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year 2 > pituitary > Flashcards

pituitary Flashcards

1
Q

where is the pituitary gland found

A

pituitary fossa of the sphenoid bone / sella turcica

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2
Q

what does the pituitary gland lie immediately inferior to

A

optic chiasm

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3
Q

what effect does a pituitary tumour have on the visual field

A

bitemporal hemianopia

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4
Q

how is the hypothalamus attached to the pituitary gland

A

pituitary stalk (infundibulum)

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5
Q

what embrylogical structure is the anterior pituitary derived from

A

Rathke’s Pouch

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6
Q

what are the 3 sections of the anterior pituitary

A

pars distalis
pars tuberalis
pars intermedia

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7
Q

what is another name for the anterior pituitary

A

adenohypophysis

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8
Q

what are the 3 cell types in the anterior pituitary

A

acidophils
basophils
chromophobes

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9
Q

how is the anterior pituitary organised into cells

A

“islands, cords of cells”

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10
Q

what is prolactin under tonic inhibition from

A

hypothalamic dopamine

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11
Q

what do basophils produce

A

corticotrophs - ACTH
thyrotrophs - TSH
gonadotrophs - FSH/LH

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12
Q

paired hormone concept refers to what

A

the pituitary released hormones (central) that are linked to peripheral hormones

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13
Q

what is another name for the posterior pituitary

A

neurohypophysis

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14
Q

what makes up the posterior pituitary

A

pars nervosa

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15
Q

the posterior pituitary is an extension of what

A

the brain - modified glial cells and axonal processes

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16
Q

what cells make up the posterior pituitary

A

non-myelinated axons of neurosecretory neurones

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17
Q

what hormones does the posterior pituitary gland release

A

ADH/vasopressin

OT/oxytocin

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18
Q

where are ADH and OT synthesised

A

hypothalamus

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19
Q

what are the 2 routes of access to the pituitary fossa

A

transcranial (under frontal bone)

transphenoidal (via nasal cavities and sphenoid sinus)

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20
Q

what structures are at risk in pituitary gland surgery

A 
optic chiasm/CN II
CN III, IV, V VI
cavernous sinus
ICA
dura mater
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21
Q

what would happen if the following was damaged in pituitary gland surgery:
optic chiasm

A

bitemporal hemianopia

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22
Q

what would happen if the following was damaged in pituitary gland surgery:
CN III

A

problems with several eye movements

dilated pupil

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23
Q

what would happen if the following was damaged in pituitary gland surgery:
CN IV

A

medial deviation of the eye

SO damage

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24
Q

what would happen if the following was damaged in pituitary gland surgery:
CN V

A

sensory symptoms on face

problems chewing food

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25
Q

what would happen if the following was damaged in pituitary gland surgery:
CN VI

A

problems with abduction of eye

LR damage

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26
Q

what would happen if the following was damaged in pituitary gland surgery:
cavernous sinus

A

venous haemorrhage

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27
Q

what would happen if the following was damaged in pituitary gland surgery:
ICA

A

haemorrhage

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28
Q

what would happen if the following was damaged in pituitary gland surgery:
dura mater

A

CSF leak

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29
Q

what are some examples of anterior pituitary hyperfunction

A

adenoma

carcinoma

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30
Q

what are some examples of anterior pituitary hypofunction

A 
surgery
radiation
haemorrhage
ischaemic necrosis (Sheehan syndrome)
tumours extending into sella
inflammatory (sarcoid)
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31
Q

what are some examples of posterior pituitary hypofunction

A

DI - lack of ADH secretion

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32
Q

what are some examples of posterior pituitary hyperfunction

A

SIADH

ectopic secretion of ADH by tumours/paraneoplastic/primary disorder in pituitary

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33
Q

what are some examples of posterior pituitary hyperfunction

A

SIADH

ectopic secretion of ADH by tumours/paraneoplastic/primary disorder in pituitary

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34
Q

do pituitary adenomas more often occur anterior or posterior

A

anterior

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35
Q

what % of intracranial tumours are pituitary adenomas

A

10% - relatively common

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36
Q

what can cause a pituitary adenoma

A

MEN1 or sporadic

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37
Q

what problems can a non-functional pituitary adenoma cause

A

hypofunction - hypoadrenalinism, hypothyroidism, hypogonadism, DI, GH deficiency

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38
Q

what local effects can a pituitary tumour cause

A 
headache
bitemporal hemianopia
compression on CN II III IV V VI 
atrophy of surrounding tissue
disturbance of hypothalamic centres of temperature
sleep and appetite affected
infarction --> panhypopituitarism
erosion through floor of sella --> CSF rhinorrhoea
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39
Q

what is the most common functional pituitary adenoma

A

prolactinoma

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40
Q

what is the 2nd most common functional pituitary adenoma

A

GH secreting

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41
Q

what would an ACTH secreting pituitary adenoma cause

A

cushings disease –> bilateral adrenocortical hyperplasia

usually a microadenoma

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42
Q

are pituitary carcinomas common or rare

A

rare (< 1% pituitary tumours)

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43
Q

are pituitary carcinomas usually non-functional or functional

A

functional - prolactin or ACTH

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44
Q

do pituitary carcinomas metastasise late or early

A

late after many recurrences

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45
Q

do prolactinomas present earlier in males or females

A

females

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46
Q

what are some s/s of prolactinoma in females

A 
galactorrhoea
menstrual irregularity/amenorrhoea
infertility
decreased libido
vaginal dryness
weight gain
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47
Q

what are some s/s of prolactinoma in males

A 
impotence
visual field abnormality
headache
decreased facial hair
galactorrhoea
infertility
decreased libido
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48
Q

how does increased prolactin cause hypogonadism, infertility and osteoporosis

A

inhibits secretion of GnRH therefore decreased LH/FSH/Testosterone/oestrogen

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49
Q

what size is a microadenoma and what is a macroadenoma

A

microadenoma < 1cm

macroadenoma >1cm

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50
Q

what investigations are done in suspected prolactinoma

A 
(pregnancy test)
serum prolactin conc
MRI pituitary
visual fields
pituitary function tests to see other hormones affected
U+Es
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51
Q

what is the first line treatment in a prolactinoma

A

dopamine agonist

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52
Q

what are 3 examples of dopamine agonists and what has the least side effects

A

Bromocriptine
Quinagoldine
Cabergoline (least side effects)

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53
Q

what do dopamine agonists do in prolactinomas

A

restore menstrual cycle and decrease tumour size

54
Q

what are some side effects of dopamine agonists

A

N+V
low mood
postural hypotension
fibrosis of heart valves

55
Q

which of the dopamine agonists cannot be used in pregnancy

A

bromocriptine

56
Q

what is the treatment in prolactinoma if the person is dopamine agonist intolerant

A

surgery

57
Q

what does a GH secreting pituitary adenoma cause

A

acromegaly

58
Q

are men or women more prone to getting a GH secreting pituitary adenoma

A

men

59
Q

why does a GH secreting pituitary adenoma cause acromegaly

A

GH stimulates IGF-1 which causes growth of bone, cartilage and connective tissue

60
Q

what are some common phrases that go with acromegaly

A

“rings and shoes dont fit anymore”
“wonky jaw”
“put on weight (muscle) but now look haggard”

61
Q

what else is a cause of acromegaly

A

hyperplasia e.g. via ectopic GHRH form carcinoid tumour (rare)

62
Q

what are some s/s acromegaly

A 
snoring/sleep apnoea 
headache
thickened soft tissues - skin, large jaw, large hands, sweaty
hypertension
wide nose
big supraorbital ridges
macroglossia
wide spaced teeth
acanthosis nigricans
amenorrhoea/reduced libido
arthralgia/back ache
DM
local pituitary effects
colon cancer/polyps
cardiac failure/early CV death
63
Q

what investigations are done in suspected GH secreting pituitary adenoma

A

IGF-1
GTT suppression test
MRI pituitary fossa
look at old photos

64
Q

blood glucose, Ca, phosphate in acromegaly

A

raised

65
Q

what would be normal results of a GTT supression test

A

GH suppresses to < 0.4 ug/L after glucose

66
Q

what would be results of a GTT suppression test that indicate acromegaly

A

GH unchanged/no suppression/paradoxical rise/remains > 1ug

67
Q

what is the treatment for a GH secreting pituitary adenoma

A

surgery
radiotherapy if unsuitable for surgery
drugs

68
Q

what might give false positives in a GTT

A 
puberty
pregnancy
hepatic and renal disease
anorexia 
DM
69
Q

what is considered clinically safe levels of GH in follow up of GHSPA

A

GH < 0.4 (post GTT) or < 2 random

70
Q

why should random GH measurement not be relied on

A

normal secretion is pulsatile

71
Q

what effect do stress, sleep, puberty and pregnancy have on GH secretion

A

increase

72
Q

what should be surveillanced after a GHSPA

A

cancer - colon/tubulovillous

CV risk factors

73
Q

as a follow up what should people with GHSPA get yearly

A

GH
IGF-1
+/- OGTT
visual fields

74
Q

what is the first line drug treatment for acromegaly

A

somatostatin analogues

75
Q

give 3 examples of somatostatin analogues

A

sandostatin LAR
lanreotide
octreotide

76
Q

what do somatostatin analogues do

A

reduce GH in most patients and tumour shrinkage in 30-50% of cases in 6-12 weeks - although reexpansion once stopped

77
Q

what drug is used to relieve headache post op within 1 hour

A

somatostatin analogue

78
Q

what are some side effects of somatostatin analogues

A 
local stinging
flatulence
diarrhoea
abdominal pain
gall stones
impaired glucose tolerance
79
Q

what other drugs can be used in the treatment of acromegaly

A

dopamine agonists

GH antagonists

80
Q

what is an example of a dopamine agonist

A

cabergoline

81
Q

when would cabergoline (dopamine agonist) be preferred

A

tumour that co-secretes GH and prolactin

82
Q

what is an example of a GH antagonist

A

Pegvisomant

83
Q

how is pegvisomant administered

A

SC

84
Q

how does pegvisomant work

A

binds to GH receptor and blocks GH activity

85
Q

does pegvisomant reduce tumour size

A

no - may see small increase in some

86
Q

does pegvisomant decrease IGF-1

A

yes

GH may rise

87
Q

where are craniopharyngiomas found

A

between pituitary and 3rd ventricle floor

88
Q

what are craniopharyngiomas derived from

A

pituitary embryonic tissue - remnants of rathke’s pouch

89
Q

what % of intracranial tumours are craniopharyngiomas

A

1-5%

90
Q

are craniopharyngiomas slow or fast growing

A

slow

91
Q

how might you describe a craniopharyngioma

A

may be solid/cystic/calcific/full of debris

92
Q

are most craniopharyngiomas suprasellar or within sella

A

suprasellar

93
Q

craniopharyngiomas have a bimodal incidence

what are the 2 most common age ranges

A

5-15 years

50-60 years

94
Q

what is the most common childhood intracranial tumour

A

craniopharyngioma

95
Q

what is the prognosis like of a craniopharyngioma if it is < 5cm

A

excellent

96
Q

what may develop following radiation treatment

A

SCC

97
Q

what are some s/s of a craniopharyngioma

A 
growth retardation in children - > 50% present with this
headache / visual disturbance
N+V
DI
behavioural changes
early/delayed puberty/oligo/amenorrhoea
impotence
reduced libido
reduced fertility
appetite/weight changes
sleep disturbance
98
Q

does pituitary hypofunction usually affect one or multiple hormones

A

usually panhypopituitarism

99
Q

what are some s/s of anterior panhypopituitarism

A 
menstrual irregularites/infertility/impotence
gynaecomastia
decreased strength
abdominal obesity
loss of facial/axillary/pubic hair
dry skin and hair
erectile dysfunction
hypothyroid
growth retardation
osteoporosis
decreased libido
decreased CO and exercise ability
100
Q

what is an example of posterior hypopituitarism

A

diabetes insipidus

101
Q

what can cause panhypopituitarism

A

tumour
secondary mets (lung breast)
local brain tumour - astrocytoma, meningioma, glioma
granulomatous disease e.g. TB, sarcoidosis, histiocytosis
vascular disease (polyarteriitis)
trauma
hypothalamic disease (syphillis, meningitis)
sheehan syndrome
infection
craniopharyngioma
irradiation of pituitary
infiltration - haemochromocytosis, amyloid
kallmans

102
Q

how do you check pituitary steroid hormone production

A

synacthen stimulation test - cortisol

insulin tolerance test (cortisol and GH)

103
Q

when would you do a prolonged glucagon test instead of an insulin tolerance test

A

epilepsy
heart disease
adrenal failure

104
Q

what is a normal cortisol following insulin tolerance test

A

> 500

105
Q

what is a normal GH following insulin tolerance test

A

> 7 ug/L

106
Q

apart from checking pituitary hormones in panhypopituitarism what else would you want to do

A

MRI for hypothalamic or pituitary tumour

107
Q

what is the treatment of panhypopituitarism

A

replace lost hormones

108
Q

how would hypothyroidism as a result of panhypopituitarism be treated

A

thyroxine

109
Q

how would secondary adrenal failure as a result of panhypopituitarism be treated

A

hydrocortisone

110
Q

how would DI as a result of panhypopituitarism be treated

A

desmospray

111
Q

how would GH be replaced

A

nightly SC

112
Q

how would sex steroids be replaced

A

HRT/oestrogen/progesterone

testosterone

113
Q

how can testosterone be given

A

IM injections, skin gel or tablets

114
Q

what are 3 side effects of testosterone replacement

A

prostate enlargement (monitor PRE and PSA)
polycynthaemia (monitor FBC)
hepatitis (only oral tablets)

115
Q

what is the problem in diabetes insipidus

A

no ADH secretion to act on kidneys to cause water retention so lots of pure water is lost in urine

116
Q

what is Na like in DI

A

high

117
Q

what are some s/s of hypernatraemia

A 
irritability
lethargy
cognitive dysfunction
tachycardia
abnormal skin turgor
dry axilla
118
Q

what are the 2 groups of causes of DI

A

central and nephrogenic

119
Q

what is a nephrogenic cause of DI

A

renal resistance to ADH

120
Q

what are some central causes of DI

A

familial (DIDMOAD) - DI, DM, optic atropy, deaf
ADH deficiency
trauma/surgery
tumours
inflammatory disorders of pituitary/hypothalamus
sarcoidosis
meningitis

121
Q

how is DI diagnosed

A

water deprivation test

122
Q

what is another test that should be done when someone presents with the symptoms of DI

A

serum glucose to exclude DM

123
Q

describe a water deprivation test

A

NBM for 8-12 hours

check urine and serum osmolalities for 8 hours then 4 hours after giving IM DDAVP

124
Q

describe the results of a water deprivation test

A

Ur/serum osmol ratio > 2 = normal
otherwise - DI
if it improves after DDAVP = cranial DI

125
Q

what is the treatment of central DI

A

desmospray

desmopressin (oral or IM) in emergency or post pituitary surgery

126
Q

what are the s/s of DI

A

similar to DM
polyuria
polydipsia
dehydration

127
Q

what is the treatment of nephrogenic DI

A

bendroflumethiazide

NSAIDs

128
Q

how do NSAIDs help in nephrogenic DI

A

lower urine vol and serum Na by inhibiting prostaglandin synthase - prostaglandins locally inhibit action of ADH

129
Q

in hormone replacement should hydrocortisone or levothyroxine be given first

A

steroid first - thyroid may ppt as adrenal crisis

130
Q

what is a pituitary apoplexy

A

rapid pituitary enlargement from bleed into a tumour which may cause mass effects and hypopituitarism –> CV collapse and death

year 2 (19 decks)

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