Acromegaly

Question 1

Define:

Answer 1

Collection of signs and symptoms caused by an excess in growth hormone

In children this is gigantism

Question 2

Aetiology/risk factors:

Answer 2

99% are caused by GH secreting adenoma

Ectopic tumour releasing GH or GHRH form e.g. bronchial and pancreatic cancer

5% are caused through MEN-1

Question 3

Epidemiology:

Answer 3

RARE
5/100,000
Affects 40-50 year olds

Question 4

Symptoms:

Answer 4

Insidious onset 
Headaches 
Rings and shoes becoming tight 
Sweating on face 
Arthralgia 
Carpal tunnel syndrome
Visual disturbances 
Hypopituitarism:  hypogonadism, hypothyroidism, hypoadrenalism
Hypoprolactinemia - impotence, irregular periods and decrease libido

Question 5

Signs in the hands:

Answer 5

o Large spade-like hands
o Thick greasy skin
o Carpel tunnel syndrome signs
o Premature osteoarthritis

Question 6

Signs in the face:

Answer 6

o	Prominent eyebrow ridge 
o	Prominent cheeks 
o	Broad nose bridge 
o	Prominent nasolabial folds 
o	Thick lips 
o	Increased gap between teeth
o	Large tongue (macroglossia)
o	Prognathism
o	Husky resonant voice (due to thickening of vocal cords) 
o	Growth of jaw
o	Puffy lips, eyelids and skin 
o	Scalp folds
o	Darkening of skin

Question 7

Signs in the neck:

Answer 7

Multi-nodular goitre

Question 8

Other signs:

Answer 8

Enlarged feet 
Obstructive sleep apnoea 
Proximal weakness 
Organomegaly 
Bitemporal hemianopia

Question 9

Investigations:

Answer 9

Bloods, U+ Es –> glucose, calcium and phosphate

IGF-1 (random GH is not useful as it is pulsatile and cyclical)

Oral glucose tolerance test - suppression test (the GH remains high after 75mg of glucose)

MRI of the brain

Visual fields and acuity

Pituitary function tests:
o	9am cortisol
o	Free T4 and TSH
o	LH and FSH
o	Testosterone
o	Prolactin

Question 10

Management:

Answer 10

Trans-sphenoidal hyposphsectomy

Radiotherapy can act as an adjuvant therapy

Somatostatin analogue e.g. octerotide

Dopamine agonists for the hyperprolactionemia e.g. bromocriptine

GH Antagonist (pegvisomant)

Monitor GH and IGF1 levels can be used to monitor disease control

Question 11

What are the side effects of somatostatin analogues:

Answer 11

abdominal pain

steatorrhoea

Question 12

What are the side effects of dopamine agonists:

Answer 12

nausea, vomiting, constipation, postural hypotension, psychosis (RARE)

Question 13

Complications:

Answer 13

Cardiomegaly 
Hypertension 
Obstructive sleep apnoea 
Colonic polyps
Renal stones 
Diabetes Mellitus 
Depression 
Psychosis 
Hypercalcemia 
Hyperphophotemia 
Hypertriglyceremia

Question 14

Complications of surgery:

Answer 14

o	Nasoseptal perforation 
o	Hypopituitarism
o	Adenoma recurrence 
o	CSF leak
o	Infection

Question 15

prognosis:

Answer 15

Good if treated early

Physical changes are irreversible