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Endocrine 2 > Pituitary Gland Dz > Flashcards

Pituitary Gland Dz Flashcards

1
Q

Where is the pituitary gland located

A

sella turcica

under optic chasm

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2
Q

Hypothalamic-pituitary-target gland axis

  • What does the hypothalamus release
  • what is result
A
  • Releasing hormones
  • Stimulate pituitary to release stimulating hormones
  • Stimulating hormones stimulate target organs to secrete their hormones
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3
Q

Hypothalamic-pituitary-target gland axis

- What hormone is an exception to releasing hormone = release of target organ’s hormone?

A

Prolactin - its secretion is under inhibitory control of dopamine secreted by the hypothalamus

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4
Q

What are the two major categories of endocrine disease?

A
  • hypo (decreased hormone secretion)

- hyper (increased hormone secretion)

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5
Q

Hypothalamic-pituitary-target gland axis

- What are four causes of hyper states?

A
  • primary disorder
  • secondary disorder
  • ectopic site production
  • Overactive target hormone receptors (dt genetic mutation)
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6
Q

Hyper states

- primary vs. secondary disorder

A
  • Primary: target gland over secretes due to pathology directly affecting it
  • Secondary: pituitary/hypothalamus over-stimulates the target gland
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7
Q

What is the change in hormone production due to a primary hyper state?

A
  • Target gland hormone concentration secretion is high
  • Stimulating hormone concentration is low (from the pituitary)
  • Negative feedback
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8
Q

What is the change in hormone production due to a secondary hyper state?

A

Both target gland and stimulating hormone levels are high

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9
Q

Ectopic site production of hormone examples

A
  • ovarian tumor
  • small cell lung cancer
  • SCC of the lung
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10
Q

Hypothalamic-pituitary-target gland axis

- 5 causes of hypo states

A
  • primary disorder
  • secondary disorder
  • tertiary disorder
  • Hormone is defective
  • Target organ receptors are unresponsive
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11
Q

Hypo state primary disorder

A
  • congenital or acquired problem of the gland
  • low target hormone level
  • high stimulating hormone level
  • loss of negative feedback
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12
Q

Hypo state secondary disorder

A
  • pituitary doesn’t secrete enough stimulating hormoen
  • low target hormone level
  • low stimulating hormone level
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13
Q

Hypo state Tertiary disorder

A
  • hypothalamus does not secrete enough releasing hormoen
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14
Q

Hypo state defective hormone

A
  • high hormone levels
  • function of hormone does not occur
  • corrected by exogenous hormone injection
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15
Q

Hypo state unresponsive target organ receptors

A
  • high stimulating hormone levels
  • organ producing hormone is trying to get target organ to respond
  • target organ will NOT respond to exogenous hormone stimulation
  • ex. nephrogenic diabetes insipidus
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16
Q

List the 6 anterior pituitary hormones and their releasing/inhibiting hormones

A
  • Growth hormone (GH) - somatomedins
  • Thyroid stimulating hormone (TSH) - T3, T4
  • Adrenocorticotropic hormone (ACTH) - cortisol
  • Prolactin - milk production
  • Follicle Stimulating Hormone (FSH) - estrogen
  • Leutinizing Hormone (LH) - progesterone, testosterone
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17
Q

List the 2 posterior pituitary hormones

A
  • antidiuretic hormone (Vasopressin)

- Oxytocin

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18
Q

Pituitary adenomas

- describe

A
  • slow growing
  • benign
  • 3rd most frequent intracranial tumor
  • over secretion of hormone
  • compression can cause hypopituitarism
  • F>M 3:1
  • Increased incidence with age
  • Seen in MEN
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19
Q

Pituitary adenoma

- two types

A
  • Microadenoma <10 mm

- Macroadenoma >10mm

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20
Q

Pituitary adenoma

- Signs and symptoms overview

A

Mass effect

  • superior extension
  • lateral extension
  • Inferior extension
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21
Q

Pituitary adenoma

- Superior extension mass effect

A
  • may compromise optic pathways, leading to impaired visual acuity and visual field defects (bitemporal hemianopsia)
  • may produce hypothalamic syndrome: disturbed thirst, satiety, sleep, temperature regulation
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22
Q

Pituitary adenoma

- lateral extension mass effect

A

may compress cranial nerves III, IV, V, VI (diplopia)

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23
Q

Pituitary adenoma

- Inferior extension mass effect

A

may lead to cerebrospinal fluid rhinorrhea

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24
Q

Pituitary adenoma

- Dx

A
  • check levels of all hormones produced by pituitary

- check levels of all target organ products

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25
Q

Pituitary adenoma

- Tx

A
  • surgical excision generally first line
  • radiation
  • medical therapy
  • Simple observation: if tumor is small, no local mass effect, nonfunctional, not affecting quality of life
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26
Q

Pituitary adenoma

- Sx removal explanation

A
  • requires neurosurgeon and ENT surgeon
  • Transsphenoidal approach MC
  • Endonasal submucosal transeptal approach
  • septal pushover/direct sphenoidotomy
  • endoscopic
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27
Q

Pituitary adenoma

- indications for sx

A
  • First line if symptomatic
  • Medical/radiotherapy failed
  • Prompt relief from excess hormone secretion and mass effect
  • Pituitary apoplexy (hemorrhage) with compressive sx
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28
Q

Four disorders of pituitary function

A
  • Cushings (ACTH)
  • Hyperthyroidism (TSH)
  • Hyperprolactinemia
  • Acromegaly
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29
Q

Cushings

- cause

A

result of excess ACTH release = increased cortisol secretion

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30
Q

Prolactinoma

- describe

A
  • MC functional pituitary tumor
  • usually microadenoma
  • can be space occupying, often with visual field defects
  • often have galactorrhea and/or amenorrhea but absence does not exclude dx
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31
Q

Prolactinoma hormone situation

A
  • elevated prolactin
  • GnRH release is decreased
  • LH and FSH are decreased
32
Q

Prolactinoma

- Female sx

A
  • amenorrhea
  • Hirtutism
  • decreased libido
33
Q

Prolactinoma

- Male sx

A
  • impotence (often ignored)
  • infertility
  • decreased libido
  • gynecomastia
  • larger tumors = more mass effects
34
Q

Why do females often present with prolactinomas earlier then men

A

amenorrhea causes them to seek medical attention

35
Q

Prolactinoma

- common causes

A
  • drugs
  • inhibited dopamine outflow
  • hypothyroidism
36
Q

Prolactinoma

  • common drug causes
  • why?
A
  • decrease dopamine stores

- phenothiazine, amitriptyline, metoclopramide

37
Q

Prolactinoma

- what other factors inhibit dopamine outflow?

A
  • estrogen
  • pregnancy
  • exogenous sources
38
Q

What prolactin level is almost always a prolactinoma

A

> 200

- even in a nursing mom

39
Q

What do prolactin levels correlate with?

A

tumor size in macroadenomas

- suspect another tumor if prolactin level is LOW and tumor is LARGE

40
Q

Prolactinoma

- dx

A
  • Assess hypersecretion (basal and fasting morning PRL levels)
  • might need to measure multiple times due to pulsatile secretion
  • Exclude hypothyroidism by measuring TSH and T4
41
Q

Prolactinoma

  • false positives
  • false negatives
A
  • false positive: aggregated from of circulating PRL which are biologically inactive (macroprolactinemia)
  • false negative: markedly elevated PRL level (>1000 ug/L) due to negative feedback
42
Q

Prolactinoma

- treatment

A
  • Medical (Cabergoline and bromocriptine) to decrease prolactin and tumor size
  • Sx: transsphenoidal sx
  • Irradiation
43
Q

Growth hormone tumor

  • overall effect
  • onset
  • Two types
A
  • make things big (hands, feet, ears, lips, tongue)
  • usually insidious, not noticeable by pt
  • Acromegaly and gigantism
44
Q

Gigantism

- describe

A

secrete excess GH before fusion of epiphyseal growth plates

45
Q

Growth hormone tumor

- signs and sx

A
  • DM or glucose intolerance
  • hypogonadism
  • large hands/feet
  • large head w/ lowered brow and coarse features
  • HTN
  • colon polyps
  • multiple skin tags
46
Q

Acromegaly

- describe

A
  • rare
  • excess secretion of GH
  • syndrome of coarsened facial features, overgrowth of hands and feet
47
Q

Acromegaly

- etiology

A

Excess secretion of GH stimulates liver to release insulin-like growth factor (IGF-1) = most of clinical features

48
Q

Acromegaly

- pathophysiology

A
  • > 90% will have benign GH-secreting adenoma of anterior pituitary
  • 10% have ectopic GH secretion, MC from pancreatic islet cell tumors, lymphoma, or hyper secretion of growth hormone releasing hormone (GHRH)
49
Q

What are common causes of hypersecretion of GHRH

A
  • hypothalamic gangliocytomas
  • peripheral neuroendocrine tumors such as carcinoid, islet cell tumors, small cell lung cancer, adrenal adenoma, medullary thyroid cancer, pheochromocytoma
50
Q

Acromegaly

- MSK and neuro signs and symptoms

A

MSK

  • enlarging shoe/ring size
  • arthralgia/myalgia

Neuro

  • HA
  • Vision change, temporal hemianopsia
  • hand numbness/carpal tunnel
  • fatigue/weakness
  • sleep disturbance
51
Q

Acromegaly

- Derm and Endocrin signs and symptoms

A

Derm

  • increased sweating
  • oily skin

Endocrine

  • deepened voice
  • decreased libido
  • amenhorrhea/menstrual dysfunction (women)
  • erectile dysfunction (men)
  • galactorrhea
52
Q

Acromegaly

- PE findings: face, Neuro, MSK

A
  • Presentation may be subtle
  • Review of old photos may reveal facial coarsening

Neuro:

  • bitemporal hemianopia
  • other CN defects

MSK:

  • hypertrophic arthropathy of spine, hips, knees, ankles
  • prognathism
  • gigantism (peds/adolescent)
53
Q

What are features of facial coarsening

A
  • enlarging jaw (macrognathia), nose, and frontal bones
  • spreading teeth, change in bite/jaw malocclusion
  • Enlarging tongue
54
Q

Acromegaly

- PE findings: derm, visceromegaly

A

Derm:

  • skin thickening
  • skin tags

Visceromegaly

  • prostate
  • kidney
  • liver
  • spleen
  • heart
  • salivary glands
  • thyroid (goiter)
  • tongue
55
Q

Acromegaly

- Dx w/u initial testing

A

Serum IGF-1

  • Best single test for dx
  • levels 2X upper limit suggestive of acromegaly
56
Q

Acromegaly

- Dx workup fu testing

A
  • 75g OGTT will show elevated glucose levels
57
Q

Acromegaly

- imaging

A

MRI of sella

  • will detect tumors as small as 2 mm
  • won’t differentiate between functioning and nonfunctioning tumor
58
Q

Acromegaly

- tx

A
  • sx
  • radiation
  • bromocriptine (temporizing measure0
  • Octreotide
59
Q

Gigantism

- overview

A
  • caused by excess secretion of GH prior to closure of epiphyseal plates in long bones (must occur before puberty)
  • commonly caused by pituitary tumors that secrete mutant protein that eliminates need for GHRH
  • tumors block gonadotropin release = amenorrhea and impotence in men
60
Q

Growth plates and chondrocytes

A
  • before puberty, first layer of growth plate cells differentiate into chrondrocytes
  • second layer of plate (chondrocytes) is responsive to GH - mitosis
  • after maturation of chondrocytes, they deposit calcium into bone matrix to form new bone
61
Q

Growth plates and growth hormone

A
  • osteoblasts use calcium depositions to form new tissue along long bone
  • excess calcium is converted into connective tissue, bones elongate
  • GH activates insulin-like growth factor (IGF1) which causes growth of muscle to keep up with bone growth
62
Q

Gigantism

  • how common
  • effect on life
  • epidemiology
A
  • 3 in a million
  • 100 cases to date in US
  • 2-3 times mortality of general population
  • no racial or sex predilection
  • not genetic
63
Q

Gigantism

- signs and symptoms

A
  • reduced life span dt medical complications
  • tall, big hands/feet, coarse facial features, excess sweating, osteoarthritis, carpal tunnel, CVD, benign tumors, DM, obesity/sleep apnea, deep voice
  • pituitary tumor can cause HA and visual impairment (optic chiasm)
64
Q

Gigantism

- dx/testing

A
  • no prenatal testing bc not genetic
  • initial growth not usually exaggerated, apparent over time
  • Blood test for IGF1
  • CT/MRI
65
Q

Gigantism

- tx

A
  • difficult bc GF continually surges…
  • Can remove pituitary tumor to stop release of GH
  • Octreotide, bromocriptine block GH effects
  • radiation to tx tumor
66
Q

Hypopituitarism

- cause

A
  • metabolically silent pituitary tumor - doesn’t secrete anything
  • damage to pituitary gland: tumor, radiation, autoimmune dz, infection, hemorrhage
67
Q

Two potential causes of pituitary hemorrhage

A
  • pituitary apoplexy: hemorrhage dt rupture of adenoma

- Sheehan’s syndrome: peri or postpartum hemorrhage

68
Q

Hypopituitarism

- what causes sx

A
  • growth of tumor
  • superior growth: bitemporal hemianopsia
  • compression fo pituitary gland itself can cause gland dysfunction
69
Q

Hypopituitarism

  • ACTH
  • TSH
  • LH/FSH
A
  • ACTH: secondary adrenal insufficiency
  • TSH: secondary hypothyroidism
  • LH/FSH: central hypoganodism. In children = pubertal delay, in adults = impotence, menstral irregularities, infertility, decreased libido
70
Q

Hypopituitarism

- GH

A
  • during childhood = pituitary dwarfism (delayed or slowed growth)
  • epiphyseal plates closer before normal height
  • proportionate little person (growth of everything is decreased)
71
Q

Two main causes of pituitary dwarfism

A
  • gene mutations

- tumors (MC craniopharyngioma)

72
Q

pituitary dwarfism

- sx

A
  • HA
  • vomitting
  • vision problems (diplopia)
  • polydipsia
  • sleep disturbances
  • everything is small and proportionate
73
Q

pituitary dwarfism

- signs and sx

A
  • child with slow growth rate (<2” per year)

- normal intelligence and capabillities

74
Q

pituitary dwarfism

- Dx

A
  • monitor growth rate/curve

- xray to détermine bone “age”

75
Q

pituitary dwarfism

- tx

A
  • GH injections

* ADR: fluid retention, joint and muscle aches

Endocrine 2 (15 decks)

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