From liver to hormones: The endocrine consequences of cirrhosis

Hepatocrinology explores the intricate relationship between liver function and the endocrine system. Chronic liver diseases such as liver cirrhosis can cause endocrine disorders due to toxin accumulation and protein synthesis disruption. Despite its importance, assessing endocrine issues in cirrhotic patients is frequently neglected. This article provides a comprehensive review of the epidemiology, pathophysiology, diagnosis, and treatment of endocrine disturbances in liver cirrhosis. The review was conducted using the PubMed/Medline, EMBASE, and Scielo databases, encompassing 172 articles. Liver cirrhosis is associated with endocrine disturbances, including diabetes, hypoglycemia, sarcopenia, thyroid dysfunction, hypogonadotropic hypogonadism, bone disease, adrenal insufficiency, growth hormone dysfunction, and secondary hyperaldosteronism. The optimal tools for diagnosing diabetes and detecting hypoglycemia are the oral glucose tolerance test and continuous glucose monitoring system, respectively. Sarcopenia can be assessed through imaging and functional tests, while other endocrine disorders are evaluated using hormonal assays and imaging studies. Treatment options include metformin, glucagon-like peptide-1 analogs, sodium-glucose co-transporter-2 inhibitors, and insulin, which are effective and safe for diabetes control. Established standards are followed for managing hypoglycemia, and hormone replacement therapy is often necessary for other endocrine dysfunctions. Liver transplantation can address some of these problems.

Refractory Hypothyroidism: Unraveling the Complexities of Diagnosis and Management

INTRODUCTION

Refractory hypothyroidism (RH) represents a challenge in the diagnosis and treatment within the field of thyroidology. It is defined as the inability to achieve disease control despite using levothyroxine (LT4) doses of 1.9 μg/kg/d or higher.

METHODS

A comprehensive review, encompassing 103 articles, was conducted using the Scielo, Scopus, and EMBASE databases, providing an approach to evaluation and diagnosis of this condition.

RESULTS

LT4 disintegrates and dissolves within an acidic gastric environment before being absorbed in the jejunum and ileum. It then extensively binds to serum transporter proteins and undergoes deiodination to yield tri-iodothyronine, the biologically active hormone. There are various nonpathological causes of RH, such as noncompliance with treatment, changes in the brand of LT4, food and drug interferences, as well as pregnancy. Pathological causes include lactose intolerance, Helicobacter pylori infection, giardiasis, among others. The diagnosis of RH involves conducting a thorough medical history and requesting relevant laboratory tests to rule out causes of treatment resistance. The LT4 absorption test allows for the identification of cases of malabsorption. The treatment of RH involves identifying and addressing the underlying causes of noncompliance or malabsorption. In cases of pseudomalabsorption, supervised and weekly administration of LT4 may be considered.

DISCUSSION

Early recognition of RH and correction of its underlying cause are of utmost importance, as this avoids the use of excessive doses of LT4 and prevents cardiovascular and bone complications associated with this condition.

Wolfram Syndrome 1 in Two Brothers Treated with Insulin Pump

Background/Objective

Wolfram syndrome (WS) is a rare genetic disorder, in which patients develop early-onset diabetes mellitus (DM), optic nerve atrophy, and neurodegeneration, which has no specific treatment available. Here, we report 2 brothers treated with an insulin pump to manage the alterations of the glycemic levels due to the DM.

Case Report

We present the case of 2 siblings diagnosed with Wolfram syndrome 1, they presented with typical endocrinological and neurodegenerative early manifestations, one brother was treated with a sensor-augmented insulin infusion system, and the other with an insulin pump. Both reached a better metabolic state and had improved quality of life.

Discussion

The management of WS is still a challenge; however, the use of a sensor-augmented insulin infusion system and the information that it provides may offer better care to patients who require frequent monitoring and adjustments in their treatment. It has been reported that the neurodegenerative progression of WS is also associated with high glucose peaks; therefore, it is necessary to control it, even when it is hard due to the difficult-to-manage DM. There is only 1 previous case report of WS with insulin pump that describes the benefits of continuous subcutaneous insulin infusion and tight metabolic control during pregnancy.

Conclusion

The use of insulin pumps may be an effective treatment for DM in WS patients, mainly in terms of improving the prognosis of difficult-to-manage DM.

Baipás gástrico versus manga gástrica para el control de diabetes tipo 2 en pacientes obesos

Introducción. La diabetes mellitus tipo 2 y la obesidad son enfermedades con alta prevalencia, gran morbimortalidad y elevados costos en salud. La cirugía bariátrica ha demostrado efectividad para inducir pérdida de peso y un control adecuado de la glicemia. Métodos. Estudio observacional analítico retrospectivo, realizado entre 2014 y 2019 en una institución de alta complejidad. Se incluyeron pacientes prediabéticos y diabéticos sometidos a cirugía bariátrica tipo baipás gástrico en Y-de-Roux o manga gástrica. Se analizaron la mejoría o resolución de la diabetes y la pérdida del exceso de peso a los 6, 12, 24 y 36 meses luego de la cirugía. Resultados. Se incluyeron 103 pacientes en el estudio, 45 pacientes diabéticos y 58 pacientes prediabéticos. La única variable perioperatoria con diferencia estadísticamente significativa fue el tiempo quirúrgico mayor en el baipás (70 vs. 47,5 minutos; p<0,001). La pérdida de exceso de peso fue mayor en el baipás. Los pacientes diabéticos sometidos a baipás tuvieron un mayor porcentaje de resolución o control comparados con los sometidos a manga gástrica. En los pacientes prediabéticos hubo resolución en ambos grupos luego de 24 meses de seguimiento. Conclusión. El baipás gástrico y la manga gástrica presentan excelentes resultados en cuanto a pérdida de peso y control metabólico en pacientes con diabetes mellitus tipo 2 y prediabetes, pero en nuestros pacientes se lograron resultados superiores en ambos aspectos con el baipás gástrico.

Neoplasia endocrina múltiple tipo 2B: un enfoque de diagnóstico genotipo-fenotipo y abordaje terapéutico

La neoplasia endocrina múltiple tipo 2B (MEN 2B) es un síndrome genético poco común, con una prevalencia estimada de 0,9 a 1,6 por millón de individuos y una incidencia de 1,4 a 2,6 por millón de nacidos vivos por año. Es causada por una mutación en el protooncogén RET y se caracteriza por la presencia de carcinoma medular de tiroides (CMT) en el 100 % de los casos, feocromocitoma hasta en el 50 % y características extraendocrinas como un fenotipo marfanoide, alteraciones musculoesqueléticas y dentales, neuromas mucosos, alacrimia y ganglioneuromatosis intestinal difusa con síntomas de dismotilidad esofágica y gastrointestinal.  Este síndrome se asocia con una calidad de vida deteriorada y una supervivencia deficiente, debidas principalmente a la agresividad del CMT, enfermedad que usualmente es de aparición temprana o metastásica. El diagnóstico generalmente se realiza de forma tardía, lo cual retrasa el enfoque integral, que incluye tipificación genética, tratamiento quirúrgico temprano del CMT y terapias específicas como inhibidores de tirosina quinasa (ITK) en caso de CMT avanzado. La cirugía es el tratamiento principal y la única posibilidad de cura, aunque el advenimiento de las terapias dirigidas parece estar mejorando la supervivencia libre de progresión en los casos avanzados. 

Therapeutic plasmapheresis for the treatment of thyrotoxicosis: A retrospective multi-center study

BACKGROUND AND AIMS

Thyroid storm and severe thyrotoxicosis remain among the most frequent endocrine emergencies, and first-line hyperthyroidism treatment is not always an option. Since the first report in 1970, plasmapheresis is a second-line treatment for severe or otherwise untreatable thyrotoxicosis when rapid euthyroidism is desired.

METHODS

We present a retrospective study of the experience in treating thyrotoxicosis with plasmapheresis between 2012 and 2020 in two specialized centers in Colombia. We register the demographic and clinical characteristic and compare the thyroid hormones and other biochemical measurements before and after treatment.

RESULTS

Data from 19 patients was obtained, 58% female with a median age of 35 years (IQR 23.5), and most of them with Graves' disease. The most frequent indication for plasmapheresis was thyroid storm. A median of 4 (IQR 2) sessions lead to a significant reduction in FT4 (P .0001) and TT3 (P < .0003) with a nonsignificant decrease in beta-blocker (P .7353) dose, no change in hepatic enzymes, and no adverse events. After plasmapheresis, thyroidectomy was performed in 10 patients.

CONCLUSIONS

Plasmapheresis is an effective and safe treatment option for reducing circulating thyroid hormones in severe thyrotoxicosis when other forms of treatment are contraindicated or in case of urgent thyroid and non-thyroid surgery. It is limited by its cost and the need for highly specialized resources.

VIPoma: a rare cause of diarrhea. A case report

Introduction: Vasoactive intestinal peptide-secreting tumor (VIPoma) is a rare functional pancreatic neuroendocrine tumor (F-PNET) characterized by secretory diarrhea, hypokalemia, and hypochlorhydria. Its low incidence and high risk of malignancy pose a clinical challenge that requires a high degree of clinical suspicion. Case presentation: A 61-year-old woman visited the emergency department of a tertiary care hospital in Medellín, Colombia, due to chronic diarrhea (7 months) that led to dehydration, renal failure, metabolic acidosis, and hypokalemia. As a result, a treatment based on loperamide, intravenous fluids and broad-spectrum antibiotics was started. In addition, chromogranin A levels of 477 ug/L (<100) were reported, while an abdominal MRI showed a 33x30mm mass in the head and uncinate process of the pancreas, so outpatient surgical management was decided. However, three days after discharge, and due to the persistence of clinical signs, the patient was admitted to another hospital (also a tertiary care hospital), where, given the high suspicion of VIPoma, and once the diarrhea was solved, the mass was removed (Whipple procedure) without any complication. Finally, the diagnosis was confirmed based on serum vasoactive intestinal peptide levels (930 pg/mL (RV<75)) and the pathology report (PNET tumor grade 2). Two years after the surgery, the patient was asymptomatic, and no residual lesions or metastases were evident in a control MRI. Conclusion: Late diagnosis of VIPoma is associated with worsened quality of life, severe complications, and high prevalence of metastasis. Therefore, it should be suspected in patients with chronic secretory diarrhea that is not caused by an infection, since early diagnosis and timely treatment can contribute to achieving better survival rates in these patients.

Perioperative management of pheocromocytoma/ paraganglioma: a comprehensive review

Pheochromocytomas are rare neuroendocrine neoplasms that require adequate preoperative evaluation in order to prevent and lessen the serious complications of catecholamine hypersecretion. Preoperative management contributes to reducing morbidity and mortality rates in patients who have not been diagnosed with this condition and undergo any surgery. However, current mortality seems to be lower, a fact attributed to preoperative management with alpha blockers.

The influence of glacial melt and retreat on the nutritional condition of the bivalve Nuculana inaequisculpta (Protobranchia: Nuculanidae) in the West Antarctic Peninsula

Due to climate change, numerous ice bodies have been lost in the West Antarctic Peninsula (WAP). As a consequence, deglaciation is expected to impact the marine environment and its biota at physiological and ecosystem levels. Nuculana inaequisculpta is a marine bivalve widely distributed around Antarctica that plays an important role for ecosystem functioning. Considering that N. inaequisculpta inhabits coastal areas under effect of glacial melt and retreat, impacts on its nutritional condition are expected due to alterations on its physiology and food availability. To test this hypothesis, biochemical composition (lipids, proteins, and fatty acids) and energy content were measured in individuals of N. inaequisculpta collected in a fjord at different distances to the retreating glacier in the WAP. Oceanographic parameters of the top and bottom-water layers (temperature, salinity, dissolved oxygen, and chlorophyll-a) were measured to investigate how the environment changes along the fjord. Results showed that surface oceanographic parameters displayed a lower temperature and dissolved oxygen, but a higher salinity and chlorophyll-a content at nearest compared to farthest sites to the glacier. In contrast, a lower temperature and chlorophyll-a, and a higher salinity and dissolved oxygen was measured in the bottom-water layer toward the glacier. N. inaequisculpta had a higher amount of lipids (17.42 ± 3.24 vs. 12.16 ± 3.46%), protein (24.34 ± 6.12 vs. 21.05 ± 2.46%) and energy content (50.57 ± 6.97 J vs. 39.14 ± 5.80 J) in the farthest compared to the nearest site to the glacier. No differences were found in total fatty acids among all sites. It seems likely that lower individual fitness related to proximity to the glacier would not be related to nutritional quality of sediment food, but rather to food quantity.

Characteristics of hypoparathyroidism in Colombia: data from a single center in the city of Medellín

OBJECTIVE

Hypoparathyroidism is a rare condition, whose most common etiology is complications of neck surgery. The aim of the study was to identify the clinical and biochemical profile of the patients with diagnosis of hypoparathyroidism, including the frequency of symptoms, clinical signs, long-term complications and disease control. Additionally, the study sought to know what the medication profile was, and the doses required by the patients.

SUBJECTS AND METHOD

A retrospective cohort study was conducted wherein all patients with ICD-10 codes associated with hypoparathyroidism between 2011 and 2018 at the Hospital Universitario San Vicente Fundación were included. We investigated the etiology of the disease; biochemical profile including lowest serum calcium, highest serum phosphorus, 25OHD levels, calciuria and calcium/phosphorus product; medication doses, disease control, and presence of complications, especially renal and neurologic complications were also evaluated.

RESULTS

The cohort included 108 patients (99 women/9 men) with a mean age of 51.6 ± 15.6 years. The main etiology was postoperative (93.5%), the dose of elemental calcium received was relatively low (mean 1,164 mg/day), and in only 9.2% of cases more than 2,500 mg/day of elemental calcium was necessary. We were able to evaluate the follow-up in 89 patients, and found that only 57.3% met the criteria for controlled disease.

CONCLUSION

The clinical profile of patients with hypoparathyroidism in our cohort is similar to that described in other international studies, with predominantly postoperative etiology. With standard therapy, only adequate control is achieved in a little more than half of patients. Arch Endocrinol Metab. 2020;64(3):282-9.

Dyslipidaemias and their treatment in high complexity centres in Colombia

BACKGROUND AND OBJECTIVE

Data is scarce on the distribution of different types of dyslipidaemia in Colombia. The primary objective was to describe the frequency of dyslipidaemias. The secondary objectives were: frequency of cardiovascular comorbidity, statins and other lipid-lowering drugs use, frequency of statins intolerance, percentage of patients achieving c-LDL goals, and distribution of cardiovascular risk (CVR).

MATERIALS AND METHODS

Cross-sectional study with retrospective data collection from 461 patients diagnosed with dyslipidaemia and treated in 17 highly specialised centres distributed into six geographic and economic regions of Colombia.

RESULTS

Mean (SD) age was 66.4 (±12.3) years and 53.4% (246) were women. Dyslipidaemias were distributed as follows in order of frequency: mixed dyslipidaemia (51.4%), hypercholesterolaemia (41.0%), hypertriglyceridaemia (5.4%), familial hypercholesterolaemia (3.3%), and low c-HDL (0.7%). The most prescribed drugs were atorvastatin (75.7%) followed by rosuvastatin (24.9%). As for lipid control, 55% of all patients, and 28.6% of those with coronary heart disease, did not achieve their personal c-LDL goal despite treatment. The frequency of statin intolerance was 2.6% in this study.

CONCLUSIONS

Mixed dyslipidaemia and hypercholesterolaemia are the most frequent dyslipidaemias in Colombia. A notable percentage of patients under treatment with lipid-lowering drugs, including those with coronary heart disease, did not achieve specific c-LDL goals. This poor lipid control may worsen patient's CVR, so that therapeutic strategies need to be changed, either with statin intensification or addition of new drugs in patients with higher CVR.

Hemorragia adrenal bilateral sin insuficiencia adrenal asociada con enoxaparina

La hemorragia adrenal bilateral es un fenómeno poco común que puede acarrear consecuencias catastróficas por una crisis adrenal. Se ha asociado con diversas entidades como la sepsis, anticoagulación, neoplasias, el trauma, síndrome antifosfolípido y estado postoperatorio, especialmente, de cirugías ortopédicas. Su diagnóstico se dificulta en la medida en que los pacientes presentan signos y síntomas inespecíficos, por lo cual, una alta sospecha clínica es el principal indicador para la realización de una imagen que confirme el dictamen. Se presenta el caso de una hemorragia adrenal bilateral sin insuficiencia adrenal en una mujer de 71 años que, durante el quinto día del posoperatorio, tras una osteosíntesis de rodilla y recibiendo profilaxis antitrombótica con enoxaparina, ingresa al servicio de urgencias por dolor abdominal tipo cólico con 12 horas de evolución, acompañado de náuseas y sin signos de inestabilidad hemodinámica.

Descripción de la experiencia en pacientes diagnosticados con insulinoma. Estudio multicéntrico en Medellín, Colombia

Objetivo: describir la experiencia de los pacientes con insulinoma, diagnosticados y tratados entre los años 2002 y 2017 en tres hospitales de la ciudad de Medellín, Colombia. Métodos: estudio descriptivo y retrospectivo de pacientes con criterios bioquímicos para hipoglucemia hiperinsulínica y confirmación histopatológica de insulinoma. Resultados: se estudiaron 19 casos, 10 eran mujeres (52,6 %), la edad media al diagnóstico fue 43 años (D.E 15,5). Hubo cuatro casos de insulinoma multifocal (21,1 %), tres asociados con NEM-1 (15,8 %) y dos malignos (10,6 %). Todos presentaron hipoglucemia en ayunas y 63,2 % posprandial. En la prueba de ayuno, el nadir de glucemia sucedió antes de 48 horas en todos los casos, en promedio 9 horas (D.E 8,0). El diagnóstico bioquímico fue realizado con hipoglucemia e insulina elevada en todos los casos, aunque el péptido C fue reportado en nueve pacientes (47,3 %) y las sulfonilureas en dos (11,1 %). La localización preoperatoria se hizo por imágenes en 12 individuos (68,5 %) y las pruebas invasivas fueron necesarias en seis (31,5 %). Las pruebas diagnósticas fueron positivas en un 83 % para resonancia, 50 % para ecografía endoscópica y prueba de estímulo intraarterial con calcio y 100 % para ecografía intraoperatoria. La cirugía se realizó en 18 casos (94,7 %). La mortalidad (15,8 %) fue derivada de complicaciones en el posoperatorio temprano; la curación se logró en todos los casos. Conclusiones: el insulinoma en nuestro medio tiene características demográficas y clínicas similares a otras series. Existen limitaciones locales para el acceso a los estudios bioquímicos y en el rendimiento diagnóstico de las pruebas de localización.

Calcitriol-mediated hypercalcemia secondary to granulomatous disease caused by soft-tissue filler injection: a case report

Soft-tissue filler (STF) injections have been used worldwide for cosmetic reasons. In most cases, they are not approved by the United States Food and Drug Administration (FDA). Regulatory boards in Latin American countries do not allow the medical use of STF injections; however, these injections are still widely used. A case of calcitriol-mediated hypercalcemia with ectopic calcifications, chronic kidney disease, nephrolithiasis and calcinosis is presented. The reported case highlights the consequences of STF use, including calcitriol-mediated hypercalcemia secondary to granulomatous reactions years after an esthetic procedure.

Parathyroid cysts: the Latin-American experience

BACKGROUND

Parathyroid cyst is an infrequent and unsuspected disease. There are more than 300 hundred cases reported in the world literature, a few of them are from Latin America. The experience of our centers and a review of the cases are presented.

METHODS

Case report of a series of patients with parathyroid cyst from our institutions according to the CARE guidelines (Case Reports). A search of Medline, Embase, BIREME (Biblioteca Regional de Medicina) LILACS (Literatura Latinoamericana y del Caribe en Ciencias de la Salud), Google Scholar and Scielo (Scientific Electronic Library on Line) databases and telephonic or email communications with other experts from Latin-America was performed .

RESULTS

Six patients with parathyroid cyst were found in our centers in Colombia. Most of them were managed with aspiration of the cyst. Two of them required surgery. Only one case was functional. Twelve reports from Latin America were found for a total of 18 cases in our region adding ours.

CONCLUSIONS

Parathyroid cysts are uncommonly reported in Latin America. Most of them are diagnosed postoperatively. Suspicion for parathyroid cyst should be raised when a crystal clear fluid is aspirated from a cyst. The confirmation of the diagnosis may be easily done if parathyroid hormone (PTH) level is measured in the cyst fluid.

[Trabecular hyalinizing adenoma of the thyroid (HAT): A report of two cases]

The hyalinizing trabecular adenoma is a rare lesion of the thyroid. There is controversy in the literature about the correct name for this disease. Dr. Carney defended the benign nature of this condition and therefore continues calling it adenoma, the World Health Organization calls for the potential of tumor malignancy, and others qualify it as a variant of papillary carcinoma based on the presence of rearranged in transformation/papillary thyroid carcinoma (RET/PTC) rearrangements. In Latin America there are few reported cases. Two cases of hyalinizing trabecular adenoma are reported. The first is a 40-year-old woman with a thyroid nodule of 3x3 cm. The immunohistochemistry was positive for thyroglobulin and calcitonin and negative for cytokeratin 19 and chromogranin. The second case is a 36-year-old patient with a thyroid nodule of 4x4 cm with an immunohistochemical pattern identical to the first case. Trabecular hyalinizing adenoma is a benign disease, easily confused with papillary or medullary thyroid carcinoma. Awareness of this entity will allow a better classification and management of thyroid conditions.

Constipation: an overlooked, unmanaged symptom of patients with pheochromocytoma and sympathetic paraganglioma

OBJECTIVE

Pheochromocytomas (PHs) and sympathetic paragangliomas (PGs) are tumors that produce catecholamines, predisposing patients to cardiovascular disease and gastrointestinal effects such as constipation.

OBJECTIVES

i) determine the prevalence of constipation, its risk factors, and its impact on survival; ii) identify whether a systematic combination of fiber, water, and laxatives was effective for treatment of constipation.

DESIGN AND METHODS

We retrospectively studied 396 patients with PH/PG diagnosed in 2005-2014. The study population was patients with constipation as a presenting symptom; the control group was patients without constipation as a presenting symptom. The MD Anderson Symptom Inventory was used to assess constipation and quality of life.

RESULTS

Twenty-three patients (6%) had constipation. Constipation was associated with headaches, palpitations, diaphoresis, weight loss, and excessive noradrenaline production (P<0.0001). Eighteen of these patients had non-metastatic primary tumors larger than 5 cm and/or extensive metastases. No statistically significant differences in age, sex, and genotype were noted between the study and control groups. In patients without metastases, resection of the primary tumor led to symptom disappearance. A systematic combination of fiber, water, and laxatives was associated with symptom improvement. Two patients who presented unmanaged constipation died because of sepsis from toxic megacolon.

CONCLUSIONS

Constipation is a rare and potentially lethal complication in patients with PH/PGs. Severe constipation can be prevented by recognizing and treating mild symptoms.

Nódulo tiroideo, enfoque y manejo. Revisión de la literatura

Introducción: el nódulo tiroideo es un hallazgo común en la actualidad, cuya incidencia viene en aumento. El objetivo principal durante la evaluación es distinguir el nódulo benigno del maligno. Materiales y métodos: se hizo una revisión narrativa de la literatura mediante búsqueda en Ovid, Medline y Lilacs desde 1950 a 2010. Resultados: la mayoría de los nódulos tiroideos son benignos, solo 4% a 8% de los casos pueden ser malignos. Los nódulos mayores de un centímetro se deben estudiar mediante aspirado con aguja fina; sin embargo, se deben tener en cuenta las características clínicas del paciente y las características ecográficas del nódulo. Entre los factores de riesgo asociados a la presencia de nódulo están la edad por encima de 45 años, el sexo femenino y el tabaquismo. No se recomienda la medición de marcadores tumorales en el estudio de los pacientes con nódulo tiroideo. Conclusión: la ecografía de tiroides y el aspirado con aguja fina son los métodos diagnósticos más importantes en la evaluación del nódulo tiroideo y han permitido cambiar las conductas terapéuticas disminuyendo el número de tiroidectomías innecesarias. El tratamiento y el pronóstico dependen de los factores de riesgo y de los hallazgos citológicos y patológicos.