Endocrinology: Pituitary Disease

Question 1

Anterior pituitary recieves blood supply from which artery? [1]

Answer 1

The superior hypophyseal artery

Question 2

The posterior pituitary recieves blood from which artery? [1]
Which blood vessel does ^ drain into? [1]

Answer 2

Inferior hypophyseal artery
Drains into the inferior hypophyseal veins – going directly into the systemic circulation

Question 3

Cushing’s Disease arises from a [excess / deficiency] of which hormone? [2]

Answer 3

Excess ACTH stimulating excessive cortisol release from the adrenal glands.

Question 4

Which hypersecretion syndrome is the most common type of pituituary adenoma? [1]

Name three male symptoms [3]
Name three female symptoms [1]

Answer 4

Prolactinoma:

men:
* impotence
* loss of libido
* galactorrhoea

Female:
* amenorrhoea
* infertility
* galactorrhoea
* osteoporosis

Question 5

What are following causes of prolactinoma:

• Physiological [1]
• Drug induced [4]
• Pathological [2]

Answer 5

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

Question 6

How would you investigate for prolactinoma?

Answer 6

Basal prolactin raised
Pregnancy test
TFT
U&E

MRI pituitary - choce

Question 7

Drug class used to manage prolactinoma? [1]

Name two drugs that are used to manage prolactinoma [2]

Answer 7

Dopamine agonists (dopamine causes tonic inhibition of prolactin release):

• bromocriptine
• cabergoline

Question 8

Contraindications of hyperprolactinaemia? [5]

Question 9

What are the classic triad signs of acromegaly? [3]

Name some other symptoms [4]

Answer 9

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.

Question 10

Name and explain which cancer ptx with acromegaly are at a higher risk of [2]

Answer 10

Increased risk of colo-rectal cancer due to high levels of IGF-1

Question 11

What is the name of this sign of acromegaly? [1]

Answer 11

Prognathism (large jaw)

Question 12

State and explain the standard investigation for acromegaly? [1]

Name two others [2]

Answer 12

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.

Question 13

Describe levels of Ca2+, PO4- and glucose in acromegaly [3]

Answer 13

All raised

Question 14

[] is one of the most frequent complications in acromegaly, with a median frequency of 33.6%

Answer 14

Hypertension is one of the most frequent complications in acromegaly, with a median frequency of 33.6%

Question 15

Describe vascular and cardiac complicatons of acromegaly [4]

Answer 15

Increased blood pressure:
- Left ventricular hypertrophy
- cardiomyopathy
- arrhythmias
- ischaemic heart disease

Question 16

Name three drug therapies for acromegaly? [3]

Answer 16

Octreotide - somatostatin analogue: lowers GH levels / blocks GH release

Pegvisomont – GH receptor antagonist; subcutaneous injection

Bromocriptine (Dopamine agonists): block growth hormone release

Question 17

What is the first line treatment for acromegaly? [1]

Answer 17

Trans–sphenoidal surgery

Question 18

Describe the difference between Cushing’s disease and Cushing’s syndrome? [2]

Answer 18

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)

Question 19

Name a cancer that can cause Cushing’s syndrome [1]

Answer 19

small cell cancers of lung

Question 20

Name and explain the diagnostic test of choice for Cushing’s syndrome

Answer 20

Normal: dexamethasone suppresses cortisol release from adrenal glands

Cushings: cortisol levels are high despite dexamethasone suppressing cortisol release

Question 21

Name three causes of ATCH independent Cushings syndrome [3]

Answer 21

• Adrenal Carcinoma
• Adrenal Adenomas
• Exogenous steroids (Cushingoid appearance)

Question 22

Pneumonic for causes of Cushing’s syndrome? [4]

Answer 22

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)

Question 23

Management of Cushing’s syndrome:

• Surgery? [1]
• Drugs? [2]

Answer 23

 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

Question 24

Name and explain what Sheehan’s syndrome is [2]
Explain when this commonly occurs? [2]

Answer 24

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

Question 25

Untreated Cushing’s disease increases chance of mortality due to what type of pathology? [1]

Answer 25

Untreated Cushings: increased vascular disease

Question 26

Name 4 causes of hypopituitarism [4]

Answer 26

Adenoma, Irradiation, Infarction (Sheehans), Infiltration
(Sarcoid, TB)

Question 27

State and explain the treatment pathway for hypopituitarism [3]

Answer 27

• 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

Question 28

What is pituitary apoplexy and when does it occur? [2]

Answer 28

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

Question 29

Presentation of pituitary apoplexy? [4]

Answer 29

▪ acute headache,
▪ meningism,
▪ visual impairment,
▪ ophthalmoplegia,
▪ Low GCS

Question 30

Treatment plan for ptx with pituitary apoplexy? [2]

Answer 30

Glucocorticoid replacement (e.g hydrocortisone) is the most important first step due to adrenal insufficiency

Followed by urgent surgical decompression

Question 31

Sheehan’s syndrome causes a lack of the hormones produced by the [] pituitary

Answer 31

Sheehan’s syndrome causes a lack of the hormones produced by the anterior pituitary

Question 32

Sheehan’s syndrome causes a lack of the hormones produced by the anterior pituitary, leading to signs and symptoms of [4]

Answer 32

Reduced lactation: lack of prolactin

Amenorrhea: lack of FSH and LH

Adrenal insufficiency & adrenal crisis: low cortisol and ACTH

Hypothyroidism: lack TSH

Question 33

There are three types of dexamethason suppression test.

Describe them [3]

Answer 33

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.

Question 34

Answer 34

Question 35

Answer 35

Question 36

Answer 36

Question 37

Answer 37

Question 38

Describe what Nelson’s syndrome is [1]

Answer 38

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

Question 39

Acromegaly can lead to which cardiac pathology? [1]

Answer 39

Cardiomyopathy

Question 40

What is the order of treatment for:
- Acromegaly [2]
- Prolactinoma [2]

Answer 40

Acromegaly:
- Surgery 1st line
- Drugs 2nd line (octreotide)

Prolactinoma:
- Drugs 1st line (Dopamine agonists: Cabergoline; bromocriptine)
- Surgery 2nd line

Question 41

Which one of the following drugs is not a cause of galactorrhoea?

Metoclopramide

Bromocriptine

Chlorpromazine

Haloperidol

Domperidone

Answer 41

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