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Year 3 - Met3b > Pituitary Disease > Flashcards

Pituitary Disease Flashcards

1
Q

what is the hypothalamus

A

Coordinating centre of the endocrine system

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2
Q

what signals does the hypothalamus get

A
  • signals from upper cortical inputs
  • autonomic function
  • environmental cues
  • peripheral endocrine feedback
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3
Q

Where does the hypothalamus deliver signals to

A

Delivers signals to pituitary, via the pituitary stalk to release hormones that influence the endocrine system of the target organ

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4
Q

what does the portal system ensure

A

Portal system, ensuring high levels of hormones reaching the pituitary only

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5
Q

What two parts is the pituitary made out of

A

 Anterior

 Posterior

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6
Q

How is the anterior pituitary connected to the hypothalamus

A

via a portal system

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7
Q

How is the posterior pituitary connected to the hypothalamus

A

via the infundibulum

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8
Q

it the pituitary inside or outside the dura

A
  • Lies outside the dura
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9
Q

where is the pituitary gland

A

 Rests in the sella turcica,

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10
Q

Is the pituitary below or above the optic chiasm

A

below the optic chiasm

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11
Q

How can you access the pituitary

A

Pituitary lies behind the eyes and can be accessed through the sphenoid bones

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12
Q

Describe the blood supply to the anterior pituitary

A

Blood supply – bathed in a capillary plexus where high concentrations of releasing hormones are present

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13
Q

What are the 6 hormones released from the anterior pituitary gland

A 
 ACTH
 TSH
 GH
 LH, FSH 
 PRL
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14
Q

Describe the blood supply for the inferior pituitary gland

A

Blood supply – inferior hypophyseal artery and drains into the inferior hypophyseal veins – going directly into the systemic circulation

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15
Q

What two hormones are released from the inferior pituitary gland

A
  • vasopressin (ADH)

- Oxytocin

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16
Q

How does the inferior pituitary gland release hormones

A
  • releases hormones directly from the neurones in the hypothalamus
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17
Q 
What does excess 
- GH 
- PRL 
- FSH/LH 
- ACTH 
- TSH 
- ADH 
produce
A
  • GH = acromegaly
  • PRL = hypogonadism
  • FSH/LH = rarely clinical
  • ACTH = Cushings disease
  • TSH = hyperthyroidism
  • ADH = SIADH
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18
Q 
What does deficient 
- GH 
- PRL 
- FSH/LH 
- ACTH 
- TSH 
- ADH 
produce
A
  • GH = GH deficiency
  • PRL = failed lactation
  • FSH/LH = hypogonadism
  • ACTH = adrenal insufficiency
  • TSH = hypothyroidism
  • ADH = diabetes insipidus
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19
Q

What happens if the pituitary gland presses on the cavernous sinus

A

Cranial nerve palsies

stroke

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20
Q

What happens if the pituitary gland presses on the optic chiasma

A

Bitemperal hemianopia

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21
Q

How does hormone hypersecretion present

A

 Prolactinoma - amenorrhoea / galactorrhoea
 Acromegaly
 Cushing’s Disease
 (Thyrotoxicosis – secondary

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22
Q

What is the commonest FUNCTIONING type of pituitary tumour

A

 Prolactinoma - amenorrhoea / galactorrhoea

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23
Q

What are the symptoms from mass effect (pituiary pressing on structures)

A

 Headaches
 Vision loss
 Pituitary gland hyposecretion (hypopituitarism)
 Pituitary apoplexy - occurs acutely

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24
Q

Name the sizes of microadenoma and macroadenoma

A
  • Microadenoma - <1cm

- Macroadenoma - >1cm

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25
Q

define amenorrhoea

A

Amenorrhoea means the absence of a menstrual period in females

26
Q

define galactorrhoea

A

excessive or inappropriate production of milk

27
Q

what are the two types of pituitary tumour

A
  • Macroadenoma - dont cure completely

- Microadenoma - only tend to cure these

28
Q

How often do prolactinomas occur

A
  • they occur in 30-40% of pituitary tumours
29
Q

What are the symptoms of prolactinomas

A
  • Amemorrhoea,
  • galactorrhoea
  • erectile dysfunction
  • If very large can lead to sight loss – chiasmal compression
30
Q

What are the signs of prolactinomas

A
  • Galactorrhoea,
  • hypogonadism,
  • bitemporal hemianopia
31
Q

What investigations should you use in prolactinomas

A
  • Prolactin
  • TFT - hypothyroidism can cause a raised prolactin
  • LH
  • FSH
  • Testostorone
  • MRI pituitary
32
Q

What is the management of prolactinomas

A
  • treated with dopamine agonists (dopamine causes tonic inhibition of prl release) – bromocriptine / cabergoline
  • useful oral agents
33
Q

What causes the inhibition of prolactin release

A

dopamine

34
Q

Apart from a prolactinoma what can cause high prolactin

A

 Lactation/Pregnancy

 Drugs:

  • Antacids (ranitidine) - H2 blockers
  • Anti-psychotics (chlorpromazine) - dopamine agonist
  • Anti-emetics (prochlorperazine) - dopamine agonist

 Stress

 Seizures

 Stalk compression - tumour compresses this this blocks the dopamine pathway and as a result prolactin levels rise

 Macroprolactin - some people produce a larger prolactin molecule which can show a higher prolactin but in reality the prolactin is normal

35
Q

What happens if you have GH excess before puberty

A

Gigantism

- This happens before the closure of growth plates

36
Q

What happens if you have GH excess after puberty

A

Acromegaly

- happens after the growth plates have closed

37
Q

What are the symptoms of acromegaly

A
  • Headaches,
  • arthralgia
  • sweating
  • increased ring/shoe size
  • weakness
  • diabetes (secondary cause)
  • carpal tunnel
  • atherosclerosis
  • increase risk of cancer - particularly colon cancer due to excess IGF-1
38
Q

What are the typical 3 symptoms of someone with acromegaly

A
  • Headaches
  • arthralgia
  • sweating
39
Q

What are the signs of acromegaly

A
  • Prognathism
  • Spade hands
  • prominent supraorb ridge
  • bi-temporal hemianopia
  • hypertension
40
Q

What investigations should you carry out to test for acromegaly

A

OGTT (oral glucose tolerance test)-

  • make them fast
  • check glucose and GH
  • give 75g of glucose
  • if you dont have growth hormone excess then GH goes to 0
  • if you do than growth hormone doesnt decrease and fails to suppress = acromegaly
  • IGF-1 - not a diagnostic test
  • MRI pituitary
41
Q

What is the treatment of acromegaly

A
  • Octreotide - somatostatin analogue = can lower GH levels
  • Pegvisomont – GH receptor antagonist = expensive but useful in people who are not responsive to octreotide
  • Surgery (Trans-sphenoidal)
42
Q

What are the two types of cushing syndrome

A
  • ACTH -dependent = 70-75%

- ACTH-Independent = 25-30%

43
Q

Describe what can cause ACTH-dependent Cushing syndrome

A
  • Corticotroph Adenoma (Cushing’s Disease)

* Ectopic Cushing’s (ACTH/CRH tumours)

44
Q

Describe what can cause ACTH-independent Cushing syndrome

A
  • Adrenal Carcinoma
  • Adrenal Adenomas
  • Exogenous steroids (Cushingoid appearance)
45
Q

What are the problems you get in cushings disease

A
  • changes in CHO, protein and fat metabolism
  • Changes in sex hormones
  • Salt and water retention
  • impaired immunity
  • Neurocognitive changes - steroid psychosis
46
Q

What symptoms in cushings do you get with changes in CHO, protein and fat metabolism

A 
 Peripheral Wasting of Fat/Muscle
 Central obesity, Moon facies, fat pads
 Osteoporosis
 Diabetes
 Hypertriglyceridemia
47
Q

What symptoms in cushings do you get with changes sex hormones

A

 Amenorrhoea/Infertility
 Excess hair growth (♀)
 Impotence

48
Q

What symptoms in cushings do you get with changes in salt and water retention

A

 HTN and Oedema

49
Q

What are the screening tests for cushings

A

Disrupted Circadian Rhythm

  • Midnight Salivary or Serum Cortisol
  • Cortisol day curve

 Increased Filtered Cortisol Load
- 24 hr Urine Free Cortisol

 Attenuated Negative Feedback- tend to do this test now

  • Low Dose (1 mg) Dexamethasone Suppression test
  • Measuring cortisol and ACTH
  • failure of suppression of cortisol is a sign of cushings
50
Q

What is the management of Cushing’s syndrome

A

 Trans-sphenoidal surgery

 Adrenolytics

  • Ketoconazole - an anti-fungal agent and blocks the steroid adrengenic pathway and reduce steroid levels in people with cushings disease
  • Metyrapone - prevents excess cortisol
51
Q

What are the physical signs of cushings syndrome

A
  • central obesity
  • purple striae over the abdomen
  • moon face
  • easy bruising
52
Q

What is hypopituitarism

A
  • Loss of all or some of pituitary hormones

- usually the anterior pituitary hormones

53
Q

What are the causes of hypopituitarism

A
  • Adenoma
  • Irradiation
  • Infarction (Sheehans) - pituitary infarction - happens after childbirth
  • Infiltration
    (Sarcoid, TB)
54
Q

What are the symptoms of hypopituitarism

A
  • Loss of libido
  • weakness
  • amenorrhoea
  • impotence
  • depression,
  • hypothyroidism
55
Q

What are the signs of hypopituitarism

A
  • Pallor
  • Hypothyroid,
  • Absent pubic/axillary hair
  • Testicular atrophy
  • Visual field defect,
  • Postural hypotension
56
Q

What are the investigations for hypopituitarism

A
  • Check hormones
  • Insulin Stress Test - lower levels of glucose you start producing GH and stuff, in hypoituitsim tend to not produce these hormones
  • Low T4, Test,
  • Oestradiol with low FSH, LH, TSH, ACTH
  • MRI pituitary
57
Q

What is the treatment for hypopituitarism

A

Hormone replacement – Hydrocortisone first line treatment, if you give then thyorxine first then you can induce an adrenal crisis, then give T4, testostorone, HRT,
- Ovulation induction for women with fertility issues

58
Q

What is pituitary apoplexy

A

Abrupt acute hemorrhagic infarction

of a pituitary adenoma

59
Q

What is the presentation of pituitary apoplexy

A 
▪ acute headache,
▪ meningism,
▪ visual impairment,
▪ ophthalmoplegia,
▪ Low GCS
60
Q

How do you treat pituitary apoplexy

A

Glucocorticoid replacement is the most important first step due to adrenal insufficiency
▪ Followed by urgent surgical decompression

Year 3 - Met3b (26 decks)

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