Clinical Aspects of Pituitary Disease Flashcards by Chloe Lee

What are the three categories of pituitary diseases?

Hypersecretion
Hyposecretion
Space occupation

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Give examples of conditions caused by hypersecretion of hormones

GH -> acromegaly (gigantism)
ACTH -> Cushing’s disease
Prolactin -> hyperprolactinaemia

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Give examples of what hormones are released in excess in hypersecretion

Anterior -> FSH/LH, GH, ACTH, TSH

* Posterior (vasopressin)

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What is another name for vasopressin?

Anti-diuretic hormone

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What is the most common cause of hyper secretion and hyposecretion?

Tumours

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What is the cause of a decrease in space occupation?

Optic chiasmal compression

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What are the two categories of the clinical features of acromegaly?

Soft tissue overgrowth and complications

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Describe the effect of soft tissue overgrowth in acromegaly

‘Spade like’ hands (rings)
Wide feet (shoes)
Coarse facial features
Thick lips and tongue
Carpal tunnel syndrome
Sweating

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What is carpal tunnel syndrome?

Condition due to compression of the median nerve as it travels through the wrist at the carpal tunnel.

The main symptoms are pain, numbness and tingling

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What are the eight possible complications of acromegaly?

Headache
Chiasmal compression
Diabetes mellitus
Hypertension
Cardiomyopathy
Sleep apnoea
Accelerated OA
Colonic polyps + CA

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Through investigations, what do you look for to diagnose acromegaly?

Can GH be suppressed?
Is IGF-1 elevated?
Is rest of pit. function normal?
Is there a pituitary tumour on MRI?
Is vision normal?

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What investigations do you carry out for acromegaly?

Random GH measurements
Serum IGF-1
OGTT (increase in Glc inhibits GH secretion, GH should be very low)
MRI of pit. fossa

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What causes Cushing’s syndrome?

Excess corticosteroids

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What is the effects of cortisol?

Cortisol is a catabolic hormone:
• Tissue breakdown - causes weakness of skin, muscle & bone
• Sodium retention - may cause hypertension + heart failure
• Insulin antagonism - may cause diabetes mellitus

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What are the high diagnostic value clinical features of Cushing’s syndrome?

Skin atrophy
Spontaneous purpura (non-blanching purple spots)
Proximal myopathy
Osteoporosis
Growth arrest in children

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What are the intermediate diagnostic value features of Cushing’s syndrome?

Pink striae
Facial mooning & hirsutism
Oedema

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What are the non specific clinical features of Cushing’s syndrome?

Central obesity

* Hypertension

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What are the three categories of clinical features of Cushing’s syndrome?

High, intermediate and non-specific value

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What are the causes of Cushing’s syndrome?

ACTH-dependent:
• Pituitary tumour (Cushing’s disease)
• Ectopic ACTH secretion (i.e. lung carcinoid)

ACTH-independent:
• Adrenal tumour (adenoma or carcinoma)
• Corticosteroid therapy (i.e. for asthma, IBD)

What is hyperprolactinaemia?

Condition of elevated serum prolactin

What are the clinical manifestations of hyperprolactinaemia in women?

Galactorrhoea 30-80% (inappropriate production of milk)
Menstrual irregularity
Infertility

What are the clinical manifestations of hyperprolactinaemia in men?

Galactorrhoea <5% (inappropriate production of milk)
Impotence
Visual field abnormalities
Headache
Extraocular muscle weakness
Anterior pituitary malfunction

What are three categories of cues of hyperprolactinaemia?

Physiological
Pharmacological
Pathological

What are the physiological causes of hyperprolactinaemia?

Pregnancy
Lactation
Stress

What are the pharmacological causes of hyperprolactinaemia?

• Dopamine (DA) depleting and DA antagonist drugs

What are the pathological causes of hyperprolactinaemia?

* Primary hypothyroidism | * Pituitary lesions (prolactinoma or pituitary 'stalk pressure')

What are the drugs which may cause hyperprolactinaemia?

* Dopamine antagonists (neuroleptic or anti-emetics) * DA depleting agents * Oestrogen * Some antidepressants

What are the clinical features of hypopituitarism in adults?

* Tiredness, weight gain, depression, reduced libido, impotence, menstrual problems * Skin pallor * Reduced body hair

What are the clinical features of hypopituitarism in children?

* Reduced linear growth | * Delayed puberty

What are conditions caused by pituitary hypofunction?

* Hypopituitarism | * Cranial Diabetes Insipidus

What is cranial diabetes insipidus?

Condition caused by the hypothalamus not producing enough anti-diuretic hormone (needed to control fluid balance). This results in passing large amounts of dilute urine and increased thirst.

Wha investigation is carried out for cranial diabetes insipidus?

Water deprivation test

Describe the water deprivation test in cranial diabetes insipidus

Initial blood and urine tests are done to measure the conc and salt levels. At hourly intervals, the same tests are repeated If the blood sodium or concentration levels rise significantly above normal along with low urine concentration

What are possible differential diagnoses of cranial diabetes insipidus?

* Idiopathic * Post-trauma (including pituitary surgery) * Metastatic carcinoma * Craniopharyngioma * Other brain tumours: eg. germinoma * Rare causes: eg. sarcoidosis

What vision defect would a large pituitary adenoma cause?

Bitemporal hemianopia

What is the management of pituitary tumours causing hypersecretion?

* Dopamine agonists (prolactinoma) * Somatostatin analogues (acromegaly) * GH receptor antagonist (acromegaly)

What is the management of pituitary tumours causing hyposecretion?

* Cortisol, T4, sex steroid, GH | * Desmopressin

What are other managements of pituitary tumours?

* Surgery (mostly transspehnoidal) | * Radiotherapy

When is pituitary surgery indicated?

Non-functional pituitary tumours and Cushing's disease

What are the benefit effects of somatostatin analogues in acromegaly?

* Improve soft tissue overgrowth, sweating, headache, sleep apnoea in most patients * Normalise GH and IGF-1 levels in over 50% patients * Induce tumour shrinkage in the majority * Reduce morbidity & mortality from acromegaly

Name two somatostatin analogues

Octreotide LAR and lanreotide autogel

What is the benefit of lanreotide atuogel over ocreotide LAR (SS analogues)?

Lower volume of auto gel prep and injection via deep subcutaneous rather than intramuscular

What are the possible adverse effects of somatostatin analogues?

* Nausea, cramps, diarrhoea, flatulence (often transient) * Cholesterol gallstones occur in 20-30% (mostly asymptomatic) * Slow-release preparations require monthly IM/SC injections

What is important to remember when using pituitary radiotherapy?

Use declining, acts slowly and can cause hypopituitarism

What is microprolactinoma?

Tumor of the pituitary gland (<10mm) that produces a hormone called prolactin

What is the treatment of microprolactinoma?

Dopamine agonists

What is he effect of dopamine agonists in microprolactinoma?

* Rapid fall in serum PRL (hours) * Tumour shrinkage (days/weeks) * Visual improvement (often within days) * Often recovery of pituitary function