Pituitary disease

Question 1

Structure of pituitary

Answer 1

pituitary gland attatched to hypothalamus via stalk and sits in pituitary fossa just below optic chiasm.
Divided into the anterior (endocrine productive) and posterior (neuro-endocrine-storage) pituitary

Question 2

Hormones produced by pituitary gland

Answer 2

Growth Hormone
Thyroid Stimulating Hormone
LH & FSH
Prolactin
ACTH

Question 3

Pituitary tumour symptoms

Answer 3

bi-temporal hemianopia
CN 3, 4 and 6
Headache
Hypothalamic control (weight gain/anorexia, thirst, hypersomulence/ alertness)
Symptoms of hormonal excess (GH, Prolactin, ACTH or combination)
Hypopituitarism. (GH/ TSH)

Question 4

Hypopituitarism of “other” aetiology

Answer 4

Vascular: Carotid aneurysm
Infective: Basal meningitis / enchepalitis / neurosyphilis
Traumatic: skull fracture
Autoimmune: various
Inflammatory: sarcoid, Haemachromatosis, Giant Cell Arteritis
Neoplastic: 1 pituitary tumour, meningioma, craniopharyngioma, glioma, lymphoma
Congenital: Kallman’s + various
Damage: radiation, fibroisis, chemo
Functional: anorexia, starvation, emotional neglect

Question 5

GH deficiency

Answer 5

Short stature in children, varied effects in adults,

GOLD STANDARD TEST: Insulin tolerance test.

Question 6

GH hypersecrection

Answer 6

Gigantism in children
Acromegaly in adults
Almost always due to pituitary tumour

Question 7

Gigantism

Answer 7

Excess GH before fusion of epiphyseal plates

Question 8

Acromegaly symptoms

Answer 8

CHANGE IN APPEARANCE
-increased size of hands, feet, ears and nose, forehead
-greasy thick skin
-weight gain
-large tongue
-hirsuitism
-interdental seperation 
-prognathism (jaw protrusion)
SYSTEMIC
-tiredness
-sweating
-polyuria / polydypsia
-weakness and joint pain
-headaches
-ammenorrhoea
-impotence + poor libido
-galactorrhoea
-breathless
NERVE COMPRESSION
-visual field defects
-carpal tunnel syndrome
- deep voice
-deafness

Question 9

Complications of acromegaly

Answer 9

Heart Failure
HTN
ACS
Bowel Tumours

Question 10

Management of acromegaly

Answer 10

TARGET: GH <2.5
Transphenoidal surgery
Radiotherapy
Somatostatin receptor/ dopamine agonists or GH antagonists

Question 11

Hyperprolactinaemia causes

Answer 11

Prolactinoma
Compression of pituitary stalk
PCOS
Hypothyroidism
Idiopathic
Organ failure
Drugs: anti-emetics, oestrogen therapy and opiates

Question 12

Symptoms of hyperprolactinaemia

Answer 12

Galactorrhoea 
Oligo/Amennorrhoea
Decreased libido / Erectile dysfunction
Subfertility
Oestrogen and androgen deficiency
Osteoporosis
Delayed / arrested puberty
Gynaecomastia
(headaches, visual field defects, symptoms from mass lesion/ other causes)

Question 13

Investigations hyperprolactinaemia

Answer 13

Serum Prolactin
+anterior pituitary screen
(TFT /LH+ FSH / Insulin tolerance test /short ATCH stimulation)

MRI

Question 14

Management hyperprolactinaemia

Answer 14

Dopamine agonists : Bromocriptine / Cabergiline / Quinagolide

Surgery if pituitary cause and small size

Radiotherapy

Pregnancy counselling (risk of growth, dopamine agonists can be used during gestation)

Question 15

what is Cushing’s Syndrome

Answer 15

Increased free circulating glucocorticoid

Question 16

Causes of Cushings SYNDROME

Answer 16

Cushing’s Disease (pituitary overproduction of ACTH)
Iatrogenic ACTH administration
ACTH producing tumours- ectopic

Adrenal adenomas / carcinomas
Iatrogenic Gluccocorticoid administration

Pseudo-cushings from alcohol

Question 17

Causes Cushing’s Disease

Answer 17

80% of CD caused by Pituitary Adenomas

Other causes: hyperthalamic overproduction of CRH

Question 18

Cushingoid appearance

Answer 18

APPEARANCE

• moon face
• central obesity
• thin skin with easy bruising
• hirsuitism
• acne
• frontal balding
• pigmnetation
• kyphosis and buffalo hump
• facial plethora
• Striae

Question 19

Non-visual presentation of Cushings

Answer 19

Depression
Insomnia
Menstrual disturbance
Poor libido
Muscle Weakness
Poor growth in children
Back pain
Psychosis
Poor wound healing & infections
HTN
Osteoporosis and pathological fractures 
Odema
Myopathy & muscle wasting
Diabetes, polyuria and polydipsia
Hypokalaemia

Question 20

Diagnosing Cushing’s

Answer 20

48hr Dexamethasone supression test
24hr free urinary cortisol
Circadian rythym serum cortisol / midnight salivary cortisol.

Question 21

Identifying cause of Cushing’s

Answer 21

Hx
Plasma ATCH
CT /MRI adrenals
MRI pituitary

Question 22

Management of Cushings

Answer 22

1. Treat the cause
2. Give Metyrapone / Ketoconazole to control secretion until definitive treatment.
3. transphenoidal Tumour resection
4. radiotherapy
5. bilateral adrenalectomy (S.E +++)

Question 23

Complications of Cushings

Answer 23

High mortality

MI, HTN, Sepsis, Heart Failure