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Year 2 Endocrine > Pituitary Pathology > Flashcards

Pituitary Pathology Flashcards

1
Q

Microadenoma

A

<1cm

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2
Q

Macroadenoma

A

> 1cm

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3
Q

What is a prolactinoma?

A

Prolactin producing tumour

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4
Q

What happens as a result of raised prolactin levels?

A

Galactorrhea (milk produced outside of pregnancy)

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5
Q

What can result in raised prolactin levels?

A 
Breast feeding (nipple stimulation)
Stress 
Dopamine antagonist 
Stalk Lesions (severance of connection)
Hypothyroidism 
Prolactinoma
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6
Q

Why do dopamine antagonist result in raised prolactin levels?

A

Dopamine inhibits prolactin production, by reducing dopamine levels you increase prolactin levels.

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7
Q

Give an example of a dopamine antagonist?

A

Metaclopramide

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8
Q

Why does a stalk lesion result in raised prolactin?

A

Prevents dopamine transmission to the pituitary so prolactin levels are not inhibited

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9
Q

Why does hypothyroidism often result in a raised prolactin ?

A

As TRH stimulate prolactin

Hypothyroidism there is negative inhibition so TRH levels are raised.

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10
Q

How does a patient with a prolactinoma present?

A 
Galactorrhea
Menstrual irregularity
Infertility
Impotence
Visual field disturbances
Headaches
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11
Q

What is the first line investigation in a suspected prolactinoma?

A

Serum prolactin levels

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12
Q

If the prolactin levels are found to be high in a suspected prolactinoma what should be undertaken?

A

MRI to determine the cause
Tumour extent and size
Stalk lesion
Optic chiasm compression

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13
Q

In pituitary tumours what is a common side effect if they are large?

A

Bitemporal Hemianopia

Compression of the optic chiasm

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14
Q

What should also be undertaken alongside an MRI in any suspected pituitary tumour?

A

Visual field test

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15
Q

After an MRI has diagnosed the tumour what should also be taken?

A

Pituitary function tests- look for other hormones affected

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16
Q

What is the treatment of choice for a prolactinoma?

A

Dopamine agonists

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17
Q

Name dopamine agonists

A

Cabergoline 1st line less side effects

Bromocriptine

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18
Q

Cabergoline in prolactinomas

A

Causes tumour shrinkage
Very successful in fertility restoration
Taken 1 or 2 times a week

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19
Q

Side effects of cabergoline

A

Low mood
Nausea
Vomiting

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20
Q

What is acromegaly?

A

Growth Hormone excess in later life

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21
Q

What s gigantism ?

A

Growth Hormone excess since birth

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22
Q

What is the difference between gigantism and acromegaly?

A

Acromegaly occurs after the growth plates have fused

Epiphyseal fusion

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23
Q

What is the appearance of someone with acromegaly?

A 
Large protruding jaw
Round doughy face
Large Hands
Prominent nasolabial folds
Thickened soft tissue
Enlarged brow
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24
Q

What are the clinical features associated with acromegaly?

A 
Sleep apnoea
Hypertension 
Headaches
Diabetes Mellitus
Visual field defects
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25
Q

What are the risks associated with acromegaly?

A

Early Cardiovascular death

Colonic polyps

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26
Q

Why are patients with acromegaly more likely to die from cardiovascular disease?

A

Increased risk of heart failure due to Left ventricular hypertrophy

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27
Q

Whilst acromegaly doesn’t directly cause colonic cancer what risks are there?

A

By inducing colonic polyps they increase the likely one of these polyps, by pure chance, could become cancerous.

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28
Q

What is the screening test for acromegaly?

A

Measuring IGF-1 levels

Results are age and sex matched

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29
Q

Why is IGF-1 not GH used in acromegaly screening?

A

IGF-1 is present in peripheral tissues for a longer time, as it has a longer stable half life.

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30
Q

What is the diagnostic test of choice for acromegaly?

A

Glucose tolerance test

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31
Q

What is a glucose tolerance test?

A

75g of glucose is taken orally

GH checked at 0 30 60 90 120 mins

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32
Q

In a healthy patient what should happen to the GH levels in a glucose tolerance test?

A

Suppressed to 0.4 ug/L

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33
Q

What happens to a patient with acromegaly in a glucose tolerance test?

A

GH levels are unaffected or increase

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34
Q

Once tests are done what should happen next in a patient with acromegaly?

A

MRI and CT

Check other hormone level

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35
Q

In acromegaly when checking the other pituitary hormones what should be measured in regards to TSH?

A

Free T3/4 not TSH

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36
Q

Is surgery curative in acromegaly?

A

90% if micro

50% if macro

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37
Q

What can be used to shrink a tumour for surgery? Acromegaly

A

Somatostatin analogue

Dopamine agonist

38
Q

Why do dopamine agonists work in acromegaly?

A

10/15% of patients with acromegaly also secrete prolactin

39
Q

Somatostatin analogues

A

Sondostatin LAR

40
Q

What are the effects of somatostatin analogues?

A

Tumour shrinkage

Reduces GH levels

41
Q

Side effects of somatostatin analogues?

A

Flatulence
Diarrhoea
Diffuse abdo pain
Increased risk of gall stones

42
Q

How are somatostatin analogues administered?

A

Injected once a month

43
Q

What is the last line therapy for acromegaly due to a tumour?

A

GH antagonist

44
Q

GH antagonist?

A

Peguisomal

45
Q

Do GH antagonist affect the tumour?

A

There is no reduction in tumour size

46
Q

Affects of GH antagonists?

A

IGF-1 and GH reduced

85% response rate

47
Q

What surveillance is undertaken in those with acromegaly?

A

Colonoscopy
CV risk - BP lips and glucose levels
Sleep apnoea studies

48
Q

What is cushings syndrome?

A

Excess cortisol production

49
Q

What is cushings disease?

A

Pituitary adenoma - producing ACTH

50
Q

Pan hypopituitarism

A

Posterior and anterior pituitary glands are completely non functional

51
Q

List some common causes of pan hypopituitarism?

A 
Pituitary tumour 
Iatrogenic 
TB Sarcoidosis
Trauma
Meningitis
52
Q

What could be some local brain tumours that could cause hypopituitarism?

A

Meningioma

Glioma

53
Q

Anterior symptoms of pan hypopituitarism

A 
Menstrual irregularity
Inferitility
Impotence
Abdominal obesity
Loss of facial hair
Dry skin
Growth retardation
54
Q

What hormone tests would be undertaken in a suspected pan hypopituitarism?

A

TSH IGF-1 LH FSH

55
Q

Why is ACTH not regularly tested for in pan hypopituitarism?

A

As ACTH levels fluctuate throughout the day

56
Q

What tolerance test would be undertaken in pan hypopituitarism?

A

SynACTHen

Insulin

57
Q

What is the treatment for someone with pan hypopituitarism?

A 
Thyroxine
Hydrocortisone
ADH
GH
Oestrogen and progesteron (female)
Testosterone (male)
58
Q

What is the dose of thyroxine in someone with pan hypopituitarism?

A

100-150mg

59
Q

What is the dose of steroids in someone with pan hypopituitarism?

A

10mg morning
5 mg midday
5 mg dinner

60
Q

What is the dose of ADH in someone with pan hypopituitarism?

A

Nasal spray

61
Q

What is the does of Growth hormone in someone with pan hypopituitarism?

A

Injection nightly

62
Q

When is oestrogen and progesterone replacement used in women?

A

Used only in pre menopausal women

63
Q

What is the dose of testosterone in someone with pan hypopituitarism?

A

Intramuscularly every 3-4 weeks

64
Q

What is the testosterone used in IM injections?

A

Sustanon

65
Q

What is the topically applied form of testosterone?

A

Testogel

66
Q

What are the benefits of using growth hormone in adults with pan hypopituitarism?

A 
Improves quality of life
Reduces abdominal fat
Increases muscle mass and strength
Increases cardiac function 
Increases bone density
67
Q

What are the risks associated with testosterone replacement?

A

Prostate enlargement - not cancerous
Polycythaemia - increased risk of MI
Hepatitis - only in oral tablet

68
Q

What is polycythaemia?

A

Increased number of red blood cells increases the viscosity of the blood

69
Q

What is the main symptom due to posterior pan hypopituitarism?

A

Cranial diabetes insipidus

70
Q

What is the diagnostic test for cranial diabetes insipidus?

A

Water deprivation test
Nil by mouth for 8hrs
Urine osmolarity should be >2 greater than normal
Diabetes insipidous if lower

71
Q

Treatment for cranial diabetes insipidus?

A

Desmospray nasally

Desmopressin oral tablets

72
Q

What tumour can spread to the pituitary and is a remnant of Rathkes pouch?

A

Craniopharyngioma

73
Q

Symptoms of craniopharyngioma?

A

Headaches
Visual disturbance
Growth retardation

74
Q

What ages are affected by craniopharyngioma?

A

5-15

6th and 7th decade

75
Q

What is the prognosis for a craniopharyngioma?

A

excellent

76
Q

Cushings Disease

A

Excess ACTH secretion from the pituitary results in High Cortisol levels

77
Q

Physical sign of Cushings disease

A 
Proximal Myopathy
Abdominal Obesity
Easy bruising
Purple Striae 
Hirsutism/Virilisation
Acne
Moon face
78
Q

Clinical manifestations of Cushings disease

A 
Diabetes Mellitus
Hypertension
Oedema Periorbital 
Psychosis depresson
Testicular atrophy
Oligo/amenorrhea
79
Q

How can you differentiate between an obese person with and without cushings?

A

Obesity protects against osteoporosis,

Cushings results in obesity with osteoporosis

80
Q

What suppression test should be undertaken if cushings is suspected?

A

Exogenous high dose oral steroid

Should produce a low serum cortisol level

81
Q

What oral steroid is used in a cortisol suppression test?

A

Dexamethasone

82
Q

What are the screening tests for cushings?

A

1mg of dexamethasone at midnight
-cortisol checked at 8am
Urine free cortisol - 24hr collection

83
Q

In the screening test involving dexamethasone what is the dosage and what is the expected level of cortisol?

A

1mg Dexamethasone
< 50nmol/l is normal
> 130nmol/l is abnormal

84
Q

In free cortisol urine sampling what is the expected values?

A

Total <250 is normal

85
Q

What is the definitive test for cushings?

A

Low dose dexamethasone test

  • 0.5mg every 6 hours for 2 days
  • 6 hours after last dose cortisol is measured
86
Q

What cortisol level indicates cushings 6 hours post final dose of dexamethasone?

A

> 130nmol/l

87
Q

If the low dose dexamethasone test is positive what else should be undertaken?

A

A ACTH test

88
Q

In a +ve low dose dexamethasone with a V.High ACTH what does this indicate?

A

Ectopic ACTH

89
Q

In a +ve low dose dexamethasone with a normal ACTH what does this indicate?

A

Pituitary pathology

90
Q

What tumours can cause ectopic ACTH secretion?

A

Lung Thymus Pancreas
Carcinoid
Small Cell lung cancer

91
Q

What is the most common cause of cushings?

A

High dosage steroid use

Year 2 Endocrine (21 decks)

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