Surgical consideration in particular patients:

Endocrine abnormalities

Poramaporn Prasarttong-Osoth, MD MSc FRCS(Glasg)Head, Neck and Breast unit

Department of SurgerySiriraj Hospital

Endocrine abnormalities

Thyroid

Parathyroid

Adrenal

Endocrine abnormalities:General concepts

Nonspecific clinical features

Disease organs Target organs

Primary disease or co-morbidities

Clinical features

HypertensionFaintingRecurrent kidney stonesRefractory epigastric pain/ peptic ulcerAnemiaOsteoporosisIncidentaloma

Thyroid abnormalitiesHyperthyroidism

Graves’ diseaseToxic multinodular goiterFactitious hyperthyroidism

HypothyroidismAutoimmune diseaseIatrogenic hypothyroidism

Thyroid hormone

Follicular cells

Colloid

Parafollicular cells

Thyroid hormoneMore than 99% bind to plasma protein

Tetraiodothyronine,Thyroxine (T4)Triiodothyronine (T3)

Monoiodotyrosine + Diiodotyrosine(DIT) Triiodotyronine (T3)

Diiodotyrosine + Diiodotyrosine Thyroxine (T4)

Factors affecting level of serum thyroid hormone

Increased TBG : High total T4 and T3Estrogen: Pregnancy, OCP, HRTDrugs: Methadone, 5-FU

Decreased TBG: Low total T4 and T3Liver diseaseAnabolic steroids, androgenGlucocorticoids

Thyroid hormoneT4 T3

Synthesis

Action

Serum

Half-life

93% 7%

Less potent More potent

Mainly from thyroid follicle

Mainly from peripheral conversion

7 days 1-3 days

HyperthyroidismSigns Symptoms

• Hyperactivity• Tachycardia/ AF• Systolic hypertension• Warm, moist skin• Tremor• Hyperreflexia• Muscle weakness

• Weakness, fatigue• Increase perspiration• Heat intolerance• Palpitation• Nervousness• Increase appetite • Weight gain• Menstrual disturbance

Thyroid hormoneCardiovascular system Increase O2 consumption, HR,

cardiac output, blood volume and pulse pressure

Respiratory system Increase O2 utilization and CO2 formation

GI system Increase appetite and intestinal movement

Musculoskeletal system

Increase activity of neuronal synapse and osteoclast

Basal metabolic rate Increase metabolism in nearly every type of cells

Achieve euthyroid stateAntithyroid drugs: 6-8 weeks

PropylthiouracilMethimazole

ß-blockersPropanololAtenolol

Corticosteroid: 5 daysHydrocortisoneDexamethasone

Lugol’s iodine: 7days

Thyroid crisis/Thyroid storm

Clinical featuresFever > 38.5°cTachycardiaConfusion/ agitationNausea/ vomitingHypertensionCongestive heart failureAbnormal liver function test

Thyroid crisis/Thyroid stormManagement

PTU 200-250mg PO every 6-8 hr

Lugol’s iodine 0.3ml PO every 8 hr

Sodium iodine 1.5g IV in 24 hr

ß-blockers IV

Digitalis

Hypothyroidism3-5/1,000 in female0.6/1,000 in male

Autoimmune thyroiditisIodine deficiencyIatrogenicDrugs (amiodarone, lithium)Congenital

HypothyroidismDepression of myocardial functionDepressed spontaneous ventilationReduced plasma volumeAnemiaHypoglycemiaHyponatremiaImpaired liver metabolismRisk of hypothermia

HypothyroidismManagement

Levothyroxine (T4) supplement

6-8 weeks

? Subclinical hypothyroidism

Parathyroid dysfunctionHyperparathyroidism

Primary hyperparathyroidism

Secondary hyperparathyroidism

Tertiary hyperparathyroidism

HypoparathyroidismIatrogenicAutoimmune disease

Calcium homeostasisCalcitonin

Hypercalcemia: causes

Metastatic bone diseaseHyperparathyroidismSarcoidosisHyperthyroidismMultiple myelomaVitamin D overdose

Hypercalcemia: managementHydration

Drink 4-6 liters/dayIV fluid

Diuretics: loop diuretics!! Volume replacement and hypo K

BisphosphanatesPamidronate 60-90mg IV3 days to act, last 3 weeks

CalcitoninLast 48 hr

Perioperative care for 2°HPTDialysis

one day preop.24-48 hr postop.

Correct postop hypocalcemiaOral/IV calcium supplementOral vitamin D3correct hypomagnesaemia

Observe bleedingomit heparin use in dialysis a day before surgeryaware of platelets dysfunction in uremia

Adrenal dysfunctionAdrenal cortex

Zona glomerulosa Aldosterone

Zona fasciculata Cortisol, DHEAZona reticularis Estrogen, Androgen

Adrenal medullaAdrenalines, Noradrenalin and Dopamine

Adrenal tumour

Corticol tumour/ Diffuse hyperplasiaCushing’s syndromeConn’s syndromeAdrenogenital syndrome

Pheochromocytoma

Cushing syndrome

ObesityLoss of connective tissueHirsutism Muscle weaknessOsteoporosisHypertensionGlucose intoleranceDelayed wound healingImpaired immune function

Adrenal crisisAddison disease

Bilateral adrenalectomy

Bilateral adrenal infarction/hemorrhage

Secondary adrenal failure

Adrenal crisisClinical features

Hypotension/ shockAnorexiaNausea/vomitingAbdominal painFeverLethargyHypoglycemia

Adrenal crisis: managementRandom cortisol(<10μg/dl) and ACTH

Fluid resuscitation with 0.9% saline

Hydrocortisone 100mg IV every 6-8 hr

Identify and treat the precipitating causes

ACTH stimulation test should not be used during critical period

Glucocorticoid supplement in maintenance dose

Thank you