Pituitary Disorders

Question 1

A pt presents with headache, diplopia, ptosis, and opthalmoplegia. You have already ruled out any ophthalmology disorders. What should you consider next?

Answer 1

Pituitary tumor (of the cranial nerve)
(Neurological Disorders)

Question 2

What are the 2 types of pituitary tumor. How do you differentiate between the 2?

Answer 2

Microadenoma is < 10mm

Macroadenoma is > 10mm

Question 3

A pt is brought to the ER by his wife. He has had a headache for a couple months, but within the past week he has developed loss of vision on the outside half of his site of view in both eyes. What might you suspect? What diagnostic tests would you run?

Answer 3

Pituitary tumor of the optic chiasm
Hormone evaluation for prolactin, GH, ACTH, FSH, LH, TSH, and T4
Pituitary hyperfunction and deficiency tests
MRI with or without GAD

Question 4

You suspect your pt has a pituitary macroadenoma, so you ordered an MRI with gadolinium dye. The MRI shows a 16mm lesion on his pituitary gland. What treatment do you recommend for this pt? What complications are you worried about following treatment?

Answer 4

Surgery (unless it is a prolactinoma)

Complications include hypopituitarism, diabetes insipidus, and visual loss

Question 5

What is the most common cause of pituitary hypersecretion and/or hyposecretion?

Answer 5

Pituitary tumor

Question 6

A pt comes in to the ER with a severe headache, vision changes in both his eyes, and ophthalmoplegia. What is the cause of his disorder? How will you treat him?

Answer 6

Pituitary Apoplexy
Caused by a hemorrhage into a pituitary adenoma (Sheehan’s syndrome)
Tx w/ Surgical decompression

Question 7

How would you treat Sheehan’s syndrome if the pt has neither visual loss nor impaired consciousness?

Answer 7

Pituitary Apoplexy

Tx w/ glucocorticoids ONLY if NO visual symptoms/impaired consciousness

Question 8

A 17 yo is brought in by his mother because she is worried about how much he has grown recently. The pt is 7’2” and has gained 60 lbs (and grown 12”) since his last visit. What disease do you most suspect? What is the most likely etiology of his disease?

Answer 8

Gigantism
Extreme linear growth prior to epiphyseal plate closure
Caused by a GH secreting pituitary adenoma which causes increased GH and IGF-1 levels

Question 9

A 19 yo male presents to your clinic. He is 8’0” tall. What other physiological problems are you worried this pt might have?

Answer 9

Macrocephaly

Cardiomegaly

Question 10

A 15 yo pt is brought in by his parents who are concerned that he is 6’10”. You run blood work and find he has elevated GH and IFG-1 levels. What treatment options might you recommend for this pt?

Answer 10

Transsphenoidal surgery (1st line)!
Bromocriptine or octretide
Radiation therapy

Question 11

A 35 yo man presents because he has recently noticed some weight gain and that he is lethargic and tired often. In his history you note that he has obstructive sleep apnea. On exam you notice large facial features and thick, beefy hands. What condition do you think this pt might have? What is the underlying cause of his disease?

Answer 11

Acromegaly
Caused by overgrowth of soft and bony tissue
GH production d/t a microadenoma or a macroadenoma
Increased IGF-1

Question 12

A 45 yo pt presents because he has recently noticed that his testicles are smaller, he has a decreased libido, and often times has ED. He also mentions that his teeth have been hurting recently and he thinks they look bigger than they used to. The pt has a history of hypertension and was recently diagnosed with Type 2 diabetes. What disease do you suspect? What tests would you do to confirm your diagnosis?

Answer 12

Acromegaly
Oral Glucose Tolerance Test (OGTT) is the gold standard
Blood tests to look for elevated IGF-1 levels
MRI w/ gadolinium dye to look for a pituitary adenoma

Question 13

A 42 yo pt came in complaining of a headache. She had recently been doing some scrapbooking, and she noticed that her face, nose, hands, and feet are all wider than they were 10 years ago. In her history you learn that last year she was diagnosed with Type 2 diabetes. You sent her to get an MRI with gadolinium dye, and the results show a pituitary microadenoma. What disease is causing this pt’s symptoms? What treatment options should you recommend?

Answer 13

Acromegaly
Surgery or radiotherapy to control the tumor mass
Reduce or relieve her symptoms (HA)
Treat her for her diabetes and any CV diseases she might have

Question 14

A 29 yo female comes in because she has had changes to her menstrual cycle and she noticed a milky discharge from her nipples. She is not and has never been pregnant although she and her husband have been trying for several months. What disorder might you suspect? What lab tests would you run?

Answer 14

Hyperprolactinemia
Check her fasting morning prolactin level
If that’s high R/O pregnancy (she denies, but still have her take a pregnancy test), hypothyroidism and medication-related
MRI of her pituitary if idiopathic

Question 15

What is the most common pituitary hypersecretion disease?

Answer 15

Hyperprolactinemia

Question 16

A 35 yo male presents with hypogonadism, a decreased libido, ED, and a milky white discharge from his nipples. You suspect he has hyperprolactinemia because of the galactorrhea. What is the underlying cause of his disease?

Answer 16

Hyperprolactinemia
Low GnRH
Decreased FSH and LH
Caused by a prolactin secreting pituitary adenoma

Question 17

Last week you saw a schizophrenic pt whom you had get some blood work done. On the blood work results you notice elevated serum prolactin, even though the pt was asymptomatic when you saw him. He is currently taking Haldol for his schizophrenia. What disease are you worried this pt might have? What treatment recommendations should you make?

Answer 17

Hyperprolactinemia
Discontinue Haldol, which is most likely causing his hyperprolactinemia
He should also avoid Elavil, SSRI’s, and opiates (all meds associated w/ hyperprolactinemia)

Question 18

Last week you saw a pt for amenorrhea and galactorrhea. You recommended she get some blood work done, which came back showing elevated serum prolactin. You ordered an MRI of her pituitary, which showed a prolactinoma. What treatment should you recommend for this pt?

Answer 18

Hyperprolactinemia
A dopamine agonist (Bromocriptine or Cabergoline) to increase inhibition and shrink the tumor
Trans-sphenoid resection

Question 19

What are the underlying causes of hyperprolactinemia?

Answer 19

Prolactinoma
Meds: Haldol, Elavil, SSRI's, opiates
Pituitary stalk damage caused by a tumor, granuloma, trauma, or radiation
Primary hypothyroidism
Renal failures
Nipple stimulation

Question 20

A female pt comes in because she has had persistent breast milk discharge from her right nipple despite that she is not and has not recently been pregnant. What disease do you suspect this pt might have? What is the most common underlying cause? What are other underlying causes of this disease?

Answer 20

Galactorrhea
Caused by hyperprolactinemia
Could also be due to an intraductal papilloma or another malignancy

Question 21

A 40 yo male pt presents because he has noticed a yellow discharge occasionally with small amounts of blood coming from his left nipple. What disease do you suspect? What treatment should you recommend for this pt?

Answer 21

Galactorrhea
Correct the underlying cause
Surgical removal if it is due to a papilloma

Question 22

A 24 yo female presents with yellowish right nipple discharge. You suspect she has galactorrhea. What should you do to confirm your diagnosis?

Answer 22

Check for elevated serum prolactin
Pregnancy test
U/S or mammogram
Pituitary MRI w/ gadolinium
Test for any causative meds, including Methyldopa, Tricyclic's, or Phenothiazines

Question 23

What is the most common pituitary adenoma?

Answer 23

Nonfunctioning pituitary adenoma

Question 24

What is the best treatment for a small nonfunctioning adenoma?

Answer 24

Follow with MRI scans

Question 25

An 8 yo is brought in by her mother because she is worried about her daughter being unusually short for her age. The child appears obese but only around her stomach; her limbs appear normal. The palms of her hands appear tan, and on exam you find that she is hypotensive and has delayed DTRs. What disease might you suspect in this pt? What is the most likely underlying cause of this pt's disease?

Answer 25

``` Hypopituitarism She has signs of GH insufficiency (growth disorder and central obesity) and ACTH insufficiency (Addison's symptoms) Most common is neoplastic Genetic or congenital Traumatic Vascular Infection ```

Question 26

A 29 yo female comes in because she her period has been "odd" recently and she and her husband have been trying to get pregnant for a year without success. In addition, she is often cold, has dry skin, and constantly feels tired, to the point where she is getting 8 hours of sleep a night but is still tired during the day. You suspect she has hypopituitarism. What diagnostic test would you run and what results would you expect to see to confirm your diagnosis?

Answer 26

``` 8AM cortisol TSH Free T4 IGF-1 PRL Look for GH and ACTH deficiency ```

Question 27

You have just diagnosed your pt with hypopituitarism affecting their FSH/LH and TSH. What treatment should you recommend for this pt?

Answer 27

Individual hormone replacement | For this pt FSH/LH and TSH replacement

Question 28

A pt presents with polydipsia, polyuria, urinary incontinence, nocturia, and fatigue. You believe the pt is dehydrated. What diagnosis do you suspect? What are the 2 types of this disease?

Answer 28

Diabetes insipidus Central DI Nephrogenic DI

Question 29

A pt presents complaining that she is always thirsty and that she drinks about 5 L of ice water per day. She also has to pee frequently and when she does she goes a lot and it is very clear. She mentions having daytime fatigue and says that she feels dehydrated despite the amount of water she's drinking. What do you think is the physiological cause of this pt's disease?

Answer 29

ADH deficiency

Question 30

A pt presents with polydipsia, polyuria, urinary frequency, enuresis, nocturia, and hypernatremia. You suspect he has central diabetes insipidus. What most likely caused this pt's disease? What are some other causes of central DI?

Answer 30

``` Most likely idiopathic (50%) Familial agenesis Congenital Genetic Trauma Pituitary damage ```

Question 31

A pt presents with polyuria, nocturia, daytime fatigue, and dehydration. You suspect nephrogenic diabetes insipidus. What is the underlying cause of this pt's disease?

Answer 31

Vasopressin (ADH) resistance Normal ADH levels Kidney tubules interfere with water reabsorption

Question 32

A 48 yo female pt comes in because she has been constantly thirsty and constantly going to the bathroom. She frequently wakes up in the middle of the night to go, and sometimes she is incontinent. What lab tests would you run for this pt and what results would you expect to see?

Answer 32

``` Diabetes insipidus Serum Na would be elevated Serum osmolarity would be elevated Urine osmolarity would be low 24 hour urine collection would be high volume and have diluted ions, elevated glucose, and elevated urea Fluid deprivation test Vasopressin challenge ```

Question 33

Explain how a vasopressin challenge is performed and how it helps determine whether a pt has central or nephrogenic diabetes insipidus.

Answer 33

Urine is tested 12 hours before and 12 hours after the pt is given Desmopressin (DDAVP) either intranasally, IV, or IM. A decreased urine output 12 hours after the exogenous ADH is administered suggests an ADH deficiency, which would be central diabetes insipidus A lack of response to the exogenous ADH would suggest ADH resistance, which is caused by nephrogenic diabetes insipidus

Question 34

A pt comes in complaining of polydipsia, polyuria, urinary frequency, enuresis, nocturia, and daytime fatigue. You suspect diabetes insipidus. What two complications are you most worried about in this pt?

Answer 34

Severe dehydration | Hypernatremia

Question 35

A pt presents with polyuria, nocturia, fatigue, and polydipsia. You perform a vasopressin challenge, and the pt's urine output decreases 12 hours after the exogenous ADH is administered. How should you treat this pt?

Answer 35

Central diabetes insipidus | Tx with desmopressin (DDAVP)

Question 36

A pt presents with nocturia, daytime fatigue, hypernatremia, and enuresis. The pt does not respond when you perform a vasopressin challenge. What should you do to treat this pt?

Answer 36

Nephrogenic diabetes insipidus | Tx with hydrochlorothiazide

Question 37

A pt comes in because she has been nauseous, vomiting, and has a headache. She appears slightly confused, but during the ROS she tells you that her urine has been very yellow recently. What disease do you suspect is causing her symptoms? What do you suspect is the underlying cause of her disease?

Answer 37

SIADH | Excess ADH

Question 38

A pt presents with anorexia, nausea, headache, confusion, and concentrated urine. You suspect SIADH. What is pathophysiologically causing this pt's disease?

Answer 38

Excess ADH is causing a water input/output imbalance ADH increases water permeability in the renal collection ducts which causes increased water reabsorption Increased ADH leads to decreased aldosterone secretion

Question 39

You suspect your pt has SIADH. What is the most common cause of this disease? What are some other possible causes?

Answer 39

Tumor is most common (small cell CA, leukemia, lymphoma, duodenal/pancreatic CA) Pituitary surgery Hypokalemia CNS disorders (trauma, stroke) Pulmonary lesions (TB, PNA) Post-Op, pain, stress, pregnancy, drugs (meth/ecstasy)

Question 40

A pt presents with anorexia, nausea, vomiting, headache, confusion and dulled sensorium. What lab tests would you run and what results would you expect to see to support your diagnosis?

Answer 40

``` SIADH Serum Na would be low Serum osmolarity would be low Urine osmolarity would be elevated Normal adrenal/thyroid hormones Normal renal function ```

Question 41

What do you need to R/O before you can diagnose a pt with SIADH?

Answer 41

R/O any volume-altering conditions such as CHF, renal insufficiency, and hypovolemia

Question 42

A pt was brought to the ER because she is nauseous, vomiting, has a headache, and is confused. Her lab results come back and show hyponatremia, low serum osmolarity, and high urine osmolarity. What is the best treatment for this pt? What do you have to be sure to AVOID when treating this pt?

Answer 42

``` Fluid restriction (only give her 600-800mL/d) Slowly increase her serum sodium levels by ```