxicosis
 Thyroid storm

All three conditions are due to excess thyroid hormone production and release.

 Hyperthyroidism is the condition of excess thyroid hormone production

and release. It is a type of thyrotoxicosis. The most common cause is
Graves’ disease.
 Thyrotoxicosis is when a high level of thyroid hormone circulates in your
body. Taking excessive thyroid hormone, hyperthyroidism, or thyroiditis are
the common causes.
 A thyroid storm or thyroid crisis occurs when the thyroid glands suddenly
release excessive thyroid hormone. It is a rare but life-threatening
complication of hyperthyroidism; immediate medical care is necessary. Its
symptoms include:
o Rapid heartbeat.
o High fever.
o Agitation and confusion.
o Diarrhea.
o Syncope.

Differential diagnosis
 Anxiety
 Pregnancy
 Cancer
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  DM etc.

GOITER
This is an enlargement of thyroid gland usually due to iodine deficiency
Two forms exist:
1. Endemic goiter
This is generally a nutritional deficiency of iodine
Therefore a disease is said to be an endemic when it consistently present but limited to a
particular region.
2. Sporadic goiter
Cause is unknown.
Therefore sporadic means occasional occurrence of disease or problem.
MECHANISM OF GOITER

Lack of Iodine

Deficient production of
thyroid hormone

Increased T.S.H
secretion

Enlargement of thyroid
gland to extract maximum
amount of iodine from
blood
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CLASSIFICATION OF GOITER BASED ON HOW IT ENLARGES
1. Simple (diffuse) goiter: this type of goiter happens when your entire thyroid gland swells
and feels smooth to touch.
2. Nodular goiter: this happens when a solid or fluid-filled lump called a nodule develops
within your thyroid and makes it feel lumpy.
3. Multi-nodular goiter: this type of goiter happens when there are many lumps (nodules)
within the thyroid gland, the nodules may be visible or only discovered through
examination or scans.

CLASSIFICATION BASED ON THYROID HORMONE LEVELS

1. Toxic goiter: this goiter happens when thyroid gland enlarged and produces too much
thyroid hormones
2. Nontoxic goiter: in this case, thyroid gland is enlarged but normal thyroid hormonal
levels.

TREATMENT

This depends on the cause, its size whether it is uniformly large or nodular and to some extent,
upon the patient’s age and wishes.

1. In childhood:
An iodine deficiency (endemic) goiter can be prevented from enlarging further by giving
potassium iodide by mouth once daily.
2. Adolescents/adults:
Give thyroxine daily as potassium iodide
3. Surgery: (Thyroidectomy).
4. Iodine oil:
Single injection of iodinated oil.

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 GOOD LUCK

What is a Thyroidectomy?

A thyroidectomy is a surgical procedure which involve the removal all or part of the thyroid

gland and used to treat diseases of the thyroid gland including: Thyroid cancer, Hyperthyroidism

(overactive thyroid gland), Large goiters or thyroid nodules causing symptomatic obstruction
such as swallowing or breathing difficulties, and Multi-nodular Goiter.

Indications for Thyroid Surgery or Thyroidectomy

 Presence of thyroid nodules: Thyroid nodules are a lump or growth of the thyroid cells
in the thyroid gland. Although generally benign or non-cancerous, thyroid nodules can be
cancerous or malignant. When the nodules have an increased risk of being cancerous,
thyroid surgery can be done to remove them.

 Goiter or non-cancerous enlargement of the thyroid gland: Goiter is an enlarged

thyroid gland with or without the presence of thyroid nodules. An enlarged thyroid gland
can affect the esophagus or the food pipe, as well as the trachea or windpipe, causing
difficulty in breathing and swallowing. Goiter can also be removed by removing half or
all of the thyroid gland relieving the obstruction.

 Thyroid cancer: Thyroidectomy is primarily done because of thyroid cancer. Cancer in

the thyroid gland may require the removal of a part or the entire thyroid gland.

 Hyperthyroidism or overactive thyroid: Hyperthyroidism can occur when the body

produces excessive thyroxin hormone. The doctor can perform a thyroidectomy when the
patient has problems in taking anti-thyroid drugs or when they do not want radioactive
iodine therapy.

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Types of Thyroid Surgery

Thyroid surgery can be total, where the entire thyroid gland is removed, or partial, where a part
of the gland is removed.

 Total thyroidectomy: A total or near-total thyroidectomy involves the surgical removal

of all or most of the thyroid gland.

 Partial thyroidectomy: The surgeon can remove a part of the thyroid gland while the
remaining takes over the functions of the entire thyroid gland.

 Thyroid lobectomy (aka hemi-thyroidectomy): The surgeon removes one thyroid lobe.

 Isthmusectomy: This is the removal of small tumors located in the thyroid tissue
between the two lobes in the thyroid gland (thyroid isthmus).

 Completion thyroidectomy: This is a second surgery to remove the second half of the
thyroid gland, typically for cases of thyroid cancer found in the first surgery.

Thyroid Surgery Risks

Surgical removal of the whole or part of the thyroid glands can have certain risks in addition to
general risks of surgery and general anesthesia.

Temporary or permanent Hypoparathyroidism:

Surgery of the thyroid gland can cause injury of or accidental removal of a portion of the four
parathyroid glands located at the back of the thyroid gland. The parathyroid glands produce
parathyroid hormone that helps balance calcium and phosphorus in the kidneys and bones.

Injury to the parathyroid glands can lower the calcium levels in the body, causing hypocalcemia.
Hypocalcemia can occur for a few weeks to months following the thyroid surgery and requires
calcium supplements.

Hypothyroidism

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When thyroid surgery removes the entire thyroid gland, patients will not have a gland to produce
thyroid hormone and will need to take thyroid hormone supplement daily.

Hoarseness or voice change

Thyroid surgery patients can experience hoarseness or changes in voice following the surgery.
This can happen because of irritating or injuring the laryngeal nerves near the thyroid gland.

While temporary irritation and inflammation of the nerves improve within the first few weeks of
the surgery, the change in voice can persist up to six months following the thyroid surgery.

In rare cases where the surgery damages the laryngeal nerves causing a permanently hoarse
voice, an ENT specialist can perform different procedures to improve the voice quality.

Dysphagia or difficulty with swallowing: They are pretty common and resolve within two
weeks following the surgery;

Neck pain and stiffness: As thyroid surgery requires the neck to be placed in an extended
position, the patients can experience neck pain and stiffness following the surgery.

Infections: Although the risk of infection is present in all surgeries, it is comparatively rare in
thyroid surgeries.

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CUSHING’S SYNDROME

What is Cushing's syndrome?

Cushing's syndrome is a condition where your body is exposed to too much of the
hormone called cortisol. This can be because your body is making too much
cortisol, or because you have taken a lot of oral corticosteroid medicines. If you
have Cushing's syndrome, it is treatable.

Cortisol is a hormone that is made by the adrenal glands. You have two adrenal
glands, one sitting on the top of each kidney.

Cortisol is involved in many different parts of your body. It is produced all day,
and especially during times of stress.

Cushing's syndrome is most often diagnosed in adults aged between 30 to 50 years.

It affects 3 times as many women as men.

What are the symptoms of Cushing's syndrome?

The symptoms and signs of Cushing's syndrome can include:

 a rounded face
 weight around the torso, shoulders and neck, but thin arms and legs
 a hump between the shoulders
 high blood sugar or diabetes

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  high blood pressure
 feeling tired or emotional
 skin problems like slow healing of wounds, bruising and stretch marks on
the tummy, hips and thighs
 brittle bones (osteoporosis)

Other symptoms for women include more hair on the face and body and irregular
periods. Men can have lower libido or erectile dysfunction.

What causes Cushing's syndrome and Cushing's disease?

Some people with Cushing's syndrome have a benign tumour in part of the brain.
This tumour tells the adrenal glands to release cortisol. This condition is known as
Cushing's disease. Cushing's syndrome can also be caused by:

 a tumour of the adrenal gland

 overgrowth of the adrenal glands
 occasionally, a tumour somewhere else in the body

Other people develop Cushing's syndrome from taking corticosteroid (steroid)

medication for a long time.

If you have Cushing's syndrome because of taking steroid medicine, do not stop
taking it suddenly, as you could become very unwell. Talk to your doctor.

How is Cushing's syndrome diagnosed?

Tests of blood, urine and saliva.

Scans such as a CT scan or MRI scan.

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Referred to an endocrinologist (a doctor who specialises in problems with
hormones).

Treatment of Cushing's syndrome

The treatment depends on the cause.

If you are taking steroids, then you and your doctor will need to talk about whether
you can reduce the dose or not.

If there are other reasons as to why you have Cushing's syndrome, then you may be
advised to have treatment such as:

 surgery
 radiotherapy
 chemotherapy
 medication to stop your body making too much cortisol

Complications of Cushing's syndrome?

 blood clots in the legs and lungs

 bone loss and fractures
 depression or other mood changes
 heart attack or stroke
 high blood pressure
 high cholesterol levels
 infections
 insulin resistance and prediabetes
 memory loss or trouble concentrating
 type 2 diabetes

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42