METABOLIC AND ENDOCRINE DISORDERS

1. Overview of Hepatic & Biliary System

✅ Definition:
The hepatic system includes the liver, gallbladder, and bile ducts, responsible for metabolism, detoxification, digestion, and bile secretion.

✅ Functions of the Liver:

Function	Description
Metabolism	Metabolizes carbohydrates, fats, and proteins.
Bile Production	Produces bile for fat digestion.
Detoxification	Detoxifies drugs, alcohol, and toxins.
Protein Synthesis	Produces albumin & clotting factors.
Storage	Stores vitamins (A, D, B12) & glycogen.
Immune Function	Contains Kupffer cells to fight infections.

✅ Functions of the Biliary System (Gallbladder & Bile Ducts):

• Stores & releases bile for fat digestion.
• Eliminates bilirubin & cholesterol from the body.

---

2. History Taking in Hepatic & Biliary Disorders

✅ Key Questions to Ask the Patient:

1. Symptoms of Liver Disease

Symptom	Possible Cause
Jaundice (Yellow skin, sclera)	Liver failure, Hepatitis, Biliary obstruction.
Fatigue & Weakness	Liver dysfunction, Chronic hepatitis.
Abdominal Swelling (Ascites)	Cirrhosis, Portal Hypertension.
Easy Bruising & Bleeding	↓ Clotting factors (Liver failure).
Dark Urine & Pale Stools	Biliary obstruction, Liver disease.
Right Upper Quadrant Pain	Gallstones, Cholecystitis.
Nausea & Loss of Appetite	Hepatitis, Fatty Liver Disease.

2. Past Medical History

• History of Hepatitis (A, B, C, E).
• Alcohol Use (Alcoholic Liver Disease).
• Liver Disease (Cirrhosis, Fatty Liver, Liver Cancer).
• Gallbladder Disease (Cholecystitis, Gallstones).
• Use of Hepatotoxic Drugs (Acetaminophen, Methotrexate).

3. Family & Social History

• Family history of liver disease.
• Smoking & Alcohol consumption.
• IV Drug Use (Risk of Hepatitis B & C).

4. Diet & Lifestyle

• High-fat diet (Gallstones, NAFLD).
• Obesity (Fatty Liver Disease).
• Unprotected sex, Tattooing (Hepatitis B & C Risk).

---

3. Physical Examination in Hepatic & Biliary Disorders

✅ Step-by-Step Examination:

1. General Inspection

• Jaundice (Yellow skin & eyes – Bilirubin buildup).
• Ascites (Fluid accumulation in abdomen – Cirrhosis).
• Muscle wasting (Chronic Liver Disease).
• Palmar Erythema (Red palms – Liver Failure).
• Spider Angiomas (Dilated blood vessels – Liver Cirrhosis).

2. Abdominal Examination

Finding	Possible Cause
Hepatomegaly (Enlarged Liver)	Hepatitis, Fatty Liver, Cancer.
Splenomegaly (Enlarged Spleen)	Portal Hypertension, Cirrhosis.
Ascites (Fluid in Abdomen)	Cirrhosis, Liver Failure.
Murphy’s Sign (RUQ Pain on Inspiration)	Cholecystitis (Gallbladder Inflammation).
Rebound Tenderness	Peritonitis (Ruptured Gallbladder).

3. Neurological Examination (Hepatic Encephalopathy)

Finding	Significance
Asterixis (Flapping Tremor)	Hepatic Encephalopathy.
Confusion, Personality Changes	Liver Failure, Ammonia Buildup.

---

4. Diagnostic Measures for Liver & Biliary Disorders

✅ Definition:
Diagnostic tests help assess liver function, bile flow, and detect liver disease.

✅ Common Hepatic & Biliary Diagnostic Tests:

4.1. Liver Function Tests (LFTs)

✅ Purpose:

• Evaluates liver damage & function.

Test	Normal Range	Clinical Significance
Alanine Aminotransferase (ALT)	7-55 U/L	↑ in Hepatitis, Fatty Liver.
Aspartate Aminotransferase (AST)	10-40 U/L	↑ in Alcoholic Liver Disease.
Alkaline Phosphatase (ALP)	40-130 U/L	↑ in Biliary Obstruction, Gallstones.
Bilirubin (Total)	0.1-1.2 mg/dL	↑ in Jaundice, Liver Failure.
Albumin	3.5-5.0 g/dL	↓ in Cirrhosis, Chronic Liver Disease.
Prothrombin Time (PT/INR)	11-13 sec / INR 1.0	Prolonged in Liver Disease.

✅ Key Points:

• ↑ ALT & AST → Liver Cell Damage.
• ↑ ALP & Bilirubin → Biliary Obstruction.
• ↓ Albumin → Chronic Liver Disease.
• Prolonged PT → ↓ Clotting Factor Production (Liver Dysfunction).

---

4.2. Imaging Studies

Test	Purpose	Findings in Disease
Ultrasound (USG Abdomen)	Detects Gallstones, Fatty Liver, Liver Tumors	Hyperechoic Liver (Fatty Liver), Gallstones.
CT Scan (Liver & Biliary System)	Detailed imaging of liver, bile ducts	Liver Mass, Hepatic Vein Obstruction.
MRI (MRCP – Magnetic Resonance Cholangiopancreatography)	Evaluates Bile Ducts	Biliary Obstruction, Tumors.

✅ Key Points:

• Ultrasound is the first-line test for liver & gallbladder diseases.
• CT/MRI is used for detecting liver tumors & complications.

---

4.3. Specialized Liver & Biliary Tests

Test	Purpose	Clinical Significance
Hepatitis Serology (HBsAg, Anti-HCV, Anti-HAV)	Detects Hepatitis A, B, C, E	Positive in Viral Hepatitis.
Liver Biopsy	Confirms Liver Disease (Cirrhosis, Cancer)	Fibrosis in Cirrhosis, Cancer Cells in Tumors.
Endoscopic Retrograde Cholangiopancreatography (ERCP)	Evaluates Biliary Tract & Pancreas	Detects Gallstones, Tumors.

✅ Key Points:

• Hepatitis Serology confirms viral hepatitis.
• Liver Biopsy is the gold standard for cirrhosis & tumors.
• ERCP is used for bile duct blockages (Gallstones, Cancer).

1. Jaundice

✅ Definition:
Jaundice is yellow discoloration of the skin, sclera (eyes), and mucous membranes due to high bilirubin levels (>2.5 mg/dL) in the blood.

✅ Types of Jaundice:

Type	Cause	Key Features
Pre-Hepatic (Hemolytic Jaundice)	Excess RBC breakdown (Hemolysis)	↑ Unconjugated Bilirubin, Normal LFTs.
Hepatic (Hepatocellular Jaundice)	Liver damage (Hepatitis, Cirrhosis)	↑ Both Unconjugated & Conjugated Bilirubin, ↑ ALT/AST.
Post-Hepatic (Obstructive Jaundice)	Bile duct blockage (Gallstones, Tumor)	Pale stools, Dark urine, Itching, ↑ ALP.

✅ Symptoms of Jaundice:

• Yellow skin & sclera.
• Dark-colored urine (↑ Bilirubin in urine).
• Pale stools (Lack of bile pigments).
• Generalized itching (Pruritus).

✅ Diagnosis of Jaundice:

Test	Findings
Serum Bilirubin	↑ Total, Direct, or Indirect Bilirubin.
Liver Function Tests (LFTs)	↑ ALT, AST (Hepatic Jaundice); ↑ ALP (Obstructive Jaundice).
Ultrasound (USG Abdomen)	Detects liver damage, gallstones, tumors.

✅ Management of Jaundice:

Type	Treatment
Hemolytic Jaundice	Treat underlying hemolysis (Sickle Cell, Malaria).
Hepatic Jaundice	Antivirals (Hepatitis), Avoid Alcohol, Liver Transplant (End-stage).
Obstructive Jaundice	ERCP for Biliary Obstruction, Surgery for Tumors.

✅ Complications:

• Liver Failure, Portal Hypertension, Hepatic Encephalopathy.

---

2. Hepatic Cirrhosis

✅ Definition:
Cirrhosis is chronic liver damage leading to fibrosis, liver failure, and portal hypertension.

✅ Causes of Cirrhosis:

Category	Examples
Alcoholic Liver Disease	Chronic alcohol consumption.
Viral Hepatitis	Hepatitis B & C.
Non-Alcoholic Fatty Liver Disease (NAFLD)	Obesity, Diabetes.
Autoimmune & Genetic	Wilson’s Disease, Hemochromatosis.

✅ Symptoms of Cirrhosis:

• Fatigue, Weakness, Weight Loss.
• Jaundice, Dark Urine, Pale Stools.
• Abdominal Swelling (Ascites).
• Spider Angiomas, Palmar Erythema (Red palms).

✅ Complications of Cirrhosis:

• Portal Hypertension → Esophageal Varices, Ascites, Splenomegaly.
• Hepatic Encephalopathy → Confusion, Asterixis (Flapping Tremor).
• Hepatocellular Carcinoma (Liver Cancer).

✅ Diagnosis of Cirrhosis:

Test	Findings
Liver Function Tests (LFTs)	↑ ALT, AST, ↓ Albumin, ↑ INR.
Ultrasound (USG Liver)	Fibrosis, Nodular Liver.
Liver Biopsy	Confirms Cirrhosis (Gold Standard).

✅ Management of Cirrhosis:

Treatment	Purpose
Avoid Alcohol & Hepatotoxic Drugs.	Prevents worsening.
Diuretics (Spironolactone, Furosemide).	Treats Ascites.
Beta-Blockers (Propranolol).	Prevents Esophageal Variceal Bleeding.
Lactulose.	Reduces Ammonia (Prevents Encephalopathy).
Liver Transplant (End-Stage).	Only definitive cure.

✅ Complications:

• Liver Failure, Bleeding, Infection (Spontaneous Bacterial Peritonitis – SBP).

---

3. Portal Hypertension

✅ Definition:
Portal Hypertension is increased pressure in the portal vein (>10 mmHg) due to liver cirrhosis, leading to complications like varices & ascites.

✅ Causes of Portal Hypertension:

Category	Examples
Pre-Hepatic	Portal Vein Thrombosis.
Hepatic (Most Common)	Cirrhosis, Hepatitis, Liver Fibrosis.
Post-Hepatic	Budd-Chiari Syndrome (Hepatic Vein Obstruction).

✅ Symptoms of Portal Hypertension:

• Splenomegaly (Enlarged Spleen).
• Esophageal & Gastric Varices (Dilated Veins, Risk of Bleeding).
• Caput Medusae (Dilated Abdominal Veins).
• Ascites (Fluid in Abdomen).

✅ Diagnosis of Portal Hypertension:

Test	Findings
Doppler Ultrasound	Measures Portal Vein Pressure.
Endoscopy	Detects Esophageal Varices.

✅ Management of Portal Hypertension:

Treatment	Purpose
Beta-Blockers (Propranolol, Nadolol).	Lowers Portal Pressure, Prevents Bleeding.
Endoscopic Band Ligation (Varices).	Prevents Variceal Rupture.
TIPS (Transjugular Intrahepatic Portosystemic Shunt).	Shunt to reduce pressure in severe cases.

✅ Complications:

• Variceal Bleeding (Life-Threatening).
• Hepatic Encephalopathy (Due to Ammonia Buildup).

---

4. Ascites

✅ Definition:
Ascites is the abnormal accumulation of fluid in the peritoneal cavity due to portal hypertension & low albumin.

✅ Causes of Ascites:

Category	Examples
Liver Disease	Cirrhosis (Most Common).
Cancer	Peritoneal Carcinomatosis.
Heart Failure	Right Heart Failure, Constrictive Pericarditis.
Kidney Disease	Nephrotic Syndrome.

✅ Symptoms of Ascites:

• Abdominal Swelling, Weight Gain.
• Shifting Dullness (Fluid moves on percussion).
• Dyspnea (Difficulty Breathing due to Pressure on Diaphragm).

✅ Diagnosis of Ascites:

Test	Findings
Ultrasound (USG Abdomen)	Detects Fluid Accumulation.
Serum-Ascitic Albumin Gradient (SAAG)	SAAG >1.1 → Cirrhosis, SAAG <1.1 → Cancer, TB.
Paracentesis (Fluid Analysis)	WBC ↑ → Infection (SBP), Protein ↓ → Cirrhosis.

✅ Management of Ascites:

Treatment	Purpose
Salt Restriction & Diuretics (Spironolactone, Furosemide).	Removes Excess Fluid.
Paracentesis (Large Volume)	Removes Fluid if Severe.
Albumin Infusion	Prevents Hypotension Post-Paracentesis.
TIPS (Shunt Surgery).	For Severe, Refractory Ascites.

✅ Complications:

• Spontaneous Bacterial Peritonitis (SBP).
• Hepatorenal Syndrome (Kidney Failure in Cirrhosis).

1. Hepatic Encephalopathy & Coma

✅ Definition:
Hepatic Encephalopathy (HE) is a neuropsychiatric disorder caused by liver failure, leading to toxin accumulation (mainly ammonia) affecting brain function.

✅ Causes of Hepatic Encephalopathy:

Category	Examples
Liver Failure	Cirrhosis, Acute Liver Failure.
Infections	Sepsis, Spontaneous Bacterial Peritonitis (SBP).
Gastrointestinal Bleeding	↑ Nitrogen Load, Ammonia Formation.
Electrolyte Imbalance	Hypokalemia, Hyponatremia.
Drugs & Toxins	Sedatives, Benzodiazepines, Alcohol.

✅ Stages of Hepatic Encephalopathy (West Haven Criteria):

Stage	Symptoms
Stage 1 (Mild Confusion)	Mood changes, Mild irritability, Sleep disturbances.
Stage 2 (Drowsiness, Asterixis)	Lethargy, Disoriented, Flapping tremors (Asterixis).
Stage 3 (Severe Confusion)	Incoherent speech, Severe disorientation, Marked Asterixis.
Stage 4 (Coma)	Unresponsive, No response to pain, Deep coma.

✅ Symptoms of Hepatic Encephalopathy:

• Confusion, Personality Changes, Memory Loss.
• Asterixis (Flapping Tremor – Hand Jerks when Extended).
• Sweet/Foul Breath (Fetor Hepaticus).
• Sleep Pattern Reversal (Day-Night Confusion).

✅ Diagnosis of Hepatic Encephalopathy:

Test	Findings
Serum Ammonia Levels	↑ High (Confirms HE).
Liver Function Tests (LFTs)	↓ Albumin, ↑ INR, ↑ Bilirubin (Liver Failure).
CT Brain/MRI	Excludes other causes of confusion (Stroke, Tumor).

✅ Management of Hepatic Encephalopathy:

Treatment	Purpose
Lactulose (First-Line Treatment).	Reduces Ammonia Absorption in Gut.
Rifaximin (Antibiotic).	Kills Ammonia-Producing Bacteria.
Protein Restriction (Severe HE).	Prevents Ammonia Overload.
Correct Electrolytes (K+, Na+).	Prevents Worsening of HE.

✅ Complications of HE:

• Hepatic Coma (Irreversible Brain Damage).
• Multi-Organ Failure, Death.

---

2. Viral Hepatitis

✅ Definition:
Viral Hepatitis is inflammation of the liver caused by viral infection.

✅ Types & Causes of Viral Hepatitis:

Type	Transmission	Acute/Chronic	Vaccine Available?
Hepatitis A (HAV)	Fecal-Oral (Contaminated Water/Food).	Acute (Self-limiting).	Yes
Hepatitis B (HBV)	Blood, Sexual, Perinatal.	Acute & Chronic.	Yes
Hepatitis C (HCV)	Blood, IV Drug Use.	Mostly Chronic.	No
Hepatitis D (HDV)	Requires HBV Co-Infection.	Chronic (Severe).	Yes (HBV Vaccine Prevents It).
Hepatitis E (HEV)	Fecal-Oral, Contaminated Water.	Acute (Severe in Pregnancy).	No

✅ Symptoms of Viral Hepatitis:

• Jaundice (Yellow Skin, Eyes).
• Dark Urine, Pale Stools.
• Right Upper Quadrant Pain (Liver Inflammation).
• Fatigue, Nausea, Vomiting.

✅ Diagnosis of Viral Hepatitis:

Test	Findings
Liver Function Tests (LFTs)	↑ ALT, AST, ↑ Bilirubin.
Hepatitis Serology (HBsAg, Anti-HCV, Anti-HAV, Anti-HEV)	Confirms Specific Hepatitis Virus.

✅ Management of Viral Hepatitis:

Type	Treatment
Hepatitis A & E	Supportive Care (Rest, Fluids).
Hepatitis B	Antivirals (Tenofovir, Entecavir).
Hepatitis C	Direct-Acting Antivirals (Sofosbuvir, Ledipasvir).
Hepatitis D	Interferon Therapy.

✅ Complications:

• Cirrhosis, Liver Cancer (Hepatitis B & C).
• Fulminant Hepatitis (Acute Liver Failure).

---

3. Tumors & Cysts of the Liver

✅ Definition:
Liver tumors and cysts can be benign (non-cancerous) or malignant (cancerous), affecting liver function and bile flow.

✅ Types of Liver Tumors & Cysts:

Type	Nature	Key Features
Hepatocellular Carcinoma (HCC)	Malignant	Most Common Liver Cancer (HBV/HCV).
Liver Metastases	Malignant	Spreads from Colon, Breast, Lung Cancer.
Hepatic Adenoma	Benign	Associated with Oral Contraceptives.
Hemangioma	Benign	Most Common Benign Liver Tumor.
Liver Cyst (Simple Cyst)	Benign	Fluid-filled, Usually Asymptomatic.

✅ Symptoms of Liver Tumors & Cysts:

• Abdominal Pain, Weight Loss (Cancer).
• Jaundice (Tumor Blocking Bile Ducts).
• Palpable Liver Mass.

✅ Diagnosis of Liver Tumors & Cysts:

Test	Findings
Ultrasound (USG Liver)	Detects Masses & Cysts.
CT/MRI Abdomen	Confirms Tumor Type.
Alpha-Fetoprotein (AFP)	↑ in Hepatocellular Carcinoma.
Liver Biopsy	Confirms Cancer Type.

✅ Management:

• Surgery (Resection, Liver Transplant).
• Chemotherapy for Liver Metastases.
• Radiofrequency Ablation (RFA) for Small HCC.

✅ Complications:

• Liver Failure, Metastasis, Jaundice.

---

4. Liver Abscess

✅ Definition:
Liver Abscess is a pus-filled infection in the liver, caused by bacterial, parasitic, or fungal infections.

✅ Types of Liver Abscess:

Type	Cause	Common Organisms
Pyogenic Liver Abscess	Bacterial Infection	E. coli, Klebsiella, Staphylococcus.
Amoebic Liver Abscess	Entamoeba Histolytica	Common in Tropics.
Fungal Liver Abscess	Candida Infection	Occurs in Immunocompromised Patients.

✅ Symptoms of Liver Abscess:

• High Fever, Chills, Night Sweats.
• Right Upper Quadrant Pain.
• Jaundice, Nausea, Vomiting.

✅ Diagnosis:

Test	Findings
Ultrasound or CT Abdomen	Detects Abscess Cavity.
Aspiration & Culture	Identifies Causative Organism.

✅ Management of Liver Abscess:

• IV Antibiotics (Ceftriaxone, Metronidazole for Amoebic Abscess).
• Percutaneous Drainage (Needle Aspiration).
• Surgical Drainage (Severe Cases).

✅ Complications:

• Sepsis, Liver Rupture, Peritonitis.

1. Cholecystitis

✅ Definition:
Cholecystitis is inflammation of the gallbladder, often caused by gallstones blocking the cystic duct.

✅ Types of Cholecystitis:

Type	Cause	Key Features
Acute Cholecystitis	Gallstones (90% cases), Bacterial Infection	Severe RUQ pain, Fever, Murphy’s Sign (+).
Chronic Cholecystitis	Repeated Gallstone Attacks	Recurrent pain, Biliary colic, Gallbladder fibrosis.

✅ Risk Factors for Cholecystitis (5 F’s Rule):

• Female, Fat, Forty, Fertile, Fair (Light Skin).

✅ Symptoms of Cholecystitis:

• Severe RUQ pain (Radiates to Right Shoulder/Back).
• Nausea, Vomiting, Fever.
• Murphy’s Sign (+) – Pain on Deep Inspiration with RUQ Palpation.

✅ Complications of Cholecystitis:

• Gangrene, Gallbladder Rupture, Peritonitis.
• Fistula Formation (Gallbladder to Intestine).

✅ Diagnosis of Cholecystitis:

Test	Findings
Ultrasound (USG Abdomen)	Gallstones, Thickened Gallbladder Wall.
HIDA Scan (If USG Inconclusive)	No Gallbladder Filling = Cystic Duct Blockage.
LFTs & WBC Count	↑ WBCs (Infection), Mild ↑ ALP, AST.

✅ Management of Cholecystitis:

Treatment	Purpose
NPO (Nothing by Mouth), IV Fluids.	Prevents Gallbladder Stimulation.
IV Antibiotics (Ceftriaxone + Metronidazole).	Treats Infection.
Pain Control (NSAIDs, Opioids).	Symptomatic Relief.
Cholecystectomy (Surgical Removal).	Definitive Treatment (Laparoscopic Preferred).

---

2. Cholelithiasis (Gallstones)

✅ Definition:
Cholelithiasis is the formation of gallstones in the gallbladder, often due to cholesterol imbalance.

✅ Types of Gallstones:

Type	Composition	Risk Factors
Cholesterol Stones (Most Common – 80%)	Cholesterol	Obesity, Pregnancy, High-Fat Diet.
Pigment Stones	Bilirubin	Hemolysis (Sickle Cell, Cirrhosis).
Mixed Stones	Cholesterol + Pigment	Chronic Infections, Biliary Stasis.

✅ Symptoms of Cholelithiasis:

• Asymptomatic in Many Cases.
• Biliary Colic (RUQ Pain, Post-Fatty Meal, Resolves in Hours).

✅ Diagnosis of Cholelithiasis:

Test	Findings
Ultrasound (First-Line Test)	Detects Gallstones.

✅ Management of Cholelithiasis:

Treatment	Purpose
Asymptomatic Gallstones	No Treatment Needed.
Symptomatic Gallstones	Cholecystectomy (Preferred).
Non-Surgical Option (For Poor Surgical Candidates)	Ursodeoxycholic Acid (Dissolves Cholesterol Stones).

---

3. Choledocholithiasis (Common Bile Duct Stones)

✅ Definition:
Choledocholithiasis is the presence of gallstones in the common bile duct (CBD), leading to bile flow obstruction.

✅ Symptoms of Choledocholithiasis:

• Severe RUQ Pain (Colicky Pain).
• Jaundice (Obstructive – Pale Stools, Dark Urine).
• Fever (If Associated with Cholangitis – Infection of Bile Ducts).

✅ Complications of Choledocholithiasis:

• Acute Cholangitis (Sepsis Risk – Charcot’s Triad: RUQ Pain, Jaundice, Fever).
• Pancreatitis (Blockage of Pancreatic Duct).

✅ Diagnosis of Choledocholithiasis:

Test	Findings
Ultrasound (First Step)	Detects Dilated CBD.
MRCP (Magnetic Resonance Cholangiopancreatography)	Confirms CBD Stone.
ERCP (Endoscopic Retrograde Cholangiopancreatography)	Diagnostic & Therapeutic.

✅ Management of Choledocholithiasis:

Treatment	Purpose
ERCP (First-Line Treatment)	Removes CBD Stones.
Cholecystectomy (After ERCP)	Prevents Future Stones.

---

4. Acute & Chronic Pancreatitis

✅ Definition:
Pancreatitis is inflammation of the pancreas, leading to enzymatic self-digestion.

✅ Causes of Pancreatitis (GET SMASHED Mnemonic):

Cause	Examples
G	Gallstones (Most Common).
E	Ethanol (Alcohol Abuse).
T	Trauma.
S	Steroids.
M	Mumps (Viral Infection).
A	Autoimmune.
S	Scorpion Sting.
H	Hyperlipidemia, Hypercalcemia.
E	ERCP.
D	Drugs (Diuretics, Valproate).

✅ Symptoms of Acute Pancreatitis:

• Severe Epigastric Pain (Radiates to Back).
• Nausea, Vomiting.
• Cullen’s Sign (Periumbilical Bruising), Grey Turner’s Sign (Flank Bruising) – Severe Cases.

✅ Diagnosis of Pancreatitis:

Test	Findings
Serum Amylase & Lipase	↑ >3 Times Normal.
CT Abdomen (Best Test for Necrosis)	Enlarged Pancreas, Fluid Collections.

✅ Management of Acute Pancreatitis:

Treatment	Purpose
NPO (No Oral Intake), IV Fluids.	Prevents Pancreatic Stimulation.
Pain Control (Opioids).	Relieves Pain.
Treat Underlying Cause (ERCP for Stones, Alcohol Cessation).	Prevents Recurrence.

✅ Chronic Pancreatitis Symptoms:

• Recurrent Epigastric Pain, Weight Loss.
• Steatorrhea (Fatty Stools – Pancreatic Insufficiency).
• Diabetes Mellitus (Pancreatic β-Cell Destruction).

✅ Management of Chronic Pancreatitis:

• Pancreatic Enzyme Supplements (Lipase, Protease).
• Pain Control (Avoid Alcohol, NSAIDs, Opioids).
• Surgical Drainage (Severe Cases).

---

5. Pancreatic Cancer

✅ Definition:
Pancreatic cancer is a highly aggressive malignancy, often detected late.

✅ Risk Factors for Pancreatic Cancer:

• Smoking, Chronic Pancreatitis, Diabetes, Family History.

✅ Symptoms of Pancreatic Cancer:

• Painless Jaundice (Head of Pancreas Tumor).
• Weight Loss, Fatigue.
• New-Onset Diabetes.

✅ Diagnosis of Pancreatic Cancer:

Test	Findings
CT Scan (Best Test).	Detects Tumor Location.
CA 19-9 (Tumor Marker).	Elevated in Pancreatic Cancer.

✅ Management of Pancreatic Cancer:

• Whipple Surgery (Curative if Early-Stage).
• Palliative Chemotherapy (For Advanced Cases).

1. Overview of Endocrine System

✅ Definition:
The endocrine system consists of glands that release hormones directly into the bloodstream, regulating metabolism, growth, reproduction, and homeostasis.

✅ Major Endocrine Glands & Their Hormones:

Gland	Hormone Produced	Function
Hypothalamus	TRH, CRH, GnRH, GHRH, Dopamine	Regulates Pituitary Gland.
Pituitary Gland	GH, ACTH, TSH, FSH, LH, ADH, Oxytocin	Controls Growth, Metabolism, Reproduction.
Thyroid Gland	T3, T4, Calcitonin	Regulates Metabolism, Calcium Balance.
Parathyroid Gland	PTH	Increases Blood Calcium.
Adrenal Glands	Cortisol, Aldosterone, Adrenaline	Controls Stress, BP, and Electrolytes.
Pancreas (Endocrine Function)	Insulin, Glucagon	Regulates Blood Sugar.
Ovaries/Testes	Estrogen, Progesterone, Testosterone	Regulates Reproductive Function.

---

2. History Taking in Endocrine Disorders

✅ Key Questions to Ask the Patient:

1. Symptoms of Endocrine Disorders

Symptom	Possible Endocrine Disorder
Weight Loss, Heat Intolerance, Palpitations	Hyperthyroidism (Graves’ Disease).
Weight Gain, Cold Intolerance, Fatigue	Hypothyroidism (Hashimoto’s).
Increased Thirst & Urination	Diabetes Mellitus, Diabetes Insipidus.
Growth Abnormalities (Tall/Short Stature)	Gigantism, Dwarfism, Acromegaly.
Buffalo Hump, Moon Face, Abdominal Obesity	Cushing’s Syndrome (Excess Cortisol).
Fatigue, Hypoglycemia, Low BP	Adrenal Insufficiency (Addison’s Disease).
Menstrual Irregularities, Infertility	PCOS, Hypopituitarism, Hyperprolactinemia.

2. Past Medical History

• History of Diabetes, Thyroid Disorders, PCOS, Adrenal Disorders.
• Family History of Endocrine Diseases.
• Previous Hormonal Therapy or Surgeries.

3. Medication & Lifestyle History

• Use of Steroids (Can Cause Cushing’s Syndrome).
• Dietary Habits (High Sugar → Diabetes, Iodine Deficiency → Goiter).

---

3. Physical Examination in Endocrine Disorders

✅ Step-by-Step Examination:

1. General Inspection

• Body Habitus (Obesity, Cachexia).
• Skin Changes (Hyperpigmentation in Addison’s, Dry Skin in Hypothyroidism).
• Hair Changes (Hirsutism in PCOS, Hair Loss in Hypothyroidism).
• Neck Swelling (Goiter in Thyroid Disorders).

2. Vital Signs

Finding	Possible Endocrine Disorder
Hypertension, Tachycardia	Hyperthyroidism, Cushing’s Syndrome.
Hypotension, Bradycardia	Addison’s Disease, Hypothyroidism.
Increased Blood Sugar	Diabetes Mellitus.

3. Systemic Examination

Region	Findings	Endocrine Disorder
Face	Puffy Face, Dry Skin	Hypothyroidism.
Neck	Goiter, Thyroid Nodules	Thyroid Disorders.
Hands	Tremors	Hyperthyroidism.
Abdomen	Purple Striae, Central Obesity	Cushing’s Syndrome.

---

4. Diagnostic Evaluation of Endocrine Disorders

✅ Definition:
Endocrine function tests help detect hormonal imbalances and glandular dysfunctions.

✅ Common Endocrine Diagnostic Tests:

4.1. Thyroid Function Tests (TFTs)

Test	Normal Range	Findings in Disease
TSH (Thyroid-Stimulating Hormone)	0.4-4.0 mIU/L	↑ in Hypothyroidism, ↓ in Hyperthyroidism.
Free T3 & T4	T3: 80-200 ng/dL, T4: 5-12 µg/dL	↑ in Hyperthyroidism, ↓ in Hypothyroidism.

✅ Additional Thyroid Tests:

Test	Purpose
Thyroid Ultrasound	Detects Nodules, Goiter.
Thyroid Antibody Test (Anti-TPO, Anti-Tg)	Confirms Autoimmune Thyroid Disease (Graves’ or Hashimoto’s).

---

4.2. Blood Sugar & Diabetes Tests

Test	Normal Range	Findings in Disease
Fasting Blood Sugar (FBS)	70-99 mg/dL	≥126 mg/dL → Diabetes.
Postprandial (2-Hour) Blood Sugar	<140 mg/dL	>200 mg/dL → Diabetes.
HbA1c (Glycated Hemoglobin)	<5.7%	≥6.5% → Diabetes Mellitus.

✅ Additional Diabetes Tests:

Test	Purpose
Oral Glucose Tolerance Test (OGTT)	Confirms Gestational Diabetes.
C-Peptide Test	Differentiates Type 1 vs Type 2 Diabetes.

---

4.3. Adrenal Function Tests

Test	Normal Range	Findings in Disease
Serum Cortisol (Morning Sample)	5-25 µg/dL	↓ in Addison’s, ↑ in Cushing’s.
ACTH Stimulation Test	Evaluates Adrenal Insufficiency	No Cortisol Increase → Addison’s Disease.
Dexamethasone Suppression Test	Diagnoses Cushing’s Syndrome	No Cortisol Suppression → Cushing’s.

✅ Additional Adrenal Tests:

Test	Purpose
CT/MRI of Adrenal Glands	Detects Tumors (Pheochromocytoma).

---

4.4. Growth Hormone & Pituitary Tests

Test	Normal Range	Findings in Disease
Growth Hormone (GH)	Varies by Age	↑ in Acromegaly/Gigantism, ↓ in Dwarfism.
Prolactin	<20 ng/mL	↑ in Prolactinoma.

✅ Additional Pituitary Tests:

Test	Purpose
MRI Brain (Pituitary Gland)	Detects Tumors (Prolactinoma, Acromegaly).

---

4.5. Parathyroid & Calcium Tests

Test	Normal Range	Findings in Disease
Parathyroid Hormone (PTH)	10-65 pg/mL	↑ in Hyperparathyroidism, ↓ in Hypoparathyroidism.
Serum Calcium	8.5-10.2 mg/dL	↑ in Hyperparathyroidism, ↓ in Hypocalcemia.

✅ Additional Parathyroid Tests:

Test	Purpose
DEXA Scan	Detects Bone Loss (Osteoporosis).

1. Overview of the Pituitary Gland

✅ Definition:
The pituitary gland (master gland) is a pea-sized endocrine gland located at the base of the brain, responsible for secreting hormones that regulate other endocrine glands.

✅ Functions of the Pituitary Gland:

Hormone	Secreted by	Function
Growth Hormone (GH)	Anterior Pituitary	Stimulates growth & metabolism.
Thyroid-Stimulating Hormone (TSH)	Anterior Pituitary	Regulates thyroid function.
Adrenocorticotropic Hormone (ACTH)	Anterior Pituitary	Stimulates adrenal gland (Cortisol secretion).
Prolactin (PRL)	Anterior Pituitary	Stimulates milk production.
Follicle-Stimulating Hormone (FSH)	Anterior Pituitary	Regulates ovarian follicles & sperm production.
Luteinizing Hormone (LH)	Anterior Pituitary	Triggers ovulation & testosterone production.
Antidiuretic Hormone (ADH/Vasopressin)	Posterior Pituitary	Controls water balance & blood pressure.
Oxytocin	Posterior Pituitary	Stimulates uterine contractions & milk ejection.

---

2. History Taking in Pituitary Disorders

✅ Key Questions to Ask the Patient:

1. Symptoms of Pituitary Disorders

Symptom	Possible Pituitary Disorder
Excessive Growth (Gigantism in Children, Acromegaly in Adults)	GH Excess (Pituitary Adenoma).
Short Stature, Delayed Puberty	GH Deficiency (Dwarfism).
Irregular Menstrual Cycles, Infertility, Galactorrhea (Breast Milk Secretion Without Pregnancy)	Prolactinoma (Excess Prolactin).
Extreme Fatigue, Hypoglycemia, Weight Loss	ACTH Deficiency (Adrenal Insufficiency).
Polyuria, Polydipsia, Dehydration	Diabetes Insipidus (ADH Deficiency).
Headache, Vision Problems (Bitemporal Hemianopia – Loss of Peripheral Vision)	Pituitary Tumor.

2. Past Medical History

• History of Pituitary Tumors, Brain Surgery, Head Injury.
• Family History of Endocrine Disorders.

3. Medication & Lifestyle History

• Use of Steroids (Affects ACTH Secretion).
• History of Radiation Therapy (Can Damage Pituitary Gland).

---

3. Physical Examination in Pituitary Disorders

✅ Step-by-Step Examination:

1. General Inspection

• Gigantism (Excessive Height) or Dwarfism (Short Stature).
• Facial Changes (Coarse Features in Acromegaly).
• Breast Enlargement, Galactorrhea (Prolactinoma).

2. Systemic Examination

Region	Findings	Pituitary Disorder
Hands & Feet	Enlarged Hands/Feet	Acromegaly.
Skin & Hair	Excess Hair Growth (Hirsutism)	Cushing’s Disease.
Neck Examination	Enlarged Thyroid (Goiter)	TSH Imbalance.
Neurological Examination	Vision Loss (Bitemporal Hemianopia)	Pituitary Tumor.

---

4. Diagnostic Evaluation of Pituitary Disorders

✅ Definition:
Pituitary function tests help detect hormonal imbalances & pituitary gland dysfunction.

✅ Common Pituitary Diagnostic Tests:

4.1. Growth Hormone (GH) Tests

Test	Normal Range	Findings in Disease
Serum GH	Varies by Age	↑ in Acromegaly/Gigantism, ↓ in GH Deficiency.
IGF-1 (Insulin-Like Growth Factor-1)	Varies by Age	↑ in Acromegaly.
Oral Glucose Tolerance Test (OGTT) for GH Suppression	GH Should Suppress	Failure to Suppress → Acromegaly.

---

4.2. Prolactin (PRL) Tests

Test	Normal Range	Findings in Disease
Serum Prolactin	<20 ng/mL (Men), <30 ng/mL (Women)	↑ in Prolactinoma.

✅ Additional Tests for Prolactinoma:

• MRI Brain (Pituitary Gland) → Detects Tumor.

---

4.3. Adrenal Function Tests (ACTH & Cortisol)

Test	Normal Range	Findings in Disease
Serum ACTH	10-50 pg/mL	↑ in Cushing’s, ↓ in Addison’s.
Serum Cortisol (Morning Sample)	5-25 µg/dL	↑ in Cushing’s, ↓ in Adrenal Insufficiency.
Dexamethasone Suppression Test	Cortisol Should Suppress	No Suppression → Cushing’s Disease.

✅ Additional Tests for Cushing’s Syndrome:

• 24-Hour Urinary Free Cortisol → Confirms Cushing’s.
• MRI Pituitary → Detects ACTH-Secreting Tumor.

---

4.4. Thyroid-Stimulating Hormone (TSH) Tests

Test	Normal Range	Findings in Disease
TSH	0.4-4.0 mIU/L	↑ in Hypothyroidism, ↓ in Hyperthyroidism.
Free T3 & T4	T3: 80-200 ng/dL, T4: 5-12 µg/dL	↓ in Hypothyroidism, ↑ in Hyperthyroidism.

✅ Additional Tests for Pituitary Hypothyroidism:

• MRI Pituitary → Detects TSH-Secreting Tumors.

---

4.5. Antidiuretic Hormone (ADH) Tests

Test	Normal Range	Findings in Disease
Serum ADH (Vasopressin)	1-5 pg/mL	↓ in Diabetes Insipidus, ↑ in SIADH.
Serum Osmolality	285-295 mOsm/kg	↑ in Diabetes Insipidus, ↓ in SIADH.

✅ Additional Tests for Diabetes Insipidus:

• Water Deprivation Test → No Urine Concentration Confirms Diagnosis.
• MRI Pituitary → Detects ADH-Secreting Tumors.

---

5. Management of Pituitary Disorders

✅ Common Pituitary Disorders & Their Treatments:

Disorder	Cause	Treatment
Acromegaly/Gigantism	GH-Secreting Pituitary Adenoma	Surgery (Transsphenoidal), Octreotide (GH Blocker).
Dwarfism (GH Deficiency)	GH Deficiency	Growth Hormone Therapy.
Prolactinoma	Excess Prolactin (Pituitary Tumor)	Cabergoline, Bromocriptine (Dopamine Agonists).
Cushing’s Disease	ACTH-Secreting Tumor	Surgery, Ketoconazole (Cortisol Blocker).
Diabetes Insipidus (ADH Deficiency)	Lack of ADH	Desmopressin (DDAVP).

1. Overview of the Thyroid Gland

✅ Definition:
The thyroid gland is a butterfly-shaped endocrine gland located in the neck, responsible for producing hormones that regulate metabolism, energy balance, and growth.

✅ Thyroid Hormones & Their Functions:

Hormone	Function
Thyroxine (T4)	Precursor hormone, converted to T3.
Triiodothyronine (T3)	Regulates metabolism, body temperature, heart rate.
Calcitonin	Lowers blood calcium levels.

✅ Regulation of Thyroid Function:

• Hypothalamus releases TRH (Thyrotropin-Releasing Hormone).
• Pituitary releases TSH (Thyroid-Stimulating Hormone).
• TSH stimulates the Thyroid Gland to produce T3 & T4.

---

2. Hyperthyroidism (Thyrotoxicosis)

✅ Definition:
Hyperthyroidism is a condition where the thyroid gland overproduces T3 & T4, leading to increased metabolism.

✅ Causes of Hyperthyroidism:

Cause	Description
Graves’ Disease (Most Common)	Autoimmune disorder (TSH receptor antibodies stimulate excessive hormone production).
Toxic Multinodular Goiter (Plummer’s Disease)	Multiple thyroid nodules secrete excess hormones.
Thyroiditis (Subacute, Postpartum, Hashimoto’s Thyroiditis – Early Stage)	Inflammation leads to hormone leakage.
Excess Iodine Intake (Jod-Basedow Phenomenon)	Overstimulation of the thyroid due to excessive iodine (e.g., Amiodarone use).

✅ Symptoms of Hyperthyroidism:

• Weight Loss, Heat Intolerance, Excessive Sweating.
• Palpitations, Tachycardia, Arrhythmias.
• Tremors, Anxiety, Hyperactivity.
• Goiter (Thyroid Enlargement).
• Exophthalmos (Bulging Eyes – Graves’ Disease).

✅ Diagnosis of Hyperthyroidism:

Test	Findings
TSH (Thyroid-Stimulating Hormone)	↓ Low in Primary Hyperthyroidism.
T3 & T4	↑ Elevated.
Thyroid Ultrasound	Detects Nodules (Toxic Nodular Goiter).
Radioactive Iodine Uptake (RAIU) Scan	Diffuse Uptake (Graves’), Focal Uptake (Toxic Nodules).

✅ Management of Hyperthyroidism:

Treatment	Mechanism
Antithyroid Drugs (Methimazole, Propylthiouracil – PTU)	Blocks Thyroid Hormone Production.
Beta-Blockers (Propranolol, Atenolol)	Controls Symptoms (Heart Rate, Tremors).
Radioactive Iodine Therapy (Preferred in Graves’ Disease)	Destroys Overactive Thyroid Tissue.
Thyroidectomy (Surgical Removal)	For Large Goiter, Cancer, Severe Cases.

✅ Complications of Hyperthyroidism:

• Thyroid Storm (Life-Threatening Crisis) → Fever, Tachycardia, Delirium.
• Heart Failure, Osteoporosis, Arrhythmias (Atrial Fibrillation).

---

3. Hypothyroidism

✅ Definition:
Hypothyroidism is a condition where the thyroid gland underproduces T3 & T4, leading to slowed metabolism.

✅ Causes of Hypothyroidism:

Cause	Description
Hashimoto’s Thyroiditis (Most Common)	Autoimmune destruction of the thyroid.
Iodine Deficiency	Most common worldwide cause.
Post-Thyroidectomy or Post-Radioactive Iodine Therapy	Surgical removal or destruction of the thyroid gland.
Congenital Hypothyroidism (Cretinism)	Present from birth due to thyroid dysfunction.
Medications (Amiodarone, Lithium)	Inhibit thyroid hormone synthesis.

✅ Symptoms of Hypothyroidism:

• Weight Gain, Cold Intolerance, Dry Skin.
• Fatigue, Depression, Slow Thinking.
• Bradycardia, Low Blood Pressure.
• Constipation, Puffy Face, Hoarseness.
• Goiter (Thyroid Enlargement).

✅ Diagnosis of Hypothyroidism:

Test	Findings
TSH (Thyroid-Stimulating Hormone)	↑ High in Primary Hypothyroidism.
T3 & T4	↓ Low.
Thyroid Antibody Test (Anti-TPO, Anti-Tg)	↑ High in Hashimoto’s Thyroiditis.

✅ Management of Hypothyroidism:

Treatment	Mechanism
Levothyroxine (T4 Replacement Therapy – First-Line Treatment)	Restores Normal Thyroid Function.

✅ Complications of Hypothyroidism:

• Myxedema Coma (Life-Threatening) → Severe Bradycardia, Hypothermia, Respiratory Failure.
• Cardiovascular Disease, Infertility, Goiter.

---

4. Thyroid Tumors

✅ Definition:
Thyroid tumors are abnormal growths in the thyroid gland, which may be benign or malignant.

✅ Types of Thyroid Tumors:

Type	Nature	Key Features
Papillary Carcinoma (Most Common – 80%)	Malignant	Slow-growing, Spreads to Lymph Nodes.
Follicular Carcinoma	Malignant	Hematogenous Spread (Lungs, Bones).
Medullary Carcinoma	Malignant	Associated with MEN-2 Syndrome.
Anaplastic Carcinoma (Most Aggressive)	Malignant	Rapid Growth, Poor Prognosis.
Thyroid Adenoma	Benign	Usually Non-Functional, Can Cause Hyperthyroidism.

✅ Symptoms of Thyroid Tumors:

• Painless Thyroid Nodule.
• Hoarseness (If Compressing Laryngeal Nerve).
• Difficulty Swallowing (Dysphagia).

✅ Diagnosis of Thyroid Tumors:

Test	Findings
Thyroid Ultrasound	Detects Nodules.
Fine Needle Aspiration (FNA) Biopsy	Confirms Malignancy.
CT/MRI of Neck	Detects Tumor Spread.

✅ Management of Thyroid Tumors:

• Surgical Removal (Thyroidectomy – First-Line for Cancer).
• Radioactive Iodine Therapy (For Differentiated Cancers).
• TSH Suppression Therapy (Levothyroxine).

---

5. Goiter

✅ Definition:
A goiter is an abnormal enlargement of the thyroid gland, which may be associated with hypo-, hyper-, or euthyroid states.

✅ Types of Goiter:

Type	Cause	Key Features
Simple (Non-Toxic) Goiter	Iodine Deficiency, Pregnancy	Thyroid Function Normal.
Toxic Goiter	Graves’ Disease, Toxic Multinodular Goiter	Hyperthyroidism Symptoms.
Endemic Goiter	Low Iodine in Diet	Common in Iodine-Deficient Regions.

✅ Symptoms of Goiter:

• Neck Swelling.
• Difficulty Swallowing/Breathing (Large Goiter).

✅ Management of Goiter:

• Iodine Supplementation (For Deficiency).
• Thyroidectomy (For Large or Toxic Goiter).

1. Overview of the Parathyroid Glands

✅ Definition:
The parathyroid glands are four small glands located behind the thyroid, responsible for regulating calcium and phosphate metabolism through parathyroid hormone (PTH).

✅ Function of Parathyroid Hormone (PTH):

Action	Effect on Calcium (Ca²⁺)	Effect on Phosphate (PO₄³⁻)
Bone	↑ Calcium Release (Bone Resorption).	↑ Phosphate Release.
Kidney	↑ Calcium Reabsorption.	↓ Phosphate Reabsorption (More Excreted in Urine).
Intestine (via Vitamin D Activation)	↑ Calcium Absorption.	↑ Phosphate Absorption.

✅ Regulation of PTH Secretion:

• ↓ Calcium → ↑ PTH Release.
• ↑ Calcium → ↓ PTH Release.
• Vitamin D Suppresses PTH Secretion.

---

2. Hyperparathyroidism

✅ Definition:
Hyperparathyroidism is excessive secretion of PTH, leading to hypercalcemia and bone demineralization.

✅ Types & Causes of Hyperparathyroidism:

Type	Cause	Pathophysiology
Primary Hyperparathyroidism (Most Common)	Parathyroid Adenoma (80-85%), Parathyroid Hyperplasia, Parathyroid Cancer.	Excess PTH → ↑ Calcium, ↓ Phosphate.
Secondary Hyperparathyroidism	Chronic Kidney Disease (CKD), Vitamin D Deficiency, Malabsorption.	Chronic Hypocalcemia → ↑ PTH (Compensatory).
Tertiary Hyperparathyroidism	Long-Standing Secondary Hyperparathyroidism.	Autonomous PTH Secretion Despite Normal Calcium.

✅ Symptoms of Hyperparathyroidism (Stones, Bones, Groans, Moans)

• Kidney Stones (Nephrolithiasis, Hypercalciuria).
• Bone Pain, Osteoporosis (↑ Bone Resorption).
• Abdominal Pain, Constipation, Peptic Ulcers (Hypercalcemia Increases Gastric Acid).
• Muscle Weakness, Depression, Confusion.

✅ Diagnosis of Hyperparathyroidism:

Test	Findings
Serum Calcium	↑ High.
Serum PTH	↑ High.
Serum Phosphate	↓ Low (Primary Hyperparathyroidism).
24-Hour Urinary Calcium	↑ High in Primary, ↓ in FHH (Familial Hypocalciuric Hypercalcemia).
Bone Density Scan (DEXA Scan)	↓ Bone Mineral Density (Osteoporosis).

✅ Management of Hyperparathyroidism:

Treatment	Indication
Parathyroidectomy (Surgical Removal – First-Line for Symptomatic Primary Hyperparathyroidism).	Parathyroid Adenoma, Severe Hypercalcemia.
Cinacalcet (Calcimimetic – Lowers PTH).	Patients Unable to Undergo Surgery.
Bisphosphonates (Alendronate, Zoledronic Acid).	Prevents Bone Loss.
Correct Vitamin D Deficiency.	Needed for Calcium Absorption.

✅ Complications of Hyperparathyroidism:

• Osteoporosis (Fracture Risk).
• Nephrolithiasis (Kidney Stones).
• Calciphylaxis (Soft Tissue Calcification in CKD).

---

3. Hypoparathyroidism

✅ Definition:
Hypoparathyroidism is deficient secretion of PTH, leading to hypocalcemia and hyperphosphatemia.

✅ Causes of Hypoparathyroidism:

Cause	Description
Surgical Removal (Most Common)	Accidental removal of parathyroid glands during thyroidectomy.
Autoimmune Hypoparathyroidism	Destruction of parathyroid glands.
DiGeorge Syndrome (Congenital Absence of Parathyroid Glands).	Genetic disorder with immune and heart defects.
Hypomagnesemia	Magnesium deficiency (Alcoholism, Malabsorption) → PTH Suppression.

✅ Symptoms of Hypoparathyroidism (Tetany & Neuromuscular Irritability):

• Tetany (Muscle Spasms, Cramps, Numbness).
• Chvostek’s Sign (+) (Facial Twitching with Tap on Cheek).
• Trousseau’s Sign (+) (Carpal Spasm with BP Cuff Inflation).
• Laryngospasm, Seizures.
• Prolonged QT Interval on ECG (Arrhythmia Risk).

✅ Diagnosis of Hypoparathyroidism:

Test	Findings
Serum Calcium	↓ Low.
Serum PTH	↓ Low.
Serum Phosphate	↑ High.
Serum Magnesium	↓ Low (If Cause is Hypomagnesemia).

✅ Management of Hypoparathyroidism:

Treatment	Mechanism
Calcium Supplements (Calcium Carbonate, Calcium Citrate).	Raises Serum Calcium.
Vitamin D Supplements (Calcitriol).	Enhances Calcium Absorption.
Magnesium Replacement (If Low).	Corrects PTH Secretion.
Recombinant PTH Therapy (For Severe Cases).	Direct Hormone Replacement.

✅ Complications of Hypoparathyroidism:

• Seizures (Severe Hypocalcemia).
• Laryngospasm (Airway Obstruction).
• Cataracts, Brain Calcifications (Chronic Hypocalcemia).

---

4. Pseudohypoparathyroidism

✅ Definition:
Pseudohypoparathyroidism is a rare genetic disorder where PTH resistance occurs, leading to hypocalcemia despite high PTH levels.

✅ Symptoms of Pseudohypoparathyroidism:

• Short Stature, Round Face, Short 4th & 5th Fingers (Albright’s Hereditary Osteodystrophy – AHO).
• Tetany, Muscle Spasms.

✅ Diagnosis:

Test	Findings
Serum Calcium	↓ Low.
Serum PTH	↑ High (No Response).
Serum Phosphate	↑ High.

✅ Management:

• Same as Hypoparathyroidism (Calcium, Vitamin D).

---

5. Hypercalcemia & Hypocalcemia – Quick Overview

✅ Causes of Hypercalcemia (High Calcium)

Cause	Example
Primary Hyperparathyroidism	Parathyroid Adenoma.
Malignancy (Cancer-Related Hypercalcemia)	PTHrP-Secreting Tumors (Lung, Breast).
Vitamin D Toxicity	Excess Supplementation.

✅ Causes of Hypocalcemia (Low Calcium)

Cause	Example
Hypoparathyroidism	Post-Thyroidectomy, Autoimmune.
Vitamin D Deficiency	Malabsorption, CKD.
Acute Pancreatitis	Calcium Deposits in Pancreas.

1. Pancreatic Disorders – Diabetes Mellitus (DM)

✅ Definition:
Diabetes Mellitus (DM) is a chronic metabolic disorder characterized by hyperglycemia (high blood sugar levels) due to insulin deficiency or resistance.

✅ Types of Diabetes Mellitus:

Type	Cause	Key Features
Type 1 DM (Autoimmune, Insulin-Dependent)	Autoimmune destruction of pancreatic β-cells → No Insulin Production.	Young age onset, Ketoacidosis risk, Insulin required.
Type 2 DM (Insulin Resistance)	Insulin resistance in muscles, liver, and adipose tissue.	Adult-onset, Associated with obesity, Controlled by diet, oral drugs, or insulin.
Gestational Diabetes Mellitus (GDM)	Insulin resistance due to pregnancy hormones.	Occurs in pregnancy, Risk of future Type 2 DM.

✅ Symptoms of Diabetes Mellitus (3P’s + Chronic Complications):

• Polyuria (Frequent Urination).
• Polydipsia (Excessive Thirst).
• Polyphagia (Excessive Hunger).
• Unexplained Weight Loss (Type 1 DM).
• Fatigue, Blurred Vision, Recurrent Infections (Fungal, UTIs).

✅ Diagnosis of Diabetes Mellitus:

Test	Normal Value	Diabetes Diagnosis
Fasting Blood Sugar (FBS)	70-99 mg/dL	≥126 mg/dL → Diabetes.
Postprandial Blood Sugar (2-Hour OGTT)	<140 mg/dL	≥200 mg/dL → Diabetes.
HbA1c (Glycated Hemoglobin, 3-Month Sugar Control)	<5.7%	≥6.5% → Diabetes.

✅ Management of Diabetes Mellitus:

Treatment	Type	Mechanism
Lifestyle Modification (Diet, Exercise).	All Types	Weight control, Insulin sensitivity.
Metformin (First-Line Drug).	Type 2 DM	Reduces Liver Glucose Production.
Insulin Therapy (Rapid, Short, Long-Acting).	Type 1 DM, Severe Type 2 DM	Replaces Insulin Deficiency.
Oral Hypoglycemics (Sulfonylureas, DPP-4 Inhibitors, SGLT2 Inhibitors).	Type 2 DM	Stimulate Insulin Release, Reduce Glucose Reabsorption.

✅ Complications of Diabetes Mellitus:

1. Acute:
   • Diabetic Ketoacidosis (DKA) – Type 1 DM: Hyperglycemia, Ketosis, Acidosis, Dehydration.
   • Hyperosmolar Hyperglycemic State (HHS) – Type 2 DM: Severe Hyperglycemia, No Ketosis.
2. Chronic:
   • Neuropathy (Tingling, Numbness).
   • Nephropathy (Kidney Damage).
   • Retinopathy (Blindness Risk).
   • Cardiovascular Disease (Heart Attack, Stroke).

---

2. Adrenal Disorders

2.1. Pheochromocytoma (Adrenal Medulla Tumor)

✅ Definition:
Pheochromocytoma is a tumor of the adrenal medulla that secretes excess catecholamines (epinephrine & norepinephrine), causing severe hypertension.

✅ Symptoms of Pheochromocytoma (5 P’s Mnemonic):

• Pressure (Hypertension – Paroxysmal or Persistent).
• Pain (Severe Headaches).
• Palpitations (Tachycardia, Arrhythmias).
• Perspiration (Excessive Sweating).
• Panic Symptoms (Anxiety, Tremors).

✅ Diagnosis of Pheochromocytoma:

Test	Findings
Plasma Metanephrines (Best Initial Test).	↑ High.
24-Hour Urine Catecholamines (Epinephrine, Norepinephrine).	↑ High.
CT/MRI Abdomen (Adrenal Imaging).	Detects Tumor Location.

✅ Management of Pheochromocytoma:

Treatment	Purpose
Alpha-Blockers (Phenoxybenzamine – First-Line).	Controls Blood Pressure Before Surgery.
Beta-Blockers (Propranolol – Given After Alpha-Blockers).	Controls Heart Rate.
Surgical Removal (Adrenalectomy – Definitive Cure).	Removes Tumor.

✅ Complications of Pheochromocytoma:

• Hypertensive Crisis (Sudden BP Spike, Stroke Risk).
• Arrhythmias, Multi-Organ Damage.

---

2.2. Addison’s Disease (Adrenal Insufficiency)

✅ Definition:
Addison’s disease is a deficiency of cortisol and aldosterone due to adrenal gland destruction.

✅ Causes of Addison’s Disease:

Type	Cause
Primary Adrenal Insufficiency (Addison’s Disease)	Autoimmune Adrenalitis (Most Common), TB, HIV.
Secondary Adrenal Insufficiency	Pituitary ACTH Deficiency, Long-Term Steroid Use.

✅ Symptoms of Addison’s Disease:

• Hyperpigmentation (Bronze Skin, Darkened Gums) – Primary Only.
• Fatigue, Weight Loss, Muscle Weakness.
• Hypotension (Low BP, Dizziness, Syncope).
• Salt Craving (Aldosterone Deficiency).

✅ Diagnosis of Addison’s Disease:

Test	Findings
Morning Serum Cortisol	↓ Low.
ACTH Stimulation Test (Gold Standard).	No Cortisol Increase → Addison’s Disease.
Serum Sodium & Potassium	↓ Sodium, ↑ Potassium (Aldosterone Deficiency).

✅ Management of Addison’s Disease:

Treatment	Purpose
Hydrocortisone (Cortisol Replacement).	Treats Cortisol Deficiency.
Fludrocortisone (Aldosterone Replacement).	For Primary Addison’s Disease.

✅ Complications of Addison’s Disease:

• Addisonian Crisis (Severe Hypotension, Shock, Coma – Medical Emergency).

---

2.3. Cushing’s Syndrome (Excess Cortisol Production)

✅ Definition:
Cushing’s Syndrome is a condition of excess cortisol, leading to hypertension, obesity, and metabolic disturbances.

✅ Causes of Cushing’s Syndrome:

Cause	Description
Cushing’s Disease (Pituitary ACTH Tumor)	Most Common Cause.
Adrenal Tumor (Adrenal Cushing’s Syndrome)	Excess Cortisol Secretion.
Long-Term Steroid Use (Exogenous Cushing’s Syndrome).	Most Common Overall.

✅ Symptoms of Cushing’s Syndrome:

• Moon Face, Buffalo Hump, Central Obesity.
• Purple Striae (Stretch Marks), Thin Skin, Easy Bruising.
• Hypertension, Diabetes, Osteoporosis.

✅ Diagnosis of Cushing’s Syndrome:

Test	Findings
24-Hour Urinary Free Cortisol	↑ High.
Dexamethasone Suppression Test (Gold Standard).	No Suppression of Cortisol → Cushing’s Syndrome.

✅ Management of Cushing’s Syndrome:

Treatment	Purpose
Surgery (Pituitary or Adrenal Tumor Removal).	Definitive Cure.
Ketoconazole (Cortisol Blocker).	Used in Non-Surgical Cases.

✅ Complications of Cushing’s Syndrome:

• Osteoporosis, Diabetes, Hypertension, Cardiovascular Disease.

1. Overview of Metabolic and Endocrine Drug Therapy

✅ Definition:
Drugs used in metabolic and endocrine disorders regulate hormone levels, treat deficiencies or excesses, and manage related metabolic abnormalities.

✅ Key Endocrine Glands Targeted by These Drugs:

• Hypothalamus & Pituitary Gland (GH, ADH, ACTH, TSH).
• Thyroid Gland (T3, T4, Calcitonin).
• Parathyroid Gland (PTH, Calcium Regulation).
• Adrenal Gland (Cortisol, Aldosterone, Catecholamines).
• Pancreas (Insulin, Glucagon, Diabetes Control).

---

2. Drugs for Diabetes Mellitus

✅ Classification of Anti-Diabetic Drugs:

Class	Example	Mechanism of Action
Insulin Therapy	Regular Insulin, NPH, Glargine	Replaces Insulin Deficiency (Type 1 & Severe Type 2 DM).
Biguanides	Metformin (First-Line for Type 2 DM)	Reduces Liver Glucose Production, Increases Insulin Sensitivity.
Sulfonylureas	Glibenclamide, Glipizide	Stimulates Pancreatic Insulin Release.
DPP-4 Inhibitors	Sitagliptin, Vildagliptin	Prolongs Action of Incretins → More Insulin Release.
SGLT-2 Inhibitors	Empagliflozin, Dapagliflozin	Increases Glucose Excretion in Urine.
GLP-1 Agonists	Liraglutide, Exenatide	Slows Gastric Emptying, Increases Insulin.
Alpha-Glucosidase Inhibitors	Acarbose	Delays Glucose Absorption in Intestines.

✅ Insulin Types & Action:

Type	Example	Onset	Duration
Rapid-Acting	Lispro, Aspart	<15 min	3-5 hrs
Short-Acting	Regular Insulin	30 min-1 hr	5-8 hrs
Intermediate-Acting	NPH (Neutral Protamine Hagedorn)	1-2 hrs	12-18 hrs
Long-Acting	Glargine, Detemir	1-4 hrs	24 hrs

✅ Complications of Diabetes Drug Therapy:

• Hypoglycemia (Most Common in Insulin & Sulfonylureas).
• Lactic Acidosis (Metformin – Avoid in Kidney Failure).
• Weight Gain (Sulfonylureas, Insulin).

---

3. Drugs for Thyroid Disorders

✅ Drugs for Hypothyroidism:

Drug	Mechanism of Action	Indications
Levothyroxine (T4 Replacement, First-Line).	Replaces Deficient T4	Hypothyroidism, Myxedema Coma.

✅ Drugs for Hyperthyroidism (Antithyroid Drugs):

Drug	Mechanism of Action	Indications
Methimazole (Preferred), Propylthiouracil (PTU – Safe in Pregnancy).	Blocks Thyroid Hormone Synthesis	Graves’ Disease, Thyrotoxicosis.
Radioactive Iodine (I-131).	Destroys Overactive Thyroid Cells	Hyperthyroidism, Thyroid Cancer.
Beta-Blockers (Propranolol, Atenolol).	Controls Symptoms (Tachycardia, Tremors)	Thyroid Storm, Graves’ Disease.

✅ Complications of Thyroid Drugs:

• Hypothyroidism (Over-Treatment with Antithyroid Drugs).
• Agranulocytosis (Rare but Severe Side Effect of Methimazole & PTU).

---

4. Drugs for Parathyroid Disorders & Calcium Regulation

✅ Drugs for Hyperparathyroidism & Hypercalcemia:

Drug	Mechanism of Action	Indications
Cinacalcet (Calcimimetic).	Increases Sensitivity of Calcium Receptors → Reduces PTH Secretion.	Primary & Secondary Hyperparathyroidism.
Bisphosphonates (Alendronate, Zoledronic Acid).	Inhibits Bone Resorption → Lowers Calcium.	Osteoporosis, Hypercalcemia.
Calcitonin.	Lowers Calcium by Inhibiting Bone Resorption.	Acute Hypercalcemia, Osteoporosis.

✅ Drugs for Hypoparathyroidism & Hypocalcemia:

Drug	Mechanism of Action	Indications
Calcium Supplements (Calcium Carbonate, Calcium Citrate).	Increases Serum Calcium.	Hypocalcemia, Osteoporosis.
Vitamin D Supplements (Calcitriol, Cholecalciferol).	Increases Calcium & Phosphate Absorption.	Vitamin D Deficiency, Hypoparathyroidism.
Recombinant PTH Therapy (For Severe Cases).	Direct Hormone Replacement.	Hypoparathyroidism.

✅ Complications of Calcium & Vitamin D Therapy:

• Hypercalcemia (Excess Calcium Supplementation).
• Kidney Stones (Long-Term High Calcium Intake).

---

5. Drugs for Adrenal Disorders

✅ Drugs for Addison’s Disease (Adrenal Insufficiency – Cortisol & Aldosterone Deficiency):

Drug	Mechanism of Action	Indications
Hydrocortisone, Prednisolone (Glucocorticoids).	Replaces Cortisol Deficiency.	Addison’s Disease, Adrenal Crisis.
Fludrocortisone (Mineralocorticoid).	Replaces Aldosterone Deficiency.	Primary Adrenal Insufficiency.

✅ Drugs for Cushing’s Syndrome (Excess Cortisol Production):

Drug	Mechanism of Action	Indications
Ketoconazole, Metyrapone.	Blocks Cortisol Synthesis.	Cushing’s Syndrome.
Surgery (First-Line for Tumor).	Removes Source of Excess Cortisol.	Adrenal/Pituitary Tumors.

✅ Drugs for Pheochromocytoma (Excess Catecholamines – Adrenal Medulla Tumor):

Drug	Mechanism of Action	Indications
Alpha-Blockers (Phenoxybenzamine – First-Line).	Controls High Blood Pressure.	Pheochromocytoma (Before Surgery).
Beta-Blockers (Propranolol – Used After Alpha-Blockers).	Controls Tachycardia.	Pheochromocytoma.

✅ Complications of Adrenal Drug Therapy:

• Adrenal Crisis (If Glucocorticoids are Suddenly Stopped).
• Osteoporosis (Long-Term Steroid Use).

---

6. Drugs for Growth Hormone (GH) Disorders

✅ Drugs for Growth Hormone Deficiency (Dwarfism):

Drug	Mechanism of Action	Indications
Somatropin (Recombinant GH).	Increases Growth in GH-Deficient Individuals.	GH Deficiency, Turner Syndrome.

✅ Drugs for Acromegaly & Gigantism (Excess GH):

Drug	Mechanism of Action	Indications
Octreotide (Somatostatin Analog).	Inhibits GH Release.	Acromegaly, Gigantism.