Acromegaly

Question 1

What is the most common cause of acromegaly?

Answer 1

A GH-secreting pituitary adenoma

Question 2

What is the difference between acromegaly and gigantism?

Answer 2

Gigantism occurs in children before epiphyseal fusion, resulting in increased height.

Acromegaly occurs in adults after epiphyseal fusion, causing thickened soft tissues but no increase in height

Question 3

What are the main symptoms of acromegaly?

Answer 3

(1) Thickened skin
(2) Large jaw/hands
(3) Snoring
(4) Headaches
(5) Hypertension
(6) Diabetes
(7) Local pituitary effects
(eg, visual field defects)

(8) GIANT
(9) increased sweating
(10) Pituitary mass

Question 4

What is the screening test for acromegaly?

Answer 4

IGF-1 (age- and sex-matched)

Elevated levels suggest acromegaly

Question 5

What does a normal IGF-1 level mean in acromegaly?

Answer 5

If IGF-1 is normal, acromegaly is unlikely

Question 6

What is the diagnostic test for acromegaly?

Answer 6

Oral Glucose Tolerance Test (OGTT)

In acromegaly, after drinking glucose, the growth hormone (GH) should normally decrease. But in acromegaly, GH either doesn’t decrease at all or even increases when it should go down. This is a key sign of the condition

Question 7

What is the gold standard test for diagnosing acromegaly?

Answer 7

GTT suppression test
= 75g glucose

= Checking GH at 0, 30, 60, 90, and 120 minutes.

If GH doesn’t suppress to <0.4 µg/L or it rises, acromegaly is confirmed

Question 8

What is the first-line treatment for acromegaly?

Answer 8

Pituitary surgery
(transsphenoidal approach)

= Effective for microadenomas with a 90% cure rate

Question 8

What imaging is used in diagnosing acromegaly?

Answer 8

1. MRI/CT pituitary scan to check pituitary adenoma size
2. Visual field testing
3. Pituitary function tests

Question 9

What to do if surgery doesn’t normalize GH levels?

Answer 9

1. Radiotherapy
2. Somatostatin
3. Dopamine agonists
   (10-15% effectiveness)
4. GH antagonists
   (eg, Pegvisomant, last-line therapy)

Question 10

What are the side effects of somatostatin analogues?

Answer 10

Local stinging, GI upset, long-term gallstones

Question 11

What cardiovascular risks are linked to acromegaly?

Answer 11

Hypertension, cardiac failure, and early cardiovascular death

Question 12

What are the complications of GH excess in acromegaly?

Answer 12

Colon polyps
colon cancer
increased risk of heart failure

Question 13

How do somatostatin analogues help in acromegaly?

Answer 13

(1) They reduce GH secretion
(2) Relieve symptoms
(3) Improve outcomes
= especially before surgery or when surgery fails

Question 14

Is surgery the first-line treatment for prolactinoma?

Answer 14

False.

Dopamine agonists
(eg, cabergoline, bromocriptine)
are the first-line treatment

Question 15

Does acromegaly increase the risk of colon cancer?

Answer 15

yes

Question 16

What does the term Acromegaly mean?

Answer 16

Big Limbs

Question 17

Apart from neurosurgery and medical therapy what other modalities of treatment can be used to treat pituitary tumours?

Answer 17

Radiotherapy

Question 18

What is the common metabolic complication of Acromegaly?

Answer 18

Type 2 diabetes

Question 19

What long term imaging / screening tests do patients with Acromegaly require?

Answer 19

Echocardiography and colonoscopy

Question 20

What is the first line test for Acromegaly?

Answer 20

IGF-1

Question 21

Physical Signs of acromegaly include what?

Answer 21

Prognathia (protruding jaw)

Macroglossia (enlarged tongue)

Enlarged hands and feet

Coarse facial features (widened nose, enlarged lips)

Thickened skin

Question 22

Symptoms of acromegaly include what?

Answer 22

Fatigue
Headaches
Snoring or sleep apnea
Increased sweating
Joint pain

Question 23

A 47-year-old gentleman presents to his GP with headaches. On examination, the GP notes a set of surprising features. These include: frontal bossing, prognathism and visibly swollen hands. Additionally, the patient reports increased sweating and tingling in the thumb and index finger of the right hand.

Given the likely diagnosis, what would be most suitable to routinely monitor disease progression?

Answer 23

Serum IGF-1 level

Question 24

A 52-year-old male is referred to an endocrinology clinic with a recent diagnosis of acromegaly. The recent scans confirm the presence of an enclosed pituitary tumour. What is the next best step in the management of this patient?

Answer 24

Transsphenoidal surgery

Question 25

A 45-year-old male is referred to an endocrinologist with a confirmed parathyroid adenoma, acromegaly and recurrent peptic ulcers. What is the most likely diagnosis?

Answer 25

Multiple endocrine neoplasia I (MEN I)

Question 26

MEN I involves what? (Multiple endocrine neoplasia I)

Answer 26

1. Parathyroid hyperplasia/adenoma 2. Pituitary prolactinoma or GH secreting tumours (acromegaly) 3. Pancreas endocrine tumours in 70% of cases. These include insulinoma and gastrinoma, which explain peptic ulceration

Question 27

Normal serum growth hormone following oral glucose suggests what

Answer 27

acromegaly as should've decreased/ suppressed

Question 28

Suppressed serum growth hormone following oral glucose suggests what

Answer 28

negative (normal) result in an oral glucose tolerance test

Question 29

Major complications of acromegaly

Answer 29

1. Type 2 diabetes 2. Obstructive sleep apnoea 3. Carpal tunnel syndrome 4. Visual loss 5. Ischaemic heart disease

Question 29

A 33-year-old man with tingling in his thumb, index and middle finger has been referred for endocrine consultation. He also complains of waking up incredibly tired and says his wife complains that he snores. On examination, he is noted to have a prominent brow ridge. Looking at old photos, it becomes clear that his facial appearance has drastically changed over time. After some blood tests and an MRI scan, he is prescribed octreotide. What is the mechanism of action of this drug?

Answer 29

Somatostatin

Question 30

Excessive growth hormone means

Answer 30

Acromegaly

Question 31

A 53-year-old male presents to his GP for an insurance medical. The GP notices that the patient has coarse facial features, a larger tongue than expected and oily skin. The patient is also sweating excessively. An excess of which hormone is likely to be responsible for this patient's symptoms?

Answer 31

Growth Hormone

Question 32

What visual field defect will the patient exhibit in acromegaly?

Answer 32

Bitemporal hemianopia