Acromegaly

Question 1

Define acromegaly

Answer 1

Constellation of signs & symptoms caused by hypersecretion of GH in adults

excess GH before puberty results in gigantism

Question 2

Aetiology of acromegaly

causes main + rare

Answer 2

Most cases caused by GH-secreting pituitary adenoma

Rarely caused by excess GHRH causing somatotroph hyperplasia from hypothalamic ganglioneuroma, bronchial carcinoid or pancreatic tumours

Question 3

Epidemiology of acromegaly

prevalence + age

Answer 3

RARE (5/1,000,000)

Affects age 40-50yrs

Question 4

Presenting symptoms of acromegaly

8

Answer 4

• very gradual progression of symptoms over many years
• rings & shoes becoming tight
• increased sweating
• headaches
• carpal tunnel syndrome
• hypopituitary symptoms
• visual disturbances (due to compression of optic chiasm by tumour)
• hyperprolactinaemia

Question 5

Signs of acromegaly on physical examination

5 groups

Answer 5

Hands
Face
Visual field loss
Neck
Feet

Question 6

Prognosis with acromegaly

2

Answer 6

• Good prognosis with early diagnosis & treatment

- Physical changes are irreversible

Question 7

Signs of acromegaly on physical examination - hands

4

Answer 7

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

Question 8

Signs of acromegaly on physical examination - face

9

Answer 8

Prominent eyebrow ridge
Prominent cheeks 
Broad nose bridge
Prominent nasolabial folds
Thick lips
Increased gap between teeth
Large tongue
Prognathism
Husky resonant voice (due to thickening of vocal cords)

Question 9

Signs of acromegaly on physical examination - visual field loss

Answer 9

Bitemporal superior quadrantopia progressing to bitemporal hemianopia

Question 10

Signs of acromegaly on physical examination - neck

Answer 10

Multi nodular goitre

Question 11

Signs of acromegaly on physical examination - feet

Answer 11

Enlarged

Question 12

Hypopituitary symptoms

3

Answer 12

Hypogonadism
Hypothyroidism
Hypoadrenalism

Question 13

Hyperprolactinaemia leads to…

3

Answer 13

Irregular periods
Decreased libido
Impotence

Question 14

Investigations for acromegaly

4

Answer 14

Serum IGF-1
Oral glucose tolerance test
Pituitary function tests
MRI brain

Question 15

Investigations for acromegaly - serum IGF 1

2

Answer 15

Useful screening test

GH stimulates IGF-1 secretion

Question 16

Investigations for acromegaly - OGTT

Answer 16

Positive result = failure of GH suppression after 75g oral glucose load

Question 17

Investigations for acromegaly - pituitary function tests

5

Answer 17

9am cortisol
Free T4 & TSH
LH & FSH
Testoterone
Prolactin

Question 18

Investigations for acromegaly - MRI brain

Answer 18

Visualise pituitary adenoma

Question 19

Management of acromegaly

3

Answer 19

Surgical
Radiotherapy
Medical

Question 20

Management of acromegaly - surgical

Answer 20

Trans sphenoidal hypophysectomy

Question 21

Management of acromegaly - radiotherapy

Answer 21

Adjunctive to surgery

Question 22

Management of acromegaly - medical

general + 4

Answer 22

(if surgery contraindicated or refused)

Subcutaneous somatostatin analogues - e.g. octreotide, lanreotide
side effects: abdo pain, steatorrhoea, glucose intolerance, gallstones

Oral dopamine agonists - e.g. bromocriptine, cabergoline
side effects: N&V, constipation, postural hypotension, psychosis (rare)

GH antagonist - pegvisomant

Monitor GH & IGF-1 levels for disease control

Question 23

Complications of acromegaly

7 groups

Answer 23

CVS
Resp
GI
Reproductive
Metabolic
Psychological
Complications of surgery

Question 24

Complications of acromegaly - CVS

2

Answer 24

Cardiomegaly

Hypertension

Question 25

Complications of acromegaly - respiratory

Answer 25

Obstructive sleep apnoea

Question 26

Complications of acromegaly - GI

Answer 26

Colonic polyps

Question 27

Complications of acromegaly - reproductive

Answer 27

Hyperprolactinaemia (in 30% cases)

Question 28

Complications of acromegaly - metabolic

Answer 28

Hypercalcaemia
Hyperphosphataemia
Renal stones
Diabetes mellitus
Hypertriglyceridaemia

Question 29

Complications of acromegaly - psychological

Answer 29

Depression
Psychosis (from dopamine agonists)

Question 30

Complications of acromegaly - complications of surgery

Answer 30

Nasoseptal perforation
Hypopituitarism 
Adenoma recurrence
CSF leak
Infection