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PITUITARY
S2iriraj Board
Review 2014
APIRADEE SRIWIJITKAMOL
DIVISION OF ENDOCRINOLOGY AND METABOLISM
DEPARTMENT OF MEDICINE
FACULTY OF MEDICINE SIRIRAJ HOSPITAL
APPROACH TO
PITUITARY DISORDER
INVESTIGATION
S2iriraj Board
Review 2014
FEEDBACK LOOP OF
HYPOTHALAMIC-PITUITARY-AXIS
AND LABORATORY INTERPRETATION
CASE AM
S2iriraj Board
Review 2014
S2iriraj Board
Hypothalamus
Pituitary
Releasing hormone
Negative
feedback
Stimulating hormone
Thyroid hormone
Review 2014
abnormal thyroid function
test ICCU
70 ACS
ICCU tachyarrthymia TFT
TT3 58 (90-180), FT4 0.78 (0.9-1.9), TSH 2.4
(0.4-4.5)
....
Corticosteroid
Sex hormone
5/1/2015
CASE AM
S2iriraj Board
Review 2014
abnormal thyroid function
test ICCU
70 ACS
ICCU tachyarrthymia TFT
TT3 58 (90-180), FT4 0.78 (0.9-1.9), TSH 2.4
(0.4-4.5)
PITUITARY VS.
NON-PITUITARY TUMOR
Floor of sella
SELLA ENLARGEMENT
S2iriraj Board
Review 2014
5/1/2015
APPROACH TO
PITUITARY DISORDER
TREATMENT
Hormone replacement
Glucocorticoid
Thyroid
Sex hormone
+GH
Treatment of underlying disease
S2iriraj Board
Review 2014
Advice
Glucocorticoid before thyroid replacement
Glucocorticoid during stress
ACROMEGALY
Vital signs: BP
Weight, Height
Typical face:
ACROMEGALY
S2iriraj Board
Review 2014
Frontal bossing
Prognathism
Macroglossia
Coarse faces
Thickening of the nose
S2iriraj Board
Review 2014
FILM FOOT
Heel pad sign
distance between the
plantar aspect of the
calcaneus and skin
surface
normal distance is 21 mm
S2iriraj Board
Review 2014
S2iriraj Board
Review 2014
Lateral radiograph of
skull reveals
Enlarged sella with
double flooring
Dilatation of air
sinus
Prognathism
Thickened skull
vault
5/1/2015
FILM HAND
FILM SKULL
S2iriraj Board
Review 2014
S2iriraj Board
Review 2014
Ungal tufting
Widening of the bases of
distal phalanges
Metacarpal osteophytes on
radial aspect (metacarpal
hooks)
Soft tissue hypertrophy
TREATMENT
DIAGNOSIS
S2iriraj Board
Review 2014
IGF-1
Screening test
Higher than same age
75 g OGTT
GH > 1 ug/L
Goal
GH < 1ug/L
Normalized IGF-1
Modalities
Surgery
Medication
Dopamine agonist
Somatostatin analog
S2iriraj Board
Review 2014
Failed to control biochemical by surgery alone
Primary medical therapy
Radiation
S2iriraj Board
Review 2014
S2iriraj Board
Review 2014
5/1/2015
APPROACH TO
PITUITARY DISORDER
CASE PS
S2iriraj Board
Review 2014
A 23-year-old woman presented with secondary
amenorrhea for 7 months. She had no other
complaints. Physical examination revealed few
drops of milk discharge on squeezing. Otherwise
were within normal limit. Progressterone challenge
test -, FSH 1.0, LH 0.8, E2 <5.
GALACTORRHEA
APPROACH TO GALACTORRHEA
Galactorrhea?
Cause of galactorrhea?
Need treatment?
S2iriraj Board
Review 2014
DEFINITION
APPROACH TO GALACTORRHEA
CAUSES OF GALACTORRHEA
Etiology
S2iriraj Board
Review 2014
HISTORY
Identify Cause
Drug use
Pituitary function
VF and VA
Hypothyroidism
CKD
PHYSICAL EXAMINATION
Galactorhea?
Signs of hypothyroidism
Signs of hypopituitarism
VF and VA
Mechanism
Prolactin
level
Drugs
Pituitary, stalk,
hypothalamic
-Production
-Prolactin inhibitory factor
Thyroid disease
-Hypo TRH
-Hyper free estrogen
CKD
-Renal clearance
-Medication: methyldopa
Neurologic
cause
Idiopathic
5/1/2015
DRUG-INDUCED GALACTORRHEA
MECHANISM
DRUGS
APPROACH TO GALACTORRHEA
S2iriraj Board
Review 2014
S2iriraj Board
Review 2014
HISTORY
Dopamine-receptor blockade
Metoclopramide
Phenothiazines
Risperidone
SSRI: fluoxitine, setraline
Tricyclic antidepressants
Dopamine-depleting agents
Methyldopa
Reserpine
Heroin
Morphine
Histamine-receptor blockade
Cimetidine
Stimulation of lactotrophs
Oral contraceptives
Verapamil
Identify Cause
Drug use
Pituitary function
VF and VA
Hypothyroidism
CKD
Assess need to treatment
Menstruation
Amount of galactorrhea
Hx and PE
In case, Hx of drug:
stop medication
for 3 days
PHYSICAL EXAMINATION
Galactorhea?
Signs of hypothyroidism
Signs of hypopituitarism
VF and VA
Hx and PE
S2iriraj Board
Review 2014
PROLACTIN MEASUREMENT
NPO 6 hours, no stress, no breast stimulation
When in doubt, sampling can be repeated on a different day
at 15- to 20-min intervals to account for possible prolactin
pulsatility
When there is a discrepancy between clinical and prolactin level,
serial dilution of serum samples to eliminate an artifact with some
immunoradiometric assays (hook effect)
S2iriraj Board
Review 2014
In case, Hx of drug:
stop medication
for 3 days
Kidney
Kidney
Kidney
Kidney
Thyroid
Thyroid
Thyroid
Thyroid
Prolactin
Prolactin
Prolactin
Prolactin
CASE PS
S2iriraj Board
Review 2014
A 23-year-old woman presented with secondary
amenorrhea for 7 months. She had no other
complaints. Physical examination revealed few
drops of milk discharge on squeezing. Otherwise
were within normal limit. Progressterone challenge
test -, FSH 1.0, LH 0.8, E2 <5. Her serum prolactin
is 104 ng/mL, serum TSH 1.0 mIu/L. MRI of pituitary
gland showed pituitary tumor size 0.8 cm.
DIAGNOSIS: .
>141.5
94.3-141.5
<94.3
Karavitaki N. Clinical Endocrinology 2006;65; 524-529.
5/1/2015
CASE PS
S2iriraj Board
Review 2014
A 23-year-old woman presented with secondary
amenorrhea for 7 months. She had no other
complaints. Physical examination revealed few
drops of milk discharge on squeezing. Otherwise
were within normal limit. Progressterone challenge
test -, FSH 1.0, LH 0.8, E2 <5. Her serum prolactin
is 104 ng/mL, serum TSH 1.0 mIu/L. MRI of pituitary
gland showed pituitary tumor size 0.8 cm.
DIAGNOSIS: .
TREATMENT:
<6 mm
6-9 mm
APIRADEE SRIWIJITKAMOL
abnormal
normal
abnormal
CALCIUM
HOMEOSTASIS
VITAMIN D PATHWAY
S2iriraj Board
Review 2014
S2iriraj Board
Review 2014
5/1/2015
APPROACH TO HYPERCALCEMIA
TREATMENT OF HYPERCALCEMIA
S2iriraj Board
Review 2014
Mild
Symptom
-Hyper PTH
-Lithium
-Familial hypocalciuric
hypercalcemia
-Vitamin D intake
-Malignancy
-Granulomatous
- PTHrP:
disease
- Sq cell CA
- Breast, lymphoma
- Humoral: NHL
- LOF: MM, Breast
-Endocrine dis.
-Drugs: vit A, thiazide
-Others
APPROACH TO HYPOCALCEMIA
-/+
Identify cause
Supportive
IV fluid*
I/O > 3L/D
IV Furosemide
Bisphosphanate**
Calcitonin***
Hemodialysis
-Vit D def.
-Low PTH:
-Critical illness
- Malabsorption
- Hypoparathyroidism
- Hyperphos.
- Liver and renal
-Low Mg
- Rhabodmyolysis
- Anticonvulsant
-PTH resistance
- Tumor lysis synd
- Elderly
- Pseudohypo PTH
- Phosphate Rx
-Vit D resistance
- Others:
- Ricket type II
-Drugs:
- Phenytoin Rx
- P450: INH, rifam, anticonvulsant
,gllucocorticoid
- Citrate
OSTEOMALACIA
Mineralization
Osteomalacia/rickets
Low bone mineral content
Osteoporosis
High bone turnover
Hyperparathyroidism
S2iriraj Board
Review 2014
OSTEOMALACIA
S2iriraj Board
Review 2014
Severe
S2iriraj Board
Review 2014
Moderate
S2iriraj Board
Review 2014
5/1/2015
Bone pain
Pathological fracture
Bone pain
Pathological fracture
Others
Metastasis bone
Rheumato
Hematologic:
MM
Clinical
Lab
X-ray
BMD
Others
Osteoporosis
Pagets
Osteoporosos
Osteopenia
Decrease
OSTEOMALACIA
Vit D def.
Osteoporosis
Pagets
Osteomalacia
Fanconis
-RTA
-Glycosuria
-hypophosphatemia
Hereditary
Hypophosphatemia
TIO
OSTEOMALACIA
S2iriraj Board
Review 2014
Rheumato
Hematologic:
MM
Osteomalacia
Osteomalacia
Pain, muscle weakness
Ca , P , Alk
Osteopenia, looser zone
Decrease
PSEUDOFRACTURE
Investigation
Blood chemistries
Calcium, Phosphate, Albumin, Alkaline
phosphatase
Renal function and Elyte
25-OH vitamin D
iPTH
Urine calcium/phosphate
Film bone survey
Bone biopsy
S2iriraj Board
Review 2014
PSEUDOFRACTURE
S2iriraj Board
Review 2014
S2iriraj Board
Review 2014
5/1/2015
HYPOPHOSPHATEMIA VS.
VITAMIN D DEFICEINCY
PSEUDOFRACTURE
S2iriraj Board
Review 2014
S2iriraj Board
Hypophosphatemic
Osteomalacia
Review 2014
Vit. D Deficiency
Osteomalacia
Normal
Normal. (Low)
Calcium
Phosphate
Low
Low
ALP
High
High
Elyte
In RTA
25-OH vitamin D
Normal
Low
iPTH
Normal,
Nornal, (High)
High
Normal
Urine phosphate
PRIMARY HYPERPARATHYROIDISM
History
Asymptomatic
50% of symptomatic:
Renal calculi
Bone pain or fracture
Other symptoms
PU, Pancreatitis
Neuromuscular and
Neuropsychiatric
Endocrine syndrome:
MEN I or MEN IIa
Film HAND
S2iriraj Board
Review 2014
Physical examination
Neck mass
Basic lab
CBC, UA
Ca, P, Alk, Alb
Electrolyte, BUN, Cr
Special test
Bone survey
BMD
MIBI scan
Acro-osteolysis
Generalized
osteopenia
Subperiosteal
resorption of the radial
aspect of the middle
phalanges of index and
middle fingers
FILM SKULL
S2iriraj Board
Review 2014
Trabecular bone
resorption resulting in
the salt-and-pepper
appearance
10
5/1/2015
FILM SKULL
RENAL OSTEODYSTROPHY
S2iriraj Board
Characteristic endplate
sclerosis
Rugger-jersey spine
RENAL OSTEODYSTROPHY
S2iriraj Board
Review 2014
S2iriraj Board
Review 2014
Biochemistry panel
Ca, P, ALP, BUN, Cr, 25(OH)D
PTH level
BMD by DXA
Lumbar spine, hip, and distal 1/3 radius
Vertebral spine X-ray or VFA by DXA
24-h urine for:
Ca, Cr, CCr
Stone risk profile esp. Ur Ca >400 mg/D
Abdominal imaging by x-ray, ultrasound, or CT scan
PRIMARY HYPERPARATHYROIDISM
Symptomatic: surgery
Asymptomatic: ?Indication
Measurement
S2iriraj Board
Review 2014
1990
2002
2008
2013
1-1.6 mg/dl
1 mg/dl
1 mg/dl
1 mg/dl
24-h Ur Ca
>400 mg/D
>400 mg/D
Ccr
by 30%
by 30%
< 60 mL/min
Serum Ca
(>upper NL)
Renal
< 60 mL/min
Ca-stone
risk
Others
Skeletal
BMD
Others
Age
Vertebral #
<50
<50
<50
<50
11