Pathologic Conditions

of Endocrine disorder

Present By
Mr. Teerayut Yoonun
ICU
Endocrine Disorder topic
• Pituitary Gland Disorder
• Syndrome of Inappropriate ADH
(SIADH)
• Diabetes Insipidus (DI)
• Thyroid disorder
• Hypothyroidism - Chronic deficie
ncy of T4 & T3
• Myxedema Coma - Acute deficie
ncy of T4 & T3
• Hyperthyroidism - Chronic increa
se in T4 & T3
• Thyrotoxicosis or Thyroid Storm
• Sick Euthyroid Syndrome
• Adrenal Disorders
• Primary Adrenal Insufficiency or
Addison’s Disease
• Secondary Adrenal Insufficiency
• Adrenal Crisis
• Cushing’s Disease
• Pheochromocytoma (Adrenal
Neoplasm)
• Primary Aldosteronism
• Pancreatic Disorders
• Diabetes Mellitus
• Pancreatic Neoplasms
• Pancreatitis
• Hypoglycemia
• Diabetic Ketoacidosis (DKA)
• Hyperglycemia and HHS
Pituitary Disorders
Pituitary Disorders
Syndrome of Inappropriate ADH (SIADH)
Syndrome of inappropriate antidiuretic hormone secretion (SIADH) occurs with abov
e normal ADH release, which causes impaired water excretion.
Possible causes :
• ADH secreting tumor
• Chemotherapy
• Oat cell carcinoma
Subjective assessment :
• Anorexia • Nausea • Headache
• Fatigue • Irritability
Objective assessment : • Weight gain • Vomiting • Muscle weakness • Muscle spasm
s or cramps • Hallucinations • Decreased level of consciousness (LOC) • Confusion • L
ow serum sodium • Low serum osmolarity • High urine osmolarity • Normal urine so
dium excretion • Low edema • Possible coma
SIADH
Pituitary Disorders
Diabetes Insipidus (DI)
Below normal ADH release or unde
r-production of ADH can result in d
iabetes insipidus (ID).
Possible causes :
• Cerebral vascular accident (CVA)
• Hypothalamic-pituitary tumors
• Cranial trauma or surgeries
• Hereditary • Drugs (lithium and p
henytoin [Dilantin])
• Alcohol (transient DI)
Subjective assessment :
• Abrupt onset of polydipsia and
polyuria • Nocturia • Sleep
disturbances related to nocturia
• Fatigue • Headache • Visual
disturbances
Objective assessment :
• Fluid intake 5-20 L/day
• Urine output of 2-20 L/day of
dilute urine
• Urine specific gravity < 1.006
• Fever
• Changes in LOC
• Hypotension • Tachycardia
 Thyroid Disorders

Introduction
The thyroid gland lies in the anterior po
rtion of the neck and straddles the trac
hea. It secretes two hormones that play
a major role in the body’s metabolism
• Thyroxine (T4)
• Triiodothyronine (T3)
Hypothyroidism - Chronic deficiency of T4
& T3
Possible causes :
• Thyroid gland dysfunction
• Inadequate release of TRH or TSH from the hypothalamic-pituitary axi
s (hypophysectomy or pituitary radiation)
• Surgical removal or radioiodine ablation with hyperthyroidism
• Hashimoto's thyroiditis (chronic inflammation of the thyroid)
Hypothyroidism - Chronic deficiency of T4
& T3
Subjective assessment :
• Diminished hearing • Cold intolerance • Fatigue • Lethargy • Complaints of consti
pation
Objective assessment : • Bradycardia • Decreased LOC • Hypothermia • Hypoventil
ation • Hypoactive bowel sounds • Weight gain • Elevated TSH • Decreased T3, T4,
free T4 • Elevated CK-MB • Increased pCO2 • Decreased P02, pH • Hypoglycemia
Myxedema Com
a
Acute deficiency of T4 & T3 Insufficient thyroid hormone or supplementation, togethe
r with an acute stressor, can lead to a myxedema coma, or acute deficiency or T4 and T
3.
Possible causes :
• Insufficient thyroid supplementation
• Increased stressors in patients with hypothyroidism (e.g. trauma, cold, anesthesia, in
fection)
Subjective assessment : • Diminished hearing • Cold intolerance • Fatigue •L
ethargy • Complaints of constipation
Objective assessment :similar to signs & symptoms of hypothyroidism but even more
pronounced: • Anasarca • Hoarseness • Pericardial & pleural effusions • Diminished h
earing • Paralytic ileus • Unresponsiveness • Decreased breathing • Hypotension • Hy
poglycemia • Hypothermia
Myxedema Com
a
 Hyperthyroid
ism
Chronic increase in T4 & T3 Hyperthyroidism
is a chronic increase in T4 and T3 levels.
Possible causes :
• Adenoma • Thyroiditis • Over treatment o
f hypothyroidism
• Discontinuation of thyroid supplements •
Stress • Iodine load with pre-existing hypert
hyroid state • Pituitary tumor

Adenoma
Hyperthyroid
ism
Subjective assessment :
• Irritability • Restlessness • Heat intolerance • Complaints of diarrhea
• Insomnia
Objective assessment :
• Tachycardia • Atrial arrhythmias • Premature atrial contractions (PACs
) • Premature ventricular contractions (PVCs) • Dyspnea • Palpitations •
Weight loss • Hyperthermia • Elevated T4 and T3 • Decreased TSH • Inc
reased TSH if from a TSH secreting tumor (in pituitary) • Positive test fo
r thyroid antibodies (Grave's Disease) • Hyperglycemia • Diaphoresis
Thyrotoxicosis or Thyroid Sto
rm
An acute increase in T4 and T3 can cause thyrotoxicosis or an acute thyr
oid storm.
The possible cause : decompensation of a pre-existing hyperthyroid stat
e after stressor (e.g. surgery, anesthesia, infection, trauma).
Subjective assessment : • Restlessness • Agitation • Changes in LOC
Objective assessment :similar to signs and symptoms of hyperthyroidis
m but even more pronounced: • Tachycardia • Diaphoresis • Fever • Di
arrhea • Confusion • Signs and symptoms associated with CHF and pul
monary edema
Sick Euthyroid Syndrome
Underproduction of TSH from the anterior pituitary (which stimulates the production an
d release of T4 and T3) can result in sick euthyroid syndrome, in which low thyroid levels
are evident on blood testing but the patient only presents with non-thyroid illness (NTI).
Possible causes :
• Acute illness
• Abnormalities in thyroid function occur in patients with serious illness not caused by p
rimary thyroid or pituitary dysfunction
Subjective assessment: may be absent.
Objective assessment : • Normal or low TSH • Abnormal T4 (low or high) • Low T3 • Abs
ence of thyroid symptoms
• The degree of reduction in thyroid hormone levels appears to be correlated with the s
everity of non-thyroidal illness.
Adrenal Disorders
Primary Adrenal Insufficiency /Addison’s Disease

• Addison's disease is the chronic deficiency or secretion of cortisol fro

m the adrenal cortex. Aldosterone is usually unaffected.
Secondary Adrenal Insufficiency

Secondary adrenal insufficiency is the chronic deficiency of ACTH from the anteri
or pituitary, which stimulates cortisol release from the adrenal cortex.
Possible causes :
• Autoimmune destruction of the adrenal gland
• Adrenal destruction from surgery, trauma, sepsis, infection, tuberculosis, hemo
rrhage, or bilateral adrenelectomy
• Suppression of gland related to medications (see Did You Know? below) • Pitui
tary hypofunction (surgery, trauma, ischemia)
Subjective assessment
• Nausea Abdominal pain • Fatigue
• Malaise • Weakness
Secondary Adrenal Insufficiency
Adrenal Crisis
Cushing’s Disease
Cushing's disease is the overproduction or secretion of ACTH from the anterior pituitary, which stimulates c
ortisol release from the adrenal cortex.
Possible causes include:
• Cortisol secreting tumor (20% of cases), such as oat cell carcinoma of the lung with destruction of the adr
enal gland
• Adrenal carcinoma
• Pituitary cortisol-secreting adrenal tumor (usually benign)
• Key subjective assessment findings are: • Weakness • Increased appetite • Irritability • Emotional lability
• • Headache • Complaints of easy bruising • Reports symptoms associated with decreased stress and imm
unologic response
• Key objective assessment findings are: • Pathologic fractures • Purple striae • Facial edema • Acne • Buff
alo hump • Poor wound healing • Peptic ulcers • Hypertension • Left ventricular hypertrophy
• • Dyslipidemia • Renal calculi (from bone demineralization) • Urinary free cortisol levels >150 mcg in 24 h
ours, hyperglycemia • Hypernatremia • Hypokalemia • Hypocalcemia • Metabolic alkalosis • Increased ly
mphocytes
Cushing’s Disease
Subjective assessment :
• Weakness • Increased appetite • Irritability • Emotional lability
• Headache • Complaints of easy bruising • Reports symptoms associat
ed with decreased stress and immunologic response
Objective assessment :
• Pathologic fractures • Purple striae • Facial edema • Acne • Buffalo h
ump • Poor wound healing • Peptic ulcers • Hypertension • Left ventric
ular hypertrophy • Dyslipidemia • Renal calculi (from bone demineraliz
ation) • Urinary free cortisol levels >150 mcg in 24 hours, hyperglycemi
a • Hypernatremia • Hypokalemia • Hypocalcemia • Metabolic alkalosis
• Increased lymphocytes
Pheochromocytoma (Adrenal Neoplasm)

Pheochromocytoma is an adrenal neoplasm resulted by the increase epinephrine and nore

pinephrine from the adrenal medulla.
The possible cause of this disorder is a tumor of the adrenal medulla.
Subjective assessment :
• Headache • Palpitations • Dizziness
• Complaints of constipation • Anxiety
Objective assessment :
• Hypertension • Hyperglycemia
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• • Dyslipidemia • Irregular heart rate
• • Diaphoresis • Syncope
Primary Aldosteronism
Primary aldosteronism is the result of an increase in production and secr
etion of aldosterone from adrenal cortex.
The possible cause of this is from a benign tumor of the adrenal gland,
which occurs in people between 30 and 50 years of age.
Subjective assessment :
• Headache • Muscle weakness
• Fatigue • Numbness
Objective assessment : • Hypernatremia • Hypervolemia
• Hypertension • Hypokalemia • Elevated plasma • Elevated urinary ald
osteronism
Pancreatic Disorder
s
Diabetes mellitus (DM)

Diabetes Mellitus is the result of the absolute decreased production of insulin (

Type I) or resistance of cells to circulating insulin (Type II).
Possible causes include:
• Type I: genetics, autoimmune disease, viral infections
• Type II: genetic factors, obesity • Gestational: pregnancy induced
Subjective assessment : • Headache • Fatigue • Lethargy • Reduced energy lev
els • Irritability • Emotional lability • Vision changes • Numbness • Tingling
Objective assessment : • Hyperglycemia • Polyuria • Polydipsia • Polyphagia
• Anorexia • Muscle cramps • Type I presents usually emergently • Type II pres
ents insidiously
Did You Know?
• The Centers for Disease Control and Prevention (CDC) estimate that a
pproximately 27.8% of the population with diabetes is undiagnosed. T
here are 21 million people in the United States diagnosed with diabet
es (both types), with an estimated 8.1 million people who don't even
know they have diabetes (CDC, 2014).
Pancreatic Neoplasms

Pancreatic neoplasms are benign or malignant tumors of the pancreas t

hat may impair insulin production and secretion.
Subjective assessment :
• Anorexia • Nausea • Malaise • Abdominal or back pain
Objective assessment :
• Jaundice • Clay-colored stool • Vomiting
• Weight loss • Blood in stool • Hypoglycemia or hyperglycemia
Pancreatitis
Pancreatitis may cause impairment of insulin production and secretion. Inflammation of the pa
ncreas occurs due to edema, hemorrhage, or necrosis.
Possible causes :
• Alcoholism • Trauma • Peptic ulcer disease • Biliary tract disease • Pancreatic cysts or tumors
• Drugs (sulfonomides, thiazides, birth control pills, NSAIDs) • Kidney failure • Organ transplant
ation • Endoscopic exam of the biliary tree
Subjective :
• Anorexia • Nausea • Malaise
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• Sever, knife-like mid-epigastric abdominal pain, which can radiate to the back
Objective assessment :
• Mottled skin • Tachycardia • Dehydration • Hypovolemia • Hemodynamic instability
• Abdominal distention • Crackles in lung bases • Pleural effusions • Increased serum amylase,
lipase, and glucose
Hypoglycemia

Hypoglycemia (low blood glucose levels) may be caused by increased in

sulin production, secretion, and/or administration.
Subjective assessment :
• Dizziness • Weakness • Nervousness • Agitation • Headache • Mental
dullness
Objective assessment :
• Pallor • Cool, clammy skin • Diaphoretic • Polyphagia • Tachycardia
• Palpitations • Confusion • Blurred vision • Paresthesias • Seizures
• Coma • Decreased blood glucose level (<60-80 mg/dL)
Diabetic Ketoacidosis (DKA)
• Hyperglycemia (high blood glucose levels) may be caused by decreased insulin administration
in Type I diabetics.
• Diabetic ketoacidosis (DKA) is a potentially life-threatening complication in patients with diab
etes mellitus. DKA results from a shortage of insulin; in response the body burns fatty acids fo
r energy and produces acidic ketone bodies that cause most of the symptoms and complicatio
ns.
Possible causes :
• Lack of circulating insulin in Type I diabetics leading to a hyperosmolar and hyperglycemic stat
e with ketone production
• New onset diabetes
• Inadequate insulin use in a known diabetic patient
• Stress (MI, CVA, trauma, surgery, emotional upset) in a known Type I diabetic • Medications (
steroids, beta blockers, thiazide diuretics)
• Alcohol use
Diabetic Ketoacidosis (DKA)
Subjective assessment :
• Myalgias • Flu-like signs and symptoms • Lethargy
• Nausea • Decreased level of consciousness • Coma
Objective assessment :
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• Warm, dry skin • Increased blood glucose levels (approximately 3007
00mg/dL) • Polydipsia • Polyuria (due to osmotic diuresis)
• Dehydration • Increased BUN, Hct, Hgb, acetone breath (exhalation of
ketones) • Positive urine and serum ketones • Metabolic acidosis • Kuss
maul's respirations • Increased serum osmolarity
Hyperglycemia and HHS

• Hyperosmolar hyperglycemic state (HHS) is a serious condition most fr

equently seen in older persons. HHS is usually brought on my illness o
r infection.
• In HHS, blood sugar levels rise, and the body attempts to lower blood
glucose levels by increasing glucose excretion in the urine. If this state
continues, severe dehydration can result, causing seizures, coma and
eventually death. The possible cause is a lack of circulating insulin in T
ype II diabetics, leading to a hyperosmolar and hyperglycemic state wi
thout ketone production.
Hyperglycemia and HHS

Subjective assessment :
• Myalgias • Flu-like signs and symptoms • Lethargy • Nausea • Decreased
level of consciousness • Coma
Objective assessment :
• Warm, dry skin • Increased blood glucose levels (approximately 4002,00
0mg/dL) • Polydipsia, polyuria (due to osmotic diuresis) • Severe dehydrati
on • Increased BUN, Hct, Hgb
• Negative urine and serum ketones • Absence of acetone breath (no keto
nes, no acidosis) • Increased serum osmolarity (>315 mOsm/kg) • Wider v
ariety of mental status changes including hallucinations, seizures, aphasia
Thank Yo
u