ENDOCRINE BLOCK

 Slides  Important  Females’ Notes  Explanation  Males’ Notes

Physiology Team 432 Endocrine Block Lecture: 5
 Diabetes Insipidus

types Symptoms and signs of DI Treatment

Central DI
SIADH*

Psychogenic
polydipsia
Causes Manifestations Signs & symptoms

Nephrogenic DI

*Syndrome of Inappropriate antidiuretic Hormone

 Slides  Important  Females’ Notes  Explanation  Males’ Notes

Physiology Team 432 Endocrine Block Lecture: 5
 Diabetes Insipidus (DI)

DI is a disorder resulting from deficiency of anti-diuretic hormone (ADH) or its action

and is characterized by the passage of copious amounts of dilute urine.
It must be differentiated from other polyuric states such as primary polydipsia & osmotic
duiresis.
Polydipsia:
Excessive or abnormal thirst

Types of DI:
Central DI Nephrogenic DI Psychogenic polydipsia
Failure of the pituitary gland to
When the renal tubules of the
secrete adequate ADH. Physiological ADH inhibition
kidneys fail to respond to
-Defect in hypothalamus. It doesn’t release the amount
circulating ADH.
-Defect in pituitary stalk. that it should be. So, the kidney
ADH is there (enough) but the
-Defect in posterior pituitary. will be unable to retain water,
problem is with its action or
Related to the synthesis, results in Polyuria.
kidney is defective.
transmission or the storage.

 Slides  Important  Females’ Notes  Explanation  Males’ Notes

Physiology Team 432 Endocrine Block Lecture: 5
 Diabetes Insipidus (DI)

Causes of DI:
1- Central DI (most common) 2- Nephrogenic DI
 Brain tumors or infections:
Lung cancer, leukemia, lymphoma most  Acquired:
common • Drugs: lithium, amphotericin, gentamicin, loop diuretics.
 Head trauma e.g. in car accident • Electrolyte disorders: hypercalcemia, hypokalemia.
 Post-neurosurgery • Renal dz: obstructive uropathy, chronic renal failure
 Idiopathic – 30-50% (because the kidney has lost the ability to concentrate
Pituitary atrophy, possible autoimmune urine), polycystic kidney, Post-transplant, pyelonephritis.
 Congenital: • Systemic processes: sarcoid, amyloid, multiple myeloma,
Mutations of ADH gene, usually autosomal sickle cell disease, pregnancy.
dominant
-Infiltrative diseases, such as histiocytosis X or  Congenital – rare:
sarcoidosis. • Present in 1st week of life.
(Sort of error in metabolism then it is • V2 ADH receptor defect – X-linked recessive.
infiltrated anywhere and can affect the • AQP2 (Aquaporin2) water channel defect – will respond
hypothalamus or hypothalamic secreting cells to ADH.
of ADH)
3- Psychogenic polydipsia
------

 Slides  Important  Females’ Notes  Explanation  Males’ Notes

Physiology Team 432 Endocrine Block Lecture: 5
 Diabetes Insipidus (DI) Male’s Slide

Psychogenic Polydipsia :

• In this condition the person has psychological urge (strong desire) to drink much water
though he doesn't need it.

• He has normal ADH secretion & normal kidney response to ADH, but the patient has
psychiatric disturbance that produces urges to drink large amounts of water.

• Urine has large volume and it is dilute.

• However, if you deprive this person of water  urine volume decreases & urine
osmolarity increases (urine becomes more concentrated).

• Subject shows normal response to water restriction.

 Slides  Important  Females’ Notes  Explanation  Males’ Notes

Physiology Team 432 Endocrine Block Lecture: 5
 Diabetes Insipidus (DI)

Symptoms and signs of DI:

1. Polyuria > 3 liters in 24 hrs.
2. Sudden onset more typical of central DI.
3. Nocturia (the complaint that brings the patient to the clinic).
4. Polydipsia (If the thirst center is damaged, they will die because they don't sense the desire
that they should drink water).
5. Dilute urine, urine osm < 200. (Patient will notice color change. Pale transparent urine
instead of yellowish).
6. Anorexia, constipation
7. Serum Na >150, rare if free access to H2O.
8. Dehydration when access to water limited (if the problem is in hypothalamus).
9. Hyperthermia & lack of sweating (hypothermia may occur in shock ).
10. Diabetes insipidus can cause dehydration which can cause:
• Dry mouth. Muscle weakness (because of loss of energy).
• Hypotension (low blood pressure). Sunken appearance of the eyes.
• Rapid heart rate. Weight loss.

 Slides  Important  Females’ Notes  Explanation  Males’ Notes

Physiology Team 432 Endocrine Block Lecture: 5
 Diabetes Insipidus (DI)

11. Diabetes insipidus can also cause an electrolyte imbalance

- Hypernatremia
- Hyperchloremia
12. Electrolyte imbalance can cause
- Headache
- Fatigue
- Irritability and muscle pains
13. Seizure secondary to Hypernatremia can happen

Treatment:
• Desmopressin
- Desamino-desarginino-vasopressin (DDAVP)
- V2-selective analogue
- Little V1 (vasoconstrictor) activity
- Drug of choice in Diabetes insipidus
• Administration:
- Oral, sub-cut, nasal spray

 Slides  Important  Females’ Notes  Explanation  Males’ Notes

Physiology Team 432 Endocrine Block Lecture: 5
 Diabetes Insipidus (DI) Male’s Slide

 Diabetes insipidus (DI) is a condition where the person:

o Passes large amounts of urine (polyuria).
o Urine is dilute (has very low Specific Gravity) & does not contain sugar.
o Feels thirsty most of the time.
o Drinks excessive amounts of water ( polydipsia).

 Signs of hypovlemia (decreased ECF volume) & dehydration such as:

o Poor skin turgor & dryness of the skin & mucous membranes.
o Small (weak), rapid pulse (tachycardia).
o Hypotension (fall in BP).

 Haemoconcentartion & increased plasma osmolarity .

 If treatment is delayed, increased body temperature & hyperthermia.
 If we decrease the patient’s water intake, his urine output does not decrease  patient
can not produce ADH in response to decreased ECF volume.
 If left untreated, diabetes insipidus can result in severe dehydration, shock and death.

 Slides  Important  Females’ Notes  Explanation  Males’ Notes

Physiology Team 432 Endocrine Block Lecture: 5
 Diabetes Insipidus (DI) Male’s Slide

Other conditions:

 Other conditions that also manifest polydipsia and should not be confused with
DI are:
o Psychogenic Polydipsia.
o Diabetes mellitus.
 ID differs from diabetes mellitus in that:
o Urine is dilute.
o Urine does not contain sugar (no glycosuria).
o Blood sugar is normal.
 Reduction of fluid intake does not change urine concentration.

 Slides  Important  Females’ Notes  Explanation  Males’ Notes

Physiology Team 432 Endocrine Block Lecture: 5
 Diabetes Insipidus (DI) Male’s Slide

Management:

• Strict measurement & recording of fluid intake & urine output + urine
specific gravity & testing and osmolarity testing hourly in the early stages.

• Recording the pulse and BP hourly in the early stages, to detect early any
signs of shock.

• Vasopressin test  If desired, Vasopressin can be injected subcutaneously 

if urine output decreases  this is not nephrogenic DI.

• Pitressin (aqueous vasopressin) can be used for treatment.

 Slides  Important  Females’ Notes  Explanation  Males’ Notes

Physiology Team 432 Endocrine Block Lecture: 5
 Syndrome of Inappropriate antidiuretic Hormone

(SIADH) :
- The syndrome of inappropriate secretion of ADH (SIADH) is characterized by :
• Non-physiologic release of ADH
• Impaired water excretion with normal sodium excretion (dilutional
hyponatremia).
- SIADH is associated with disease that affect osmoreceptors in the hypothalamus.

Causes:
• Cancer :Many tumours. Most common is small cell cancer of the lung (oat cell
carcinoma of the lung )
• Brain : Meningitis ,Cerebral abscess ,Head injury, Tumors
• Lung :pneumonia ( severe stress ) ,Tuberculosis, lung abscess
• Metabolic
• Drugs

 Slides  Important  Females’ Notes  Explanation  Males’ Notes

Physiology Team 432 Endocrine Block Lecture: 5
 Syndrome of Inappropriate antidiuretic Hormone

 Slides  Important  Females’ Notes  Explanation  Males’ Notes

Physiology Team 432 Endocrine Block Lecture: 5
 Syndrome of Inappropriate antidiuretic Hormone

Manifestations:
• Fluid retention
• Serum hypo-osmolarity
• Dilutional hyponatraemia
• Hypochloremia
• Concentrated urine in the presence of normal or increased intravascular volume
• Normal renal function

 Hyponatraemia and hypo-osmolarity lead to acute edema of the brain cells.

(If there is a tumor (oat cell) secrets ADH, it will increase water absorption by the kidney.
Normally ADH which is secreted by posterior pituitary is under negative feed back by the drop of
serum osmolarity. But the tumor secrets excessive ADH (inappropriately) without negative feed back,
so excessive water distributes throughout total body water. As water flowed into the cells
(intracellular fluid ICF), their volume is increased  brain cells swelling occur .. It might end up by
coma and death.
 An increase in brain water content of more than 5-10% is incompatible with life.

 Slides  Important  Females’ Notes  Explanation  Males’ Notes

Physiology Team 432 Endocrine Block Lecture: 5
 Syndrome of Inappropriate antidiuretic Hormone

Symptoms and signs:

 Headache.
 Nausea.
 Vomiting .
 Impaired consciousness.
 Neurological signs (severe hyponatraemia):
- Drowsiness.
- Disorientation.
- Delirium.
- Seizures.
 Coma & death (severe cases).

- (SIADH) is treated with an ADH antagonist Or water restriction.

- There is no edema why ? Because it is dilutional hyponatremia lead to increase ICF
rather than ECF.

 Slides  Important  Females’ Notes  Explanation  Males’ Notes

Physiology Team 432 Endocrine Block Lecture: 5
 Videos

 Slides  Important  Females’ Notes  Explanation  Males’ Notes

Physiology Team 432 Endocrine Block Lecture: 5
- DI results from deficiency in ADH secretion or in its action :

Central DI Nephrogenic DI Signs and symptoms of ID:

Posterior pituitary fail to Renal tubule fail to Polyuria, nocturia, polydipsia, dehydration,
secrete ADH respond to ADH constipation, hyperthermia, electrolyte
imbalance, seizures.
Large volume diluted urine
 (SIADH):
Increase serum osmolarity
• Inappropriate secretion of ADH
Elevated ADH • Impair water excretion with normal Na
Low ADH (high osmolarity stimulates excretion.
its secretion)  Causes:
- Treated with an ADH • Tumors (oat cell of the lung).
- Treated with thiazide • Brain (meningitis ,abscess, tumor, injury).
analogue (desmopressin)
diuretic • Lung (pneumonia, TB).
- Mostly as nasal spray
• Metabolic and Drugs.
- Acquired (electrolyte
- It can be caused by:  Manifestations and symptoms:
disorder, drugs, renal
tumors, trauma, post o Fluid retention, hyponatremia and
diseases).
surgery, infiltrative disease, concentrated urine.
- Congenital (V2
congenital, idiopathic. o Headache, vomiting, neurological signs,
receptor defect).
coma & death.

 Slides  Important  Females’ Notes  Explanation  Males’ Notes

Physiology Team 432 Endocrine Block Lecture: 5
1. Treatment of nephrogenic DI ?? 4. The drug of choice for central diabetes insipidus
A) ADH antagonist is desmopressin. Mechanism of action of it is to ??
B) ADH analogue A) Block vasopressin and increases kidney salt excretion.
C) Thiazides diuretics B) Mimic vasopressin and increases kidney salt excretion.
C) Mimic vasopressin and increases kidney water
2. Regarding syndrome of inappropriate reabsorption.
secretion of ADH (SIADH) ??
A) low level of ADH
B) serum hyperosmolarity and diluted urine 5. Dehydrated patient with Diabetes insipidus
C) could be caused by oat cell carcinoma can present with all of the following except ??
(small cell cancer of the lung ) A) Dry mouth.
B) Weight gain.
C) Sunken appearance of the eyes.
3. What electrolyte abnormalities can 1 C
D) Muscle weakness.
cause diabetes insipidus ??
2 C
A) Hypercalcemia and hyperkalemia
B) Hypercalcemia and hypokalemia 3 B
C) Hypocalcemia and hyperkalemia 4 C
D) Hypocalcemia and hypokalemia
5 B

 Slides  Important  Females’ Notes  Explanation  Males’ Notes

Physiology Team 432 Endocrine Block Lecture: 5
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