Endocrinology Handbook Endocrine Unit Imperial College Healthcare NHS Trust Charing Cross, Hammersmith and St. Mary’s Hospitals Updated: March 2010 First published 1988. Available as a 290 kB .pdf file since 1999 on: http://imperialendo.co.uk http://meeran.info 1 INTRODUCTION ..................................................................................................... 6 ANTERIOR PITUITARY ........................................................................................... 7 ANTERIOR PITUITARY FUNCTION .................................................................................................7 INSULIN TOLERANCE TEST (ITT) ..............................................................................................7 GLUCAGON TEST ......................................................................................................................9 THYROTROPHIN RELEASING HORMONE (TRH) TEST...........................................................10 GONADOTROPHIN RELEASING HORMONE GNRH/LHRH TEST.............................................11 COMBINED PITUITARY FUNCTION TESTS (CPT) ....................................................................12 VISUAL FIELD TESTING (GOLDMANN OR HUMPHREYS PERIMETRY) ..................................14 SUSPECTED CUSHING'S DISEASE..............................................................................................16 LOW DOSE DEXAMETHASONE SUPPRESSION TEST (LDDST)..............................................16 BILATERAL SIMULTANEOUS INFERIOR PETROSAL SINUS SAMPLING (IPSS) WITH CRF .....17 HIGH DOSE DEXAMETHASONE SUPPRESSION TEST (HDDST) ............................................19 PRE-OPERATIVE PREPARATION OF PATIENTS WITH CONFIRMED CUSHING’S DISEASE/SYNDROME..............................................................................................................20 PERIPHERAL VENOUS SAMPLING FOR SOURCES OF ECTOPIC ACTH ................................21 OVERNIGHT DEXAMETHASONE SUPPRESSION TEST ..........................................................21 CRH TESTING (WITHOUT DEXAMETHASONE). ......................................................................22 CUSHING’S DAY CURVE ..........................................................................................................23 PROLACTINOMAS AND NON FUNCTIONING PITUITARY ADENOMAS .......................................24 ASSAY PROBLEMS TO BE AWARE OF WITH PROLACTIN......................................................24 DISTINGUISHING PITUITARY MACROADENOMAS SECRETING PROLACTIN FROM NON FUNCTIONING TUMOURS .......................................................................................................24 PROTOCOL FOR CABERGOLINE SUPPRESSION...................................................................24 PREGNANCY AND THE PITUITARY.........................................................................................25 DOPAMINE AGONIST TREATMENT OF HYPERPROLACTINAEMIA.........................................25 PITUITARY TUMOURS ..................................................................................................................27 OPERATIVE MANAGEMENT OF PITUITARY TUMOURS..........................................................27 HYDROCORTISONE REPLACEMENT PRE- AND POST-PITUITARY SURGERY......................27 POST OPERATIVE MANAGEMENT OF DIABETES INSIPIDUS.................................................28 IMMEDIATE POST-OPERATIVE ASSESSMENT OF GH BURDEN IN ACROMEGALY...............29 IMMEDIATE POST-OPERATIVE ASSESSMENT OF EARLY REMISSION IN CUSHING’S DISEASE ..................................................................................................................................30 CUSHING’S DAY CURVE FOR ASSESSMENT OF EARLY REMISSION FOLLOWING TRANS- SPHENOIDAL SURGERY FOR CUSHING’S DISEASE ..............................................................33 FOLLOW UP OF PATIENTS WITH CUSHING’S DISEASE FOLLOWING BILATERAL ADRENALECTOMY...................................................................................................................33 POLICY ON SPERM STORAGE PRIOR TO PITUITARY RADIOTHERAPY................................34 HYDROCORTISONE DAY CURVE (HCDC) ...............................................................................35 GROWTH HORMONE....................................................................................................................36 2 A WORD ON UNITS ..................................................................................................................36 HUMAN GROWTH HORMONE (HGH) PRESCRIBING FOR ADULT ONSET GROWTH HORMONE DEFICIENCY (AOGHD) ..........................................................................................36 EXERCISE TEST ......................................................................................................................37 ARGININE STIMULATION TEST................................................................................................38 ORAL GLUCOSE TOLERANCE TEST FOR ACROMEGALY.......................................................39 FOLLOW UP FOLLOWING PITUITARY SURGERY AND RADIOTHERAPY................................40 SCREENING COLONOSCOPY IN ACROMEGALY....................................................................40 HISTORICAL METHODS OF ASSESSING EXCESS GROWTH HORMONE...............................41 FINGER SIZE ASSESSMENT....................................................................................................41 MEASURING SKIN-FOLD THICKNESS .....................................................................................41 POSTERIOR PITUITARY....................................................................................... 43 DIABETES INSIPIDUS...................................................................................................................43 WATER DEPRIVATION TEST ...................................................................................................43 PROLONGED WATER DEPRIVATION TEST (MILLER AND MOSES).........................................46 INDICATION..............................................................................................................................46 THERAPEUTIC TRIAL OF DDAVP.............................................................................................47 ADRENAL INVESTIGATIONS ............................................................................... 48 SHORT SYNACTHEN TEST......................................................................................................48 LONG SYNACTHEN TEST........................................................................................................50 ADRENAL TUMOURS ...................................................................................................................52 OPERATIVE MANAGEMENT OF BILATERAL ADRENALECTOMY.............................................52 HYPERALDOSTERONISM ............................................................................................................54 PLASMA ALDOSTERONE, AND PLASMA RENIN ACTIVITY.....................................................54 ADRENAL VENOUS SAMPLING FOR ALDOSTERONE.............................................................56 SELENIUM CHOLESTEROL SCANNING FOR CONN’S TUMOURS ..........................................60 PHAEOCHROMOCYTOMAS AND PARAGANGLIOMAS ...............................................................61 PLASMA/URINE CATECHOLAMINE MEASUREMENT ..............................................................61 PLASMA/URINE METANEPHRINE MEASUREMENT ................................................................62 MANAGEMENT OF SUSPECTED PHAEMOCHROMOCYTOMA................................................63 PENTOLINIUM SUPPRESSION TEST.......................................................................................63 CLONIDINE SUPPRESSION TEST............................................................................................65 GENETIC SCREENING FOR PHAEOCHROMOCYTOMAS .......................................................66 MIBG SCAN ..............................................................................................................................67 THYROID AND PARATHYROID. .......................................................................... 69 PROTOCOL FOR THE POST-RADIOIODINE TREATMENT TELEPHONE CLINIC.....................69 INSTRUCTIONS FOR THOSE RUNNING THE PHONE CLINIC. ................................................71 PREPARATION OF THYROTOXIC PATIENTS FOR THYROIDECTOMY ...................................73 3 PENTAGASTRIN TEST FOR MEDULLARY THYROID CARCINOMA .........................................74 CALCIUM INFUSION TEST FOR MEDULLARY CA THYROID ...................................................75 FINE NEEDLE ASPIRATION OF A THYROID NODULE (FNA) ...................................................76 HYPERPARATHYROIDISM............................................................................................................79 PANCREAS........................................................................................................... 81 DIABETES.....................................................................................................................................81 GLUCOSE TOLERANCE TEST .................................................................................................81 AUTONOMIC FUNCTION TESTS ..............................................................................................82 GUT HORMONE TUMOURS ................................................................................