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1. Internal Medicine I > 19. Diseases of the pituitary > Flashcards

19. Diseases of the pituitary Flashcards

1
Q

What are the three most common hormone producing adenomas of the anterior pituitary?

A

Prolactin, GH, and ACTH.

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2
Q

What is the most common type of pituitary adenoma?

A

Prolactinoma.

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3
Q

What is the limit for micro and macroadenomas?

A

1cm

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4
Q

What are the consequences of micro and macroadenomas?

A
  • Hormone overproduction
  • Mass effects : visual field disturbance, hormone deficiencies, increased prolactin, intracranial hypertension, and neurological complications.
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5
Q

What are the five most common types of pituitary adenomas?

A
  1. Prolactinoma,
  2. Hormonally inactive (including gonadotropin secretion without clinical consequences),
  3. GH,
  4. PRL + GH,
  5. Cushing-disease.
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6
Q

What are the common hormonal examinations for screening pituitary adenomas?

A
  • Prolactin,
  • cortisol, ACTH,
  • TSH, fT4,
  • IGF-1,
  • LH, FSH, and sexual steroids.
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7
Q

What are the typical symptoms of prolactinoma in women?

A
  • Galactorrhea,
  • amenorrhea
  • osteoporosis
  • mass effects (visual field, hormone deficiency)
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8
Q

What are the typical symptoms of prolactinoma in men?

A
  • Loss of libido,
  • impotence,
  • osteoporosis
  • mass effects (visual field, hormone deficiency)
    (but less visible symptoms than in women)
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9
Q

What are the drug causes of hyperprolactinemia?

A
  • Dopamine-antagonist drugs (D2-receptor antagonists),
  • antipsychotic drugs (e.g., risperidone),
  • antidepressants,
  • antiemetic drugs (e.g., metoclopramide),
  • antihypertensive drugs (e.g., verapamil, methyldopa).
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10
Q

What is the therapy for prolactinoma?

A
  • Drug therapy : dopamine agonists (cabergolin),
  • surgery if threatening visual field loss or neurological consequences
  • irradiation therapy
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11
Q

What are the symptoms of acromegaly?

A
  • Growth of the hands, feet, nose, tongue, ears, lips, carpal tunnel syndrome (!!)
  • visceromegaly (cardiomegaly),
  • increased colon tumor prevalence,
  • sweating and oily skin (!!)
  • diabetes mellitus
  • endocrine disorders (impotence, amenorrhea)
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12
Q

What is the most common cause of death in acromegaly patients?

A

Cardiovascular (heart insufficiency) is the most common cause of death

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13
Q

What is the laboratory screening test for acromegaly?

A

Serum IGF-1.

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14
Q

What is the confirmation test for acromegaly?

A
  • OGTT (Oral glucose tolerance test) with 75 g glucose per os,
  • blood taking at 0, T+30, T+60, T+ 90, T+120, T+180
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15
Q

What is the normal GH level during an OGTT?

A

Normally GH goes below 1 ng/ml, but in the case of acromegaly, it does not go below 2 ng/ml, and often a paradoxical increase of GH is observed.

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16
Q

What are the three types of drug therapy for acromegaly?

A
  • Somatostatin Analogues (Octreotide, Lanreotide, Pasireotide),
  • GH-Receptor Antagonist, Pegvisomant (Somavert),
  • Dopamine Agonists (Cabergolin).
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17
Q

What are non-drug treatment options for acromegaly?

A

Surgery and irradiation.

18
Q

What is the order of the loss of anterior lobe hormones in hypopituitarism?

A

The order of the loss of anterior lobe hormones in hypopituitarism is
1. GH,
2. LH/FSH,
3. TSH,
4. ACTH.

19
Q

What are the causes of hypopituitarism?

A
  • neoplastic : tumors
  • traumatic (operation, trauma, irradiation),
  • congenital (e.g. Prader-Willi sy),
  • inflammatory : autoimmune hypophysitis, Syphilis, Meningoencephalitis,
  • infiltrative : Sarcoidosis,
  • vascular : postpartal necrosis, stroke
  • drug induced (long steroid therapy)
20
Q

What is Sheehan syndrome?

A

Sheehan syndrome occurs when the anterior pituitary gland is damaged due to significant blood loss. Classically, this happens after delivery

21
Q

What are some symptoms of hypopituitarism?

A
  • Weight loss, fatigue, fine wrinkles on the face, and hypotension
  • Secondary hypogonadism / hypothyroidism / adrenal insufficiency
22
Q

Why is there no aldosterone deficiency in hypopituitarism?

A

Because part of it is controlled by RAAS, which is enough to compensate

23
Q

What is the difference in LH and FSH levels between primary and secondary hypogonadism?

A

In primary hypogonadism, LH and FSH levels are high, while in secondary hypogonadism, LH and FSH levels are low.

24
Q

What is the hormonal diagnosis for GH-deficiency?

A
  • Low IGF-1 levels
  • Low LH, FSH
  • Low TSH, ft4
  • Low ACTH and cortisol
25
Q

How can we exclude adrenal insufficiency when we see low ACTH?

A

if cortisol is above 20ug/dl in the morning, adrenal insufficiency can be excluded

26
Q

How is the Insulin-Hypoglycemia Test performed?

A
  1. Give rapid acting insulin to provoke ACTH and GH
  2. Blood taken every 15 Min. after insulin and during hypoglycemia (blood sugar <2.2 mmol/l).
27
Q

How can we interpret results of the insulin-hypoglycemia test for GH?

A
  • Children : GH deficiency if GH<3ng/mL
  • Adults : GH deficiency if GH<7ng/mL
28
Q

What is the therapy for GH-deficiency?

A
  • Glucocorticoid substitution
  • L-Thyroxine
  • Substitution with sex hormones (for growth, development and fertility)
  • GH substitution (daily)
29
Q

What are the types of glucocorticoid substitutions?

A
  • Hydrocortisone - 15-20 mg/D - highest dose in the morning.
  • Prednisolone 5 mg/D.
  • Strong increase in acute cases (e.g. 3x100 mg Hydrocortison/D intravenously in shock, surgery).
30
Q

What is the dose of L-thyroxine used?

A

Based on weight : 1.6-1.8 ug/kg/D so in general 100-150 ug/D

31
Q

What are the main forms of Diabetes insipidus?

A
  • Central Diabetes insipidus,
  • Nephrogenic diabetes insipidus,
  • Transient Diabetes insipidus during pregnancy,
  • “Primary Polydipsia.”
32
Q

What are the main causes of central Diabetes insipidus?

A
  • Trauma,
  • neurosurgery (for a pituitary tumor),
  • tumors of the hypothalamus and pituitary,
  • rare inflammatory diseases (sarcoidosis),
  • intracranial bleeding,
  • Sheehan Syndrome
  • very rare congenital forms
33
Q

What are the main symptoms and diagnosis of Diabetes insipidus?

A
  • Polyuria,
  • Polydipsia,
  • Low urine density and osmolality (<200 mosmol/kg)
34
Q

Diagnosis of central diabetes insipidus

A
  • 2 step water deprivation test
  • Saline infusion test (20 ml/kg water and 0.9% NaCl for 2 days)
35
Q

What is the main treatment for central DI?

A

ADH-analogue Desmopressin, DDAVP, mostly as nasal spray, also available as tablets.

36
Q

What are the two main forms of nephrogenic DI?

A
  • Rare congenital forms (VP2 or AQP2 mutations)
  • acquired forms (chronic renal diseases, metabolic disorders/hypercalcemia, hypokalemia, gout)
37
Q

What is the recommended treatment for nephrogenic DI?

A
  • NSAIDs : reduces the polyuria, increases osmolality.
  • Mild volume depletion, thiazides in combination with NSAID. K-sparing diuretics (amiloride) + thiazides is also effective.
38
Q

What are the main causes of SIADH syndrome?

A

Paraneoplastic syndromes (mainly lung cancer), CNS diseases.

39
Q

What are the main characteristics of SIADH syndrome?

A
  • Hyponatremia,
  • low serum osmolality,
  • high urine osmolality,
  • relatively high urinary sodium concentration in relation to the serum.
40
Q

What is the treatment for acute severe hyponatremia caused by SIADH?

A
  • Na-supplementation in infusion (hypertonic NaCl solution or addition of NaCl).
  • The rise of serum Na cannot exceed 12 mmol/L/24 h (0.5 mmol/L/hour) to avoid central pontine myelinolysis (demyelinisation damage).
41
Q

What is the treatment for chronic hyponatremia caused by SIADH?

A
  • Fluid restriction (800-1200 mL/d),
  • Carbamide (urea)

1. Internal Medicine I (20 decks)

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