Endocrinology: Pituitary Disease Flashcards
Anterior pituitary recieves blood supply from which artery? [1]
The superior hypophyseal artery
The posterior pituitary recieves blood from which artery? [1]
Which blood vessel does ^ drain into? [1]
Inferior hypophyseal artery
Drains into the inferior hypophyseal veins – going directly into the systemic circulation
Cushing’s Disease arises from a [excess / deficiency] of which hormone? [2]
Excess ACTH stimulating excessive cortisol release from the adrenal glands.
Which hypersecretion syndrome is the most common type of pituituary adenoma? [1]
Name three male symptoms [3]
Name three female symptoms [1]
Prolactinoma:
men:
* impotence
* loss of libido
* galactorrhoea
Female:
* amenorrhoea
* infertility
* galactorrhoea
* osteoporosis
What are following causes of prolactinoma:
- Physiological [1]
- Drug induced [4]
- Pathological [2]
Physiological:
- Pregnancy: breastfeeding
- Stress
Drug induced:
- Anti-physotics: Haloperidol; Methyldopa; Chlorpromazine
- Anti-acid: ranitidine
- Anti-emetic: prochlorperazine; metoclopromide
- MDMA
Pathological:
- Prolactinoma (micro or macro)
- Stalk damage: pituitary adenomas, trauma, surgery
- Hypothalamic disease
How would you investigate for prolactinoma?
Basal prolactin raised
Pregnancy test
TFT
U&E
MRI pituitary - choce
Drug class used to manage prolactinoma? [1]
Name two drugs that are used to manage prolactinoma [2]
Dopamine agonists (dopamine causes tonic inhibition of prolactin release):
- bromocriptine
- cabergoline
Contraindications of hyperprolactinaemia? [5]
What are the classic triad signs of acromegaly? [3]
Name some other symptoms [4]
Headaches, arthralgia, sweating
Increased ring/shoe size, weakness, diabetes, carpal tunnel, atherosclerosis
TOM TIP: When preparing for the PACES exam, the link between bilateral carpal tunnel syndrome and acromegaly came up several times. Cases would present a patient with symptoms of bilateral carpal tunnel syndrome. The challenge was not only to diagnose carpal tunnel syndrome but also to identify the features of the underlying cause. Whenever you see a patient in an OSCE station, and you make a diagnosis, ask yourself whether that diagnosis might have an underlying cause and look for features of that cause.
Name and explain which cancer ptx with acromegaly are at a higher risk of [2]
Increased risk of colo-rectal cancer due to high levels of IGF-1
What is the name of this sign of acromegaly? [1]
Prognathism (large jaw)
State and explain the standard investigation for acromegaly? [1]
Name two others [2]
OGTT:
- Make patient fast
- At time 0, check glucose and GH
- Give 75g dose of glucose and wait 2hrs
- Normal response: suppression of GH when glucose given
- Acromegaly response: GH increases despite glucose given
Insulin-like growth factor-1 (IGF-1):
can be tested on a blood sample. It indicates the growth hormone level and is raised in acromegaly.
MRI pituitary
Testing growth hormone directly is unreliable: fluctuates in the day.
Describe levels of Ca2+, PO4- and glucose in acromegaly [3]
All raised
[] is one of the most frequent complications in acromegaly, with a median frequency of 33.6%
Hypertension is one of the most frequent complications in acromegaly, with a median frequency of 33.6%
Describe vascular and cardiac complicatons of acromegaly [4]
Increased blood pressure:
- Left ventricular hypertrophy
- cardiomyopathy
- arrhythmias
- ischaemic heart disease
Name three drug therapies for acromegaly? [3]
Octreotide - somatostatin analogue: lowers GH levels / blocks GH release
Pegvisomont – GH receptor antagonist; subcutaneous injection
Bromocriptine (Dopamine agonists): block growth hormone release
What is the first line treatment for acromegaly? [1]
Trans–sphenoidal surgery
Describe the difference between Cushing’s disease and Cushing’s syndrome? [2]
Cushing disease:
* ACTH dependent occurs when the pituitary gland’s corticotrophs make excess ACTH due to corticotroph adenoma
Cushing syndrome:
* is the set of symptoms that results when there is a surplus of cortisol in the body (e.g. from neuroendrocrine tumours or small cell cancers of lung)
Name a cancer that can cause Cushing’s syndrome [1]
small cell cancers of lung
Name and explain the diagnostic test of choice for Cushing’s syndrome
Normal: dexamethasone suppresses cortisol release from adrenal glands
Cushings: cortisol levels are high despite dexamethasone suppressing cortisol release
Name three causes of ATCH independent Cushings syndrome [3]
- Adrenal Carcinoma
- Adrenal Adenomas
- Exogenous steroids (Cushingoid appearance)
Pneumonic for causes of Cushing’s syndrome? [4]
CAPE
C – Cushing’s disease (a pituitary adenoma releasing excessive ACTH)
A – Adrenal adenoma (an adrenal tumour secreting excess cortisol)
P – Paraneoplastic syndrome
E – Exogenous steroids (patients taking long-term corticosteroids)
Management of Cushing’s syndrome:
- Surgery? [1]
- Drugs? [2]
Trans-sphenoidal surgery
Adrenolytics:
Ketoconazole: causes steroidogenesis inhibition.
Metyrapone: reduces the production of cortisol in the adrenals and is occasionally used in treating of Cushing’s
Name and explain what Sheehan’s syndrome is [2]
Explain when this commonly occurs? [2]
Pituitary infarction
- Commonly after childbirth: develop an increased vasculature around pituitary gland
- If suffer from PPH then blood pressure drops and causes infarction
- Results in hypopituitarism
Untreated Cushing’s disease increases chance of mortality due to what type of pathology? [1]
Untreated Cushings: increased vascular disease
Name 4 causes of hypopituitarism [4]
Adenoma, Irradiation, Infarction (Sheehans), Infiltration
(Sarcoid, TB)
State and explain the treatment pathway for hypopituitarism [3]
- Hydrocortisone: if give thyroxine first and have a lack of glucocorticoids then can cause adrenal crisis by increasing metabolic rate from thyroxine
- Thyroxine
- Testosterone / HRT / Ovulation induction
What is pituitary apoplexy and when does it occur? [2]
If someone has a long standing pituitary tumour, can develop abrupt acute hemorrhagic infarction of a pituitary adenoma
The term pituitary apoplexy or apoplexia refers to the “sudden death” of the pituitary gland, usually caused by an acute ischemic infarction or hemorrhage
Presentation of pituitary apoplexy? [4]
▪ acute headache,
▪ meningism,
▪ visual impairment,
▪ ophthalmoplegia,
▪ Low GCS
Treatment plan for ptx with pituitary apoplexy? [2]
Glucocorticoid replacement (e.g hydrocortisone) is the most important first step due to adrenal insufficiency
Followed by urgent surgical decompression
Sheehan’s syndrome causes a lack of the hormones produced by the [] pituitary
Sheehan’s syndrome causes a lack of the hormones produced by the anterior pituitary
Sheehan’s syndrome causes a lack of the hormones produced by the anterior pituitary, leading to signs and symptoms of [4]
Reduced lactation: lack of prolactin
Amenorrhea: lack of FSH and LH
Adrenal insufficiency & adrenal crisis: low cortisol and ACTH
Hypothyroidism: lack TSH
There are three types of dexamethason suppression test.
Describe them [3]
Low-dose overnight test (used as a screening test to exclude Cushing’s syndrome)
- A normal result is that the cortisol level is suppressed.
- Failure of the dexamethasone to suppress the morning cortisol could indicate Cushing’s syndrome, and further assessment is required. THINK CAPE
Low-dose 48-hour test (used in suspected Cushing’s syndrome)
- 0.5mg is taken every 6 hours for 8 doses, starting at 9 am on the first day.
- Cortisol is checked at 9 am on day 1 (before the first dose) and 9 am on day 3 (after the last dose)
- A normal result is that the cortisol level on day 3 is suppressed
- Failure of the dexamethasone to suppress the day 3 cortisol could indicate Cushing’s syndrome, and further assessment is required.
High-dose 48-hour test (used to determine the cause in patients with confirmed Cushing’s syndrome)
- carried out the same way as the low-dose test, other than using 2mg per dose (rather than 0.5mg).
- This higher dose is enough to suppress the cortisol in Cushing’s disease, but not when it is caused by an adrenal adenoma or ectopic ACTH.
Describe what Nelson’s syndrome is [1]
Nelson’s syndrome involves the development of an ACTH-producing pituitary tumour after the surgical removal of both adrenal glands due to a lack of cortisol and negative feedback
Acromegaly can lead to which cardiac pathology? [1]
Cardiomyopathy
What is the order of treatment for:
- Acromegaly [2]
- Prolactinoma [2]
Acromegaly:
- Surgery 1st line
- Drugs 2nd line (octreotide)
Prolactinoma:
- Drugs 1st line (Dopamine agonists: Cabergoline; bromocriptine)
- Surgery 2nd line
Which one of the following drugs is not a cause of galactorrhoea?
Metoclopramide
Bromocriptine
Chlorpromazine
Haloperidol
Domperidone
Which one of the following drugs is not a cause of galactorrhoea?
Metoclopramide
Bromocriptine
Bromocriptine is a treatment for galactorrhoea, rather than a cause
Chlorpromazine
Haloperidol
Domperidone
