Anterior Pituitary Disorders: Acromegaly and Hypopituitarism Flashcards
What can happen if you have a Pituitary Tumour? (Gland too large?)
Presses on adjacent structures
What can happen if you have a Pituitary Tumour? (to hormones…) (2 things)
Excess hormone secretion Deficient hormone secretion
How can deficient hormone secretion happen?
post surgery or radiotherapy pressure on normal cells from tumour
How do we tackle a Pituitary Problem? (3 things)
Take the History Examine the patient Do relevant special investigations
Most pituitary tumours are …
benign
How do we tackle a Pituitary Problem?
- Discuss management with the multidisciplinary pituitary team and the person with the problem - Decide on best personalised treatment (surgery, radiotherapy, medication, watch and wait)
What are 4 personalised treatment options for a pituitary problem?
Surgery Radiotherapy Medication Watch and wait
Pituitary History - check 6 things
Presenting Complaint Past History Family History Personal History Gynaecological History Systemic Inquiry
Examination for Pituitary
ENT - biopsy of nasal mass Histology - Pituitary Tumour
What is this showing?
What is it for?
What test is it?
phoropter - used during an eye examination to measure refractive error and determine eyeglass prescriptions. Typically, the patient sits behind the phoropter and looks through it at an eye chart
Goldman vision test
What is the most common way to remove a pituitary tumour?
Transsphenoidal surgery.
Transsphenoidalmeans that the surgery is done through the sphenoid sinus, a hollow space in the skull behind the nasal passages and below the brain. The back wall of the sinus covers the pituitary gland
What is Transsphenoidal hypophysectomy ?
Transsphenoidal hypophysectomy is an effective surgical technique for the removal of pituitary and other intrasellar tumors with minimal morbidity and hospital sta
What is Bitemporal hemianopsia (or Bitemporal hemianopia) ?
The medical description of a type of partial blindness where vision is missing in the outer half of both the right and left visual field.
What is a Pituitary adenoma?
They are benign (not cancerous) slow-growing tumors in the pituitary gland.
pPost Op Progress - What Clinical Problems?
Polyuria due to Diabetes Insipidus
What is prescribed for polyuria as a result of Diabetes Insipidus?
DDAVP (desmopressin acetate tablets)
it is an antidiuretic replacement therapy
Biochemistry after surgery for pituitary tumour - what can be an issue?
Low Thyroxine levels
What is prescribed for low thyroxine levels?
Levothyroxine
What test is perfomed to check if your adrenal glands are producing enough cortisol? (after surgery)
Short synacthen test checks if your adrenal glands are producing enough steroid hormone called cortisol.
If you have a poor cortisol response, what happens?
hydrocortisone
Estrogen Deficiency Symptoms after surgery.
What do you do?
Estrogel prescribed
mirena intrauterine system
What is the GHRH Arginine stimulation test?
GHRH stimulates growth hormone production by the pituitary gland, which is a small gland beneath the brain. You will also be given an injection of arginine, a natural amino acid (the building blocks of proteins) that also stimulates growth hormone release.
This test is used to assess your body’s ability to make growth hormone
Why is the GHRH Arginine Stimulation test done in adults Post op?
In adults, a lack of growth hormone sometimes reduces their quality of life. It may also affect their body composition (the amounts of fat and muscle in the body), with a tendency to have more fat and less muscle.
What does lack of growth hormone do in adults?
Reduce quality of life
After the operation, what will you have? (3 things)
Follow up MRIS
Annual Clinic visits - discuss medications, biochemical testing, discussion with specialist nurse
Check visual fields
Skin Tags in Acromegaly, what does it increse risk of?
Colon Cancer
What is Acromegaly?
Acromegaly is a hormonal disorder that develops when your pituitary gland produces too much growth hormone during adulthood.
To test if too much growth hormone and confirm diagnosis what do you do?
IFG1. The insulin-like growth factor-1 (IGF-1) test is an indirect measure of the average amount of growth hormone (GH) being produced by the body
Glucose tolerance test + Growth hormones
Glucose tolerance test + Growth hormones, what results do you expect and what do you see in acromegaly?
glucose should supress growth hormone
in acromegaly, failure to supress the growth hormone
Yes - tumour is present
Possible further work up for acromegaly - tests normal
Vision - visual fields (Goldmans)
Cardiac (ECG, Echocardiogram)
Lung Function / Sleep Study (e.g. obstructive sleep apnoea)
Colonoscopy
What do you check levels of to screen for pituitary hormone deficiency in acromegaly?
Cortisol
Thryoxine
FSH / LH (not done in menstruating)
Arginine Vasopressin (if symptoms of diabetes insipidus or abnormal serum sodium)
Discharge from hospital after surgery for acromegaly, what 3 things must be done?
Information
Hydrocortisone replacement
Pituitary clinic appointment
Post Op Tests for Acromegaly
Assess growth hormone
Asssess other hormones (free thyroxine, synacthen test for cortisol levelts)
E and Urea
Prolactin
Do we need to normalise the growth hormone?
Yes - increases survival
How to make the IFG1 normal…
surgery? yes or no
medications? yes or no
radiotherapy? yes or no
Further surgery? no - no safe surgical target
medications - yes
dopamine agonist (Carbergoline)
long acting somatostatin analogue (sandostatin LAR)
GH receptor antagonist (Pegvisomant - very expensive, not given often)
Radiotherapy - yes - to neurooncologist
Why is Pegvisomant (GH receptor antagonist) not prescribed often to make the IGF1 normal?
very expensive
What constitutes a pituitary service?
Biochemists with good assays
Clinical nurse specialists
Endocrinologists
Histopathologists
MDT co-ordinator
Medical Secretaries
Neurooncologists
Neuroradiologists
Neurosurgeons
The person with the problem
Acromegaly change what features?
facial features
What is this showing?
Prominent orbital and occipital ridging
Clinical manifestations of acromegaly: the hands?
Increased size of hands and feet - rings tight, carpal tunnel
What is this showing?
Increased size of feet in acromegaly
Clinical manifestations of acromegaly - mouth/jaw
Overgroth of mandible
Prognathism
What other hormone levels do you check in acromegaly?
Prolactin levels
Serum Calcium
Discussion regarding diagnosis and management of acromegaly.
Where do you visit?
whos involved?
what surgery?
Combined Pituitary clinic
- advanced pituitary nurse
- patient representative
- pituitary surgeon
= transsphenoidal hypophysectomy - surgery
Post op visit to CPC - what questions ? (Acromegaly)
General wellbeing
change in physical signs
vision
sense of smell
urine flow? (diabetes insipidus)
view histology (pituitary adenoma?)
post op tests
