The pituitary gland clinical case discussion Flashcards
What happens when the pituitary gland decides to go into a rebellious phase
What are the pituitary diseases?
- Hypersecretion (tumours)
- GH Acromegaly (gigantism)
- ACTH Cushing’s disease
- Prolactin Hyperprolactinaemia - Hyposecretion (mostly tumours, other causes)
- Anterior (FSH/LH, GH, ACTH, TSH)
- Posterior (vasopressin) - Space occupation
- optic chiasmal compression
What are the clinical features if acromegaly?
- Soft tissue overgrowth
- ‘spade like’ hands (rings)
- wide feet (shoes)
- coarse facial features
- thick lips & tongue
- carpal tunnel syndrome
- sweating
What are the complications of acromegaly
- headache
- chiasmal compression
- diabetes mellitus
- hypertension
- cardiomyopathy
- sleep apnoea
- accelerated OA
- colonic polyps & CA
What should one do for the diagnosis of acromegaly?
- Can GH be suppressed?
- Is insulin like growth factor-1 elevated?
- Is the rest of the pituitary function normal?
- Is there a pituitary tumour on MRI?
- Is vision normal?
What does cortisol do?
- Tissue breakdown
- causes weakness of skin, muscle & bone
- Sodium retention
- may cause hypertension & heart failure
- Insulin antagonism
- may cause diabetes mellitus
What are the high value signs and symptoms of Cushing’s disease?
- skin atrophy
- spontaneous purpura
- proximal myopathy
- osteoporosis
- growth arrest in children
What are the intermediate value signs and symptoms of Cushing’s disease?
- pink striae
- facial mooning & hirsutism
- oedema
What are the non-specific signs and symptoms of Cushing’s disease?
- central obesity
- hypertension
What can cause Cushing’s syndrome?
ACTH-dependent
- Pituitary tumour (Cushing’s disease)
- Ectopic ACTH secretion (eg lung carcinoid)
ACTH-independent
- Adrenal tumour (adenoma or carcinoma)
- Corticosteroid therapy (eg for asthma, IBD)
What are the causes and pathologies of hyperprolactinemia?
Physiological - Pregnancy, lactation, stress Pharmacological - DA depleting and DA antagonist drugs Pathological - Primary hypothyroidism - Pituitary lesions (prolactinoma or pituitary ‘stalk pressure’)
What are the drugs which may cause hyperprolactinemia?
Dopamine antagonists - neuroleptics (eg chlorpromazine) - antiemetics (eg metoclopramide) DA-depleting agents Oestrogens (not in OCP dosage) Some antidepressants
- Don’t forget to ask about homeopathic or herbal remedies!
What are the clinical features of hypopituitarism in adults?
- Tiredness, weight gain, depression, reduced libido, impotence, menstrual problems
- Skin pallor
- Reduced body hair
What are the clinical features of hypopituitarism in children?
- Reduced linear growth
- Delayed puberty
How do you manage pituitary tumours?
Hypersecretion - dopamine agonists (prolactinoma) - somatostatin analogues (acromegaly) - GH receptor antagonist (acromegaly) Hyposecretion (of the normal pituitary) - cortisol, T4, sex steroids, GH - desmopressin Tumour - surgery (mostly transsphenoidal) - radiotherapy
What are the beneficial effects of somatostatin analogues in acromegaly?
- Improve soft tissue overgrowth, sweating, headache, sleep apnoea in most patients
- Normalise GH and IGF-1 levels in over 50% patients
- Induce tumour shrinkage in the majority
- Reduce morbidity & mortality from acromegaly
