Acromegaly

Question 1

What is acromegaly?

Answer 1

Signs + symptoms caused by hypersecretion of GH in adults

Question 2

What is the term used for excess GH before puberty?

Answer 2

GIGANTISM

Question 3

What causes acromegaly?

Answer 3

GH-secreting pituitary adenoma
RARELY caused by excess GHRH causing somatotroph hyperplasia from hypothalamic ganglioneuroma, bronchial carcinoid or pancreatic tumours

Question 4

Describe the epidemiology of acromegaly

Answer 4

RARE
5/ 1,000,000
Age: 40-50 yrs

Question 5

List 6 features of the presenting complaint in acromegaly

Answer 5

Rings + shoes becoming tight  
Increased sweating  
Headaches  
Carpal tunnel syndrome  
Hypopituitary symptoms
Hyperprolactinaemia

Question 6

How do symptoms arise in acromegaly?

Answer 6

Very gradual progression of symptoms over many years

Question 7

What 4 signs are seen in the hands in acromegaly?

Answer 7

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

Question 8

Acromegaly can give symptoms of hypopituitarism. Describe these

Answer 8

Hypogonadism
Hypothyroidism
Hypoadrenalism
Visual disturbances (compression of optic chiasm by tumour)

Question 9

What 9 signs may be seen in the face of a patient with acromegaly?

Answer 9

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 10

What 3 general signs are seen in acromegaly?

Answer 10

Bitemporal superior quadrantopia progressing to bitemporal hemianopia
Multinodular goitre
Enlarged feet

Question 11

What investigations should be used in acromegaly?

Answer 11

Serum IGF-1: screening test  
GH stimulates IGF-1 secretion  
Oral Glucose Tolerance Test
Pituitary Function Tests 
MRI of Brain: visualise pituitary adenoma

Question 12

Describe the surgical treatment of acromegaly

Answer 12

Trans-sphenoidal hypophysectomy
with adjunctive Radiotherapy
Only curative tx

Question 13

What is used to monitor acromegaly disease control?

Answer 13

GH + IGF1 levels

Question 14

Describe the medical treatment of acromegaly

Answer 14

SC Somatostatin Analogues
Oral Dopamine Agonists
GH Antagonist (pegvisomant)

Question 15

List 5 metabolic complications of acromegaly

Answer 15

Hypercalcaemia 
Hyperphosphataemia 
Renal stones  
Diabetes mellitus  
Hypertriglyceridaemia

Question 16

List 5 non metabolic complications of acromegaly

Answer 16

Cardiomegaly  
HTN
Obstructive sleep apnoea 
Colonic polyps  
Hyperprolactinaemia (in 30%)

Question 17

What is the prognosis in acromegaly?

Answer 17

GOOD with early dx + tx

Physical changes are irreversible

Question 18

What 5 complications may arise due to surgery in acromegaly?

Answer 18

Nasoseptal perforation  
Hypopituitarism 
Adenoma recurrence  
CSF leak 
Infection

Question 19

What does hyperprolactinaemia cause?

Answer 19

Irregular periods
Decreased libido
Impotence

Question 20

What is a positive result in a oral glucose tolerance test?

Answer 20

Failure of suppression of GH after 75 g oral glucose load

Question 21

What is measured in pituitary function tests?

Answer 21

9am cortisol
Free T4 + TSH
LH + FSH
Testosterone
Prolactin

Question 22

When is acromegaly managed medically?

Answer 22

if surgery is contraindicated or refused

Question 23

Give an examples of subcutaneous somatostatin analogues. List 4 side effects of these medications

Answer 23

Octreotide
Abdominal pain
Steatorrhoea
Glucose intolerance
Gallstones

Question 24

Give 2 examples of oral dopamine agonists. List 4 side effects of these medications

Answer 24

Bromocriptine, Cabergoline 
N+V
Constipation
Postural hypotension
Psychosis (RARE)