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LCSR 2 - Endo - NSH > 1. Hyposecretion of ant pit > Flashcards

1. Hyposecretion of ant pit Flashcards

1
Q

What are the anterior pituitary hormones?

A 
FSH/LH
Prolactin
GH
TSH
ACTH
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2
Q

Draw and label the pituitary gland

A

[slide 3]

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3
Q

what do FSH/LH stand and control?

A

Follicle stimulating hormone
lutenising hormone
control gonads

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4
Q

what is prolactin involved in?

A

lactation post-partum

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5
Q

what does TSH do?

A

tells thyroid to make T3 and T4

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6
Q

what does ACTH do?

A

tells adrenal cortex to make cortisol

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7
Q

draw the hypothalamo-pituitary thyroid axis and label primary secondary and tertiary endocrine gland disease.

A 
[slide 4]
tertiary is at the hypothalamus level
TRH at hypo
TSH at pit
T3 and T4 at thyroid
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8
Q

how can you get autoimmune destruction of the thyroid gland?

A

the endocrine system is very susceptible to autoimmune attack

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9
Q

what happens in primary hypothyroidism

A

eg. autoimmune attack
problem with thyroid gland
T4 goes down
TSH goes up

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10
Q

what happens with secondary hypothyroidism

A

problem with the pit gland

T4 and TSH is low

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11
Q

define panhypopituitarism

A

decreased production of all anterior pituitary hormones

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12
Q

which is more common, congenital or acquired pit problems?

A

acquired

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13
Q

what is congenital panhypopituitarism due to?

A

usually due to mutations of transcription factor genes needed for normal anterior pit development

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14
Q

give example

A

PROP1 mutation
this is a transcription factor that allows the development of the pituitary gland to take place (leads to problems with all the anterior pituitary hormones)

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15
Q

how does panhypopituitarism usually develop in and adult?

A

progressive loss of pituitary secretion

The loss of secretion usually happens in the following order:
Gonadotrophins (LH and FSH)
GH
Thyrotrophin
Corticotrophin
Prolactin deficiency is uncommon/unrecognised

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16
Q

when else is this order of loss seen?

A

If someone has been given radiotherapy on their pituitary gland, their anterior pituitary hormones tend to fail in a certain order stated above

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17
Q

how do people with congenital panhypopituitarism present?

A

short stature
hypoplastic ant pit gland on MRI
deficient in GH and at least 1 other ant pit hormone

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18
Q

state acquired problems and what type of damage it causes

A 
tumours
radiation
infection (eg meningitis)
traumatic brain injury
infiltrative disease (often involving pituitary stalk eg neurosarcoidosis)
inflammatory (hypophysitis)
pituitary apoplexy (from haemorrhage or infarction)
sheehan's syndrome
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19
Q

state types of tumours

A

hypothalamic - craniopharyngiomas

pituitary - adenomas, metastases, cysts

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20
Q

explain how radiation causes damage

A

hypothalamic/pituitary damage

GH most vulnerable, TSH relatively resistant

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21
Q

what is simmond’s disease

A

not often used now but just refers to symptoms due to deficient hormones

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22
Q

how does lack of FSH/LH present?

A

secondary hypogonadism

reduced libido
erectile dysfunction
secondary amenorrhoea

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23
Q

what would primary hypogonadism be

A

eg preamture ovarian failure, issue with the endocrine gland itself

24
Q

how does lack of ACTH present?

A

secondary hypoadrenalism (cortisol deficiency)

fatigue
addison’s?

25
Q

how does lack of TSH present?

A

secondary hypothyroidism

fatigue

26
Q

draw and lable pituitary with vessels and neurones

A

[slide10]

27
Q

what is sheehans syndrome?

A

specifically describes post-partum hypopituitarism secondary to hypotension (PPH - post partum haemmohage)

28
Q

why might this happens

A

ant pit enlarges during pregnancy (lactotroph hyperplasia)

PPH leads to pit infarction

29
Q

how does sheehans syndrome present?

A

lethargy, anorexia, weight loss
- TSH/ACTH/GH deficient

failure of lactation
- PRL deficiency

failure to resume menses post delivery

posterior pit usually not affected

30
Q

what is pituitary apoplexy

A

intra-pituitary haemmorhage or (less commonly) infarction

31
Q

how does pituitary apoplexy present?

A

Often dramatic presentation in patients with pre-existing pituitary tumours (adenomas)
pituitary adenoma

32
Q

how to treat pit apoplexy?

A

Can be precipitated by anti-coagulants

33
Q

try and label image on [slide 13]?

A

good luck

34
Q

how can a tumour in the pituitary present?

A

SEVERE sudden onset headache
Visual field defect – compressed optic chiasm, bitemporal hemianopia
Cavernous sinus involvement may lead to diplopia (IV, VI), ptosis (III)

35
Q

what is the normal order of diagnosis

A

take history
biochemical tests
radiological tests

36
Q

2 biochemical tests?

A

Basal plasma concentrations of pituitary or target endocrine gland hormones
Stimulated (‘Dynamic’) Pituitary Function Tests

37
Q

using Basal plasma concentrations ?

A
  • interpretation may be limited
  • undetectable cortisol
  • what time of day?
  • T4 – circulating t1/2 6 days
  • FSH/LH – cyclical
  • GH/ACTH -pulsatile
38
Q

using Stimulated (‘Dynamic’) Pituitary Function Tests?

A
  • ACTH & GH = ‘stress’ hormones
  • Hypoglycaemia (<2.2mM) = ‘stress’
  • Insulin-induced hypoglycaemia stimulates GH release,
    ACTH release (cortisol measured)
  • TRH stimulates TSH release
  • GnRH stimulates FSH & LH release
39
Q

RADIOLOGICAL DIAGNOSIS?

A

Pituitary MRI
May reveal specific pituitary pathology
eg haemorrhage (apoplexy), adenoma

Empty sella – thin rim of pituitary tissue

40
Q

write the replacement and check for each deficient hormone

A

ACTH
Hydrocortisone
Serum cortisol

TSH
Thryoxine
Serum free T4

FSH/LH (women)
HRT (E2 plus progestagen)
Symptom improvement, withdrawal bleeds

FSH/LH (men)
Testosterone
Symptom improvement, serum testosterone

GH
GH
IGF1, growth chart (children)

41
Q

effects of GH deficiemcy in kids and adults

A

in children results in short stature (=2 SDs < mean height for children of that age and sex)

in adults, effects less clear

42
Q

genetic causes of short stature

A

Down’s syndrome, Turner’s syndrome, Prader Willi syndrome

43
Q

systemic diseases?

A

Cystic Fibrosis, Rheumatoid arthritis

44
Q

endocrine diseases?

A

Cushing’s syndrome, Hypothyroidism, GH deficiency, poorly controlled T1DM

45
Q

other causes

A

Emotional Deprivation
Malabsorption (Coeliac disease)
Skeletal dysplasias
(Achondroplasia, osteogenesis imperfecta)

46
Q

draw a schematic diagram of the growth axis

A

[slide 22]

47
Q

add the following labels to the diagram:
prader willi syndrome
laron dwarfism
pituitary dwarfism

A

[slide 23]

48
Q

describe achrondoplasia

A

Mutation in Fibroblast Growth Factor Receptor 3 (FGF3)
Abnormality in growth plate chondrocytes - impaired linear growth
Average size trunk
Short arms and legs

49
Q

why does pituitary dwarfism occur

A

Childhood GH deficiency

50
Q

LARON DWARFISM?

A

Mutation in GH receptor

IGF-1 treatment in childhood can increase height

51
Q

define MID PARENTAL HEIGHT

A

A predicted adult height –

based on father’s & mother’s height

52
Q

GH PROVOCATION TESTS?

A

GHRH + ARGININE (i.v.) (in combination more effective than each alone)
INSULIN (i.v.) – via hypoglycaemia
GLUCAGON (i.m.)
EXERCISE (e.g. 10 min step climbing; when appropriate)

Measure plasma GH at specific time-points (before and after)

53
Q

draw GROWTH HORMONE SECRETION IN RESPONSE TO HYPOGLYCAEMIA for normal and GH deficient

A

[slide 33]

54
Q

how to prepare and administer growth hormone therapy

A

Preparation:
Human recombinant GH (approved name: SOMATOTROPIN)

Administration:
Daily, subcutaneous injection
Monitor clinical response & adjust dose to IGF-1

55
Q

GH DEFICIENCY IN ADULTS: SIGNS AND SYMPTOMS

A

Reduced lean mass, increased adiposity, increased waist:hip ratio

Reduced muscle strength & bulk  reduced exercise performance

Decreased plasma HDL-cholesterol & raised LDL-cholesterol

Impaired ‘psychological well being’ and reduced quality of life

56
Q

POTENTIAL BENEFITS OF GH THERAPY IN ADULTS

A

Improved body composition – decreased waist circumference, less visceral fat

Improved muscle strength and exercise capacity

More favourable lipid profile - higher HDL-cholesterol, lower LDL-cholesterol

Increased bone mineral density

Improved psychological well being and quality of life

57
Q

POTENTIAL RISKS OF GH THERAPY IN ADULTS

A

Increased susceptibility to cancer
– no data to support this currently

Expensive – NICE estimated cost of lifelong GH treatment in adult = £42K

LCSR 2 - Endo - NSH (2 decks)

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