Endocr. Anterior pituitary 11-01 (1) Flashcards
Prolactinoma.
causes? 3
Prolactin secreting tumor - Benign.
Other causes of hyperprolactinemia:
Dopamine antagonists.
Very high TRH levels (hypothyroidism).
Prolactinoma.
CP women?
Women:
▪ Amenorrhea; due to suppression of GnRH.
▪ Galactorrhea.
▪ Presents earlier –> microadenoma. No field cuts.
Galactorrhea is milk production from the breast unrelated to pregnancy or lactation.
.
Prolactinoma.
CP men?
Decreased libido.
infertility, impotence, gynecomastia
Macroadenoma –> Bitemporal hemianopsia, headache.
Amenorrhea is the absence of menstruation.
.
Prolactinoma. In premenopausal women CP?
related to hormones - galactorrhea, amenorrhea, decr. bone density
Prolactinoma. In postmenopausal women CP?
mass effect - headache, visual field
Prolactinoma.
Labs. prolactin?
> 200
correlates with size of prolactinoma
Prolactinoma.
what to check when diagnosig? 4 things
Check medications first
TSH levels
Prolactin levels
MRI for tumor
Prolactinoma. what to rule out when diagnosing?
Renal insuff - lab: Cr
Hypothyroidism - lab: TSH, tyroxine
Prolactinoma. imaging for diagnosis?
MRI
Prolactinoma. management scheme in premenopausal. First step?
Detailed clinical evaluation
+
Rule out secondary cause (eg pregnancy)
Prolactinoma. management scheme in premenopausal. Clinical + secondary cause —> what next?
MRI of pituitary
Prolactinoma. management scheme in premenopausal. MRI = asymptomatic prolactinoma (<10 mm) –> treatment?
NO TREATMENT
Prolactinoma. management scheme in premenopausal. MRI = MACROPROLACINOMA (>10 mm)
OR
Symptomatic microprolactinoma –> treatment?
Abu variantai:
Dopamine agonists
arba
Resection: Very large (>=3 cm) arba incr. in size while on drug treatment.
Jeigu galima, tai pradedam drugs –>jeigu neefektyvu –> resection
Acromegaly. pathophysiology?
Growth hormone increases hepatic production of insulin-like growth factor (IGF-1) –> causes excessive growth of bone and soft tissue
Acromegaly.
Surgery can minimize the hypertrophic stages but will not
reverse degenerative changes.
Diastolic heart failure due to hypertension.
.
Acromegaly. first step test?
Suspected acromegaly –> IGF-I level
Acromegaly.
IGF-I level –> elevated –> what next step?
Oral glucose suppression test
Acromegaly.
IGF-I level –> elevated –> normal –> next step?
normal level rules out acromegaly
Acromegaly.
IGF-I level –> elevated –>Oral glucose suppression test –> adequate suppression –>?
suppression rules out acromegaly
Acromegaly.
IGF-I level –> elevated –>Oral glucose suppression test –> NO adequate suppression –>?
MRI of brain
Acromegaly. in general sequence in diagnosis?
elevated IGF-I –> Inadequate GH suppression on oral glucose suppression test –> do MRI.
Acromegaly.
IGF-I level –> elevated –>Oral glucose suppression test –> NO adequate suppression –> MRI pituitary mass –> ?
Surgical versus medical management
Acromegaly.
IGF-I level –> elevated –>Oral glucose suppression test –> NO adequate suppression –> MRI NO pituitary mass –> ?
Evaluate extrapituitary cause of acromegaly (ectopic GH and GHRH secreting tumor)
Acromegaly.
Glucose test mechanism?
Oral glucose given –> insulin increases –> growth hormone should decrease but it stays the same.
yra atspausdinta lentele su clinical features of untreated acromegaly.
.
Acromegaly.
Surgery can minimize the hypertrophic stages but will not
reverse degenerative changes.
.
Hypopituitarism. acute. causes?
Causes: infection, infarction, or iatrogenic.
Hypopituitarism. acute. diagnosis?
Assessment of cortisol and T4 levels
Hypopituitarism. acute. treatment?
replace hormones
Hypopituitarism. acute. RECOGNIZE sheenan and apoplexy
.
Sheenan CP?
Lactation failure (decr. prolaclin)
Amenorrhea, hot flashes, vaginal atrophy(decr. FSH, LH)
Fatigue, bradycardia (decr. TSH)
Anorexia, weight loss, hypotension (decr. ACTH)
Decreased lean body mass (decr. growth hormone)
Hypopituitarism. Chronic. causes?
Causes: autoimmune, deposition disease, or slow growing tumor.
Hypopituitarism. Chronic. cp?
GH and FSH/LH will be sacrificed to maintain TSH and ACTH.
Decreased libido.
Fatigue.
Menstrual irregularities
Hypopituitarism. Chronic. diagnosis?
a) Insulin stimulation test.
Give insulin –> glucose drops –> GH should increase but it stays the same.
b) Vasopressor stimulation test.
If tests positive –> MRI.
Hypopituitarism. Chronic. treatment?
Replace the hormones.
Fix underlying disease.
Hypopituitarism. table. Pituitary causes? 3
Primary (eg adenoma) or metastatic
Infiltration (hemochromatosis, lymphocytic hypophysitis)
Hemorrhage (apoplexy) or infarction (sheenan)
Hypopituitarism. table. Hypothalamic causes? 5
Mass lesion
Radiation therapy
Infiltration (sarcoidosis)
Trauma to skull base
Infections (TBC meningitis)
Hypopituitarism. table. CP.
ACTH deficiency (secondary adrenal insuf)?
Postural hypotension, tachy, fatigue, weight loss, hypoglycemia, eosinophilia
Hypopituitarism. table. CP.
Hypothyroidism (central)?
Fatigue, cold intolerance, constipation, dry skin, brady, slowed deep tendon reflexes
Hypopituitarism. table. CP.
Gonadotropins?
Women - amenorrhea, infertility
Men - infertility, loss of libido
Empty Sella syndrome:
Pituitary is not in the Sella –> located somewhere else.
CP, diagnosis and treatment?
● C/P: asymptomatic.
● Diagnosis: MRI.
● Treatment: do nothing.
Pituitary apoplexy. CP?
Sudden hemorrhage into an enlarged pituitary adenoma.
Headache, ptosis, and vision changes.
Adrenal crisis.
M. acromegaly. caused by?
Caused by excess growth hormone secretion (usually by a tumor) following closure of the growth plates ( GH secretion prior to growth plate closure causes gigantism).
M. acromegaly. GH goes to the liver, which causes it to secrete ……?
IGF-1.
M. acromegaly. then IGF-1 that induces ….?
growth effects at tissues.
M. acromegaly.
An NBME Q gives easy vignette of acromegaly and then asks what you check; ????
serum GH is wrong; answer is serum IGF-1.
M. acromegaly. CP.
Acromegaly causes prognathism (lantern jaw), large ears/nose, arthritis and carpal tunnel syndrome (due to joint and tendon growth), enlargement of hands/feet, hypertension, type II diabetes (GH causes insulin resistance), and risk of arrhythmia and cardiomyopathy.
.
M. acromegaly. Tx?
Treatment is somatostatin analogue (octreotide).
Somatostatin is aka growth hormone-inhibiting hormone (GHIH) and shuts off its secretion from the anterior pituitary. It also ̄ secretion of insulin and glucagon from the pancreas.
.
50-year-old man comes to the office due to a 4-month history of achy joint pain in the lower back,shoulders, hips, and knees. The pain increases with activity, and he has no morning stiffness. The patient also has excessive sweating, polyuria, and erectile dysfunction. Medical history is unremarkable. The patient has a 25-pack-year smoking history and drinks moderate amounts of alcohol on social occasions. BP 150/90 mm Hg, pulse is 80/min, and respirations are 16/min. Examination shows crepitus on passive movement of the knee joints. There is increased interdental spacing and an enlarged tongue, and the remainder of the examination is normal. Plain radiography of the hand reveals widening of the joint spaces, osteophytes, and thickened soft tissues. Laboratory evaluation reveals low testosterone and hyperglycemia. What is the most likely diagnosis?
ACROMEGALY
