Chapter 65: Pituitary And Adrenal Gland Problems Flashcards
Hypopituitarism
ACTH and TSH deficiencies can be life threatening. Deficiency of LH and FFH can cause sterility it in fertility. Growth hormone deficiencies can affect cartilage growth and maintenance resulting in short stature and growth retardation. It can also lead to osteoporosis.
Causes: tumors, malnutrition, shock and hypoxia, trauma, infection, radiation, surgery, aids, or idiopathic. Postpartum hemorrhage is the most common cause called sheehans syndrome.
One of the first signs of tumor is visual changes and Temporal headaches. Changes in sella tursica may be seen.
Treatment is to replace the hormones deficient.
Anterior pituitary
Aka adenohypophysis
Controls growth, metabolic activity, and sexual development.
Thyroid stimulating hormone/thyrotropin TSH: target thyroid: synthesis and release of thyroid hormone
adrenocorticotropic hormone ACTH: target adrenal cortex: corticosteroids and adrenocortical growth
luteinizing hormone LH: ovary testes: ovulation and progesterone; testosterone secretion
follicle-stimulating hormone FSH: ovary testes: estrogen and follicle maturation; spermatogenesis
prolactin: mammary glands: breast milk production
growth hormone: bone and soft tissue: growth
Melanocyte stimulating hormone: melanocytes: pigmentation
Hyperpituitarism
Most common causes a pituitary adenoma. Symptoms may include visual changes, headache, increased intracranial pressure. Increase in prolactin is the most common. This causes breast milk production, amenorrhea, and infertility.
GH increase leads to gigantism or acromegaly. Giantism occurs before puberty. acromegally occurs after growth plates have closed and increases skeletal thickness, hypertrophy of the skin, enlargement of organs. This leads to joint degeneration, Hypertrophy of ligaments, Fulquartz, eustachian tubes, nerve entrapment, hyperglycemia because growth hormone block action of insulin. Excess ACTH can cause Cushing’s disease. Excess prolactin can cause difficult with sexual functioning.
Treated with dopamine agonist or radiation.
Bromocriptine
Aka parlodel
Dopamine agonist to Trt hyperpituitarism.
Side effects include orthostatic hypotension, gastric irritation, nausea, headache, abdominal cramps, constipation. Take with a meal or snack. Serious side effects include cardiac dysrhythmias, coronary artery spasms, and cerebral spinal fluid leakage. Seek treatment immediately if there is chest pain, dizzy, Watery nasal discharge.
Somatostatin analogs
Sandostatin
Blocks growth hormone and is given as an injection daily or weekly. It can cause gallbladder disease.
Hypophysectomy
Surgical removal of the pituitary gland in tumor is the most common treatment for hyperpituitarism. Nasal packing is present for 2 to 3 days and mouth breathing is a must. Cannot brush teeth, cough, sneeze, below the nose, or bend forward after surgery.
Post operatively monitor neurological response, possible diabetes insipidus, cerebral spinal fluid leakage, infection, increased intracranial pressure. Report any postnasal drip. Keep the head of the bed elevated. Frequent oral rinses. If the entire gland is removed thyroid hormones and glucocorticoid replacement is lifelong. Activities that increased intracranial pressure should be avoided for two months. Do not brush your teeth for two weeks. Mouthwash and flossing is adequate. Numbness and decreased smell last 3 to 4 months.
Diabetes Insipidus.
Is a disorder of the posterior pituitary gland and in excess of vasopressin an antidiuretic hormone. There is an excretion of large amounts of urine. The kidney tubule do not reabsorb water leading to polyurea And dehydration. Do not deprive a patient with this of water for more than four hours. Nephrogenic diabetes insipidus is inherited with the kidneys do not respond to ADH. Primary diabetes insipidus is caused by a lack of ADH. Can also be drug-related caused by lithium and Declomycin.
Manifestations are urinary frequency and excessive thirst and problems with dehydration. First lab done would be a 24 hour fluid intake and output measurement. Output can be greater than 4 L and more in the intake. Urine has a low specific gravity and Lola osmolarity from 50 to 200.
DDAVP desmopressin
Synthetic form of vasopressin given orally or intranasally. During severe dehydration it can be given IV or IM.
Side effects of intranasal include ulcers of the mucous membranes, allergy, chest tightness, pulmonary inhalation. Do not use if you have an upper respiratory infection. Polyurea and polydipsia or signals for the need for another dose. These drugs can cause fluid overload and water toxicity. Weighed daily. Signs of water toxicity be a persistent headache and confusion. Wear a medical alert bracelet. Blow nose before use. Sit upright. Cannot drink more than 3 L of fluid.
Syndrome of inappropriate antidiuretic hormone SIADH
ADH is secreted even when I osmolarity is low or normal. Also known as the Schwartz Bartter syndrome. Water is retained resulting in hyponatremia and an increase of extracellular fluid volume. This causes in increase in glomerular filtration rate and inhibits rennin in aldosterone which leads to increased sodium loss.
Manifestations include G.I. disturbances such as anorexia, nausea and vomiting. Weight gain. Dependent edema is not present even though water is retained. CNS Is affected. Lethargy, headaches, seizures, coma, decreased deep tendon reflexes. Tachycardia, hypothermia is present. Urine volume decreases in osmolarity increases. Elevated sodium levels in the urine and elevated specific gravity. NA <110.
Restrict fluids, promote water excretion, replace sodium. Fluid restrictions may be as low as 500 to 600 mL. The weight gain of 2 pounds is a concern. 1kg=1L.
3% NACL if NA is really low. Caution because of fluid overload and heart failure. Saline solution should always be used overwater solutions. Monitor for fluid overload at least every two hours. Provide a safe environment if sodium is below 120. Check level of consciousness every two hours.
Adrenal gland hypofunction
ACTH.
Loss of aldosterone and cortisol action.
Impaired cortisol decreases gluconeogenesis and depletes liver and muscle glucose>hypoglycemia
Reduced aldosterone causes Hyperkalemia, hyponatremia, hypovolemia and can lead to acidosis.
Low androgen>decreased hair.
Acute adrenal insufficiency or addisonian crisis
Life-threatening event when there is not enough cortisol or aldosterone available. Often a response to a stressful event fletch such as surgery, trauma, infection. Without intervention sodium levels fall and potassium levels rise. Hypotension results.
Treated with hormone replacement, hyperkalemia management and hypoglycemia management. See pic.
Addison’s disease
Adrenal insufficiency primary causes or secondary causes which are tumors, radiation, or hypophysectomy. Suddenly stopping long-term glucocorticoid therapy can cause this. Manifestations include muscle weakness, fatigue, muscle and joint pain, anorexia, nausea and vomiting, abdominal pain, bowel changes, salt craving, Vitiligo, hyperpigmentation (not in secondary), anemia, hypotension, hyponatremia, hyperkalemia, hypercalcemia.
ACTH stimulation test.
Promote fluid balance, monitor for deficit, prevent hypoglycemia. Weighed daily, assess vitals often
Hydrocortisone given, 2/3 in am, 1/3 in afternoon. Report rapid wt gain, round face (Cushings syndrome), and fluid retention.
Cushings disease/hyperaldosteronism
Excess glucocorticoids-cortisol. Can be from the adrenal cortex, problem with the anterior pituitary, or the hypothalamus. It alters metabolism. There is an increase in total body fat. Buffalo hump, truncal obesity, and moon face. Bone density loss. Inflammatory and immune response is reduced.
Most common cause is a pituitary adenoma. Nitrogen depletion leads to muscle and bone changes (osteoporosis and weakness). Glucose levels are high. Immunosuppression. Inflamatory response decreased. Change in emotions. GI bleed (take antacids regularly).
See pic.
Increased androgens causes acne, hirsutism, clitoral hypertrophy, oligomennorrhea.
Saliva test at midnight 3lbs week or 1-2 lbs in 24 hrs. Infection prevention. Wear bracelet. Take cortisol in am and afternoon with food, increase when extra stress. Never skip. Injection needed if vomiting doesn’t allow oral. IM injection.
Hyperaldosteronism
Causes mineralocorticoid excess. Excess aldosterone is secreted from the adrenal gland. Usually caused by a tumor. Causes sodium retention with potassium and hydrogen excretion. This results in hypernatremia, hypokalemia, and metabolic alkalosis. Blood pressure increases can cause strokes and kidney damage.
Manifestations include headache, fatigue, muscle weakness, nocturia, loss of stamina, polydipsia, polyurea, paresthesias, visual changes.
Surgical removal of the adrenal glands is used for treatment but potassium levels must be normal. They may need temporary glucocorticoid replacement. If both glands are removed they will need lifetime replacement.
Spironlactone which is k sparring may be used if no surgery. Report gynecomastia, diarrhea, drowsiness, headache, rash, confusion, erectile dysfunction, amenorrhea, hirsutism
Pheochromocytoma
A tumor in the adrenal medulla. Usually benign. They produce, store, and release epinephrine and norepinephrine. Intermittent episodes of hypertension in which there is severe headache, palpitations, diaphoresis, Flushing, apprehension, sense of doom, pain in the chest or abdomen, nausea and vomiting. Heat intolerance, weight loss, tremors
Antidepressants, glucagon, metoclopramide, nalaxone can induce a hypertensive crisis. Food or beverages high in tyramine such as age cheese and red wine induce hypertension.
24 hour urine collection for BN a. MRI and CT scan to locate the tumor. Surgery is the treatment where one or both adrenal glands are removed. Do not palpate the abdomen. Blood pressure closely.
