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Y3(M) - Endocrinology > Pituitary Pathology > Flashcards

Pituitary Pathology Flashcards

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1
Q

Where does the pituitary gland sit in the head?

A

Sella turcica of the sphenoid bone

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2
Q

What structure sits superior to the pituitary gland?

A

Optic chiasm

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3
Q

What structures sit laterally to the pituitary gland?

A

Cavernous sinuses

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4
Q

What are the contents of the cavernous sinus?

A

Cranial nerves: III, IV, Va, Vb and VI

Internal carotid artery

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5
Q

What is the venous drainage of the pituitary gland?

A

Pituitary gland -> Cavernous sinus -> Petrosal sinus -> Internal Jugular Vein

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6
Q

What is the arterial supply to the pituitary gland?

A

Hypothalamic-hypophyseal portal system

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7
Q

How does size of pituitary change in:

-pregnancy?
-with age?

A

Pregnancy = doubles in size

Age = shrinks

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8
Q

What are the hormones produced by the anterior pituitary gland?

A

TSH
ACTH
FSH
LH
Prolactin
Growth hormone

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9
Q

What are the hormones produced by the posterior pituitary gland?

A

ADH
Oxytocin

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10
Q

What does the hypothalamus produce to stimulate the production of TSH by the anterior pituitary gland?

A

TRH

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11
Q

What does the thyroid gland produce in response to TSH?

A

T3
T4

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12
Q

What does the hypothalamus produce to stimulate the production of ACTH by the anterior pituitary gland?

A

CRH

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13
Q

What does the adrenal glands produce in response to the anterior pituitary gland producing ACTH?

A

Cortisol

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14
Q

What does the hypothalamus produce to stimulate the production of FSH and LH by the anterior pituitary gland?

A

GnRH

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15
Q

What do the testes and ovaries produce in response to the anterior pituitary gland producing FSH and LH?

A

Oestrogen
Testosterone
Progesterone

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16
Q

What does the hypothalamus produce to stimulate the production of GH by the anterior pituitary gland?

A

GHRH

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17
Q

What does the production of GH lead to the production of?

What produces this?

A

IGF-1

Liver produces IGF-1

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18
Q

What is the function of cortisol?

A

Increases blood glucose
Increases alertness
Increases metabolism
Inhibits immune system
Inhibits bone formation

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19
Q

What is the function of GH and IGF-1?

A

Stimulates muscle growth
Increases bone density and strength
Stimulates cell regeneration and reproduction
Stimulates growth of internal organs

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20
Q

What is the function of ADH?

A

Acts on vasopressin receptors in thhe collecting duct leading to translocation of aquaporins leading to water reabsorption

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21
Q

What are the 3 types of Hypopituitarism?

A

Partial
Complete
Panhypopituitarism

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22
Q

What is the definition of Hypopituitarism?

A

Partial or. Complete deficiency of anterior and/or posterior pituitary gland

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23
Q

What are some causes of Hypopituitarism?

A

Tumours
Infections
Infiltration
Infarction
Pituitary apoplexy
Congenital
Kallmans
Trauma

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24
Q

What are some infiltration pathologies that can cause hypothyroidism?

A

Sarcoidosis
Haemochromatosis.

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25
What type of infarction can cause Hypopituitarism?
Sheehans syndrome
26
What is sheehans syndrome and how does it cause pituitary infarction causing Hypopituitarism?
Infarction to anterior pituitary following a postpartum haemorrhage/massive blood loss In pregnancy there’s hyperplasia of lactotrophs so have a high demand for blood Mass blood loss leads to necrosis of the anterior pituitary
27
What is pituitary apoplexy?
Sudden haemorrhage/infarction of the pituitary gland
28
How does Hypopituitarism present?
Depends on the hormones that are affected/reduced
29
How does a patient with Hypopituitarism leading to low GH present?
Reduced exercise tolerance Reduced lean mass Weight loss Stunted growth if in children
30
How does a patient with Hypopituitarism leading to low FSH and LH present?
Amenorrhoea Anovulation Erectile dysfunction Low libido Impaired sexual development
31
How does a patient with Hypopituitarism leading to low ACTH present?
Hyperkalaemia Hypoadrenal crisis Fatigue Hypoglycaemia Hyponatraemia
32
How does a patient with Hypopituitarism leading to low TSH present?
Hypothyroidism presentation
33
How does a patient with hypothyroidism present?
Weight gain Fatigue Constipation Dry skin Fluid retention Coarse hair
34
How does a patient with Hypopituitarism leading to low prolactin present?
Failure to lactate
35
How does a patient with Hypopituitarism leading to low ADH present?
Polyuria Polydipsia
36
What are the principles in investigating anterior pituitary gland issues?
Check levels of end gland hormones in the blood (cortisol, T3, T4, oestrogen, testosterone , IGF-1) Then check the levels of the pituitary hormones (GH, FSH, LH, TSH, ACTH, TSH) THEN DYNAMIC TESTING
37
What are the principles of dynamic testing for anterior pituitary issues?
If hormone is HIGH = SUPPRESS IT If hormone is LOW= STIMULATE IT
38
What are the principles of investigating a posterior pituitary gland issue?
ADH issue Check serum and urine osmolality, Na+ Do fluid deprivation test
39
What is the gold standard imagining for the pituitary gland?
MRI
40
What is the principle for treating pituitary issues?
Replace final hormone not the pituitary hormone Surgical removal
41
What are the size classifications for pituitary tumours?
Microadeomas < 1cm Macroadenomas > 1cm Isoadenoma = 1cm
42
What is the most common type of pituitary tumour?
Adenomas: Prolactinoma Non functioning adenoma Gonadotropinoma Thyrotropinoma
43
How does a Prolactinoma present?
Hormone issue: Galactorrhoea Gonadal dysfunction: -period irregularities -low libido -Erectile dysfunction Mass effect: -Headache -Cranial. Nerve involvement (eye issues = optic chiasm) -Hypopituitarism
44
How can the presentation of a pituitary tumour be remembered?
Mass effect of tumour (space it takes up) Hormone specific effects
45
Why does a Prolactinoma cause gonadal dysfunction: -period irregularities -low libido -ED
Prolactin inhibits the production of GnRH by the hypothalamus leading to low levels of FSH and LH being made Dopamine also normally inhibits prolactin levels and vice Versa
46
What investigations do you do for Prolactinomas?
MRI pituitary Prolactin levels PRH levels Pituitary hormone test (FSH and LH) Pregnancy test U+Es LFTs
47
What can cause Prolactinomas?
PCOS Sevre hypothyroidism
48
Why does severe hypothyroidism cause Prolactinomas?
TRH increases leading to decreased dopamine which means levels of prolactin can increase
49
What visual defects are common with pituitary tumours?
Bitemporal hemianopia
50
What are the treatment options for Prolactinomas?
Nothing Give Test or Oestradiol to restore gonadal function DOPAMINE AGONISTS (BROMOCRIPTINE OR CABERGOLINE) Transphenoidal surgery
51
What is acromegaly?
Too much growth hormone (growth after the age of growing)
52
How can acromegaly present?
Mass effect (headache, Bitemporal hemianopia) Prorminent forehead Sweaty skin Large nose Large hands and feet Large tongue (macroglossia) Large protruding jaw (prognathism) Tiredness
53
What are some associated conditions with acromegaly?
Hypertrophic heart HTN Carpal tunnel syndrome (often bilateral) Arthritis Colorectal cancer
54
What investigations should be ordered if you think someone has acromegaly?
IGF-1 levels Pituitary function test Oral glucose tolerance test (75g glucose drink) GH and cortisol levels should reduce in a healthy individual MRI
55
What should you suspect if the oral glucose tolerance test doesn’t reduce GH levels and the MRI doesn’t identify a pituitary lesion?
Might not be imaged Ectopic production of GHRH from an ectopic source like a carcinoid tumour of the lungs or pancreas
56
What is the treatment for acromegaly?
Transphenoidal surgery of the pituitary adenoma = GOLD STANDARD If caused by an ectopic carcinoid cancer surgical removal of these too Somatostatin analogues and dopamine agonists have little proven efficacy
57
What is Cushing’s disease?
Excess ACTH production leading to elevated levels of cortisol/glucocorticoids in the body
58
What is Cushing’s syndrome?
The clinical manifestation of excessive exposure to glucocorticoids like cortisol
59
What are the signs a patient has Cushing’s disease or Cushing’s syndrome?
Plethoric moon shaped face Central adiposity Purple striae Proximal limb muscle wasting Enlarged upper back fat pad (buffalo hump) Impaired skin healing Hyperpigmentation of skin
60
Which type of Cushing’s will have skin hyperpigmentation and why?
Cushings disease Cushing’s disease has increased ACTH which is what leads to increased. Prodcution of MSH Cushing’s syndrome doesn’t have elevated ACTH
61
What disease Condtions can Cushings disease or syndrome cause on the body?
Oestoporosis HTN T2DM Dyslipidaemia Cardiac hypertrophy Depression Anxiety
62
What do patients with Cushing’s mostly die of and why?
PE Due to hyper coagulability of blood
63
What are the causes of Cushing’s?
Cushing’s disease pituitary adenoma Adrenal adenoma making cortisol Paraneoplastic syndrome (small cell lung tumour releasing ACTH) Exogenous (Prednisolone, dexamethasone)
64
What is the gold standard test to screen for Cushing’s syndrome?
Low dose overnight Dexamethasone suppression test
65
How does the low dose overnight Dexamethasone suppression test work to screen for Cushing’s syndrome?
Give dexamethasone att 11pm and it should supress the 9am cortisol levels If not requires further testing
66
What further tests would be required if the low dose overnight Dexamethasone suppression test is positive for Cushing’s?
1.) Low dose 48hr dexamethasone suppression test 2.) High dose48hr Dexamethasone suppression test
67
What is the purpose of doing a 48hr low dose dexamethasone suppression test?
?Cushing’s syndrome
68
What is the purpose of doing a 48hr high dose dexamethasone suppression test?
Levels of dexamethasone will be high enough to suppress a pituitary adenoma (Cushing’s disease) leading to low suppressed levels of cortisol in the
69
How are adrenal adenomas and ectopic ACTH producing tumours affected by the 48hr high dexamethasone suppression test?
Unaffected
70
What are ACTH levels like in adrenal adenomas causing Cushing’s?
Low due to negative feedback
71
What are the cortisol levels following a 48hr low dose then high dose dexamethasone suppression test and the ACTH levels for CUSHINGS DISEASE/PITUITARY ADENOMA?
Low dose: cortisol HIGH High dose: cortisol LOW/SUPPRESSED ACTH levels: HIGH (the cause)
72
What are the cortisol levels following a 48hr low dose then high dose dexamethasone suppression test and the ACTH levels for an adrenal adenoma?
Low dose: HIGH High dose: HIGH (NON SUPPRESSED) ACTH: LOW
73
What are the cortisol levels following a 48hr low dose then high dose dexamethasone suppression test and the ACTH levels for an ectopic ACTH producing tumour?
Low dose: HIGH High dose: HIGH (NOT SUPPRESSED) ACTH: HIGH
74
What Investigations would be done if you suspect Cushing’s?
Low dose dexamethasone suppression test High dose suppression test Midnight cortisol (most sensitive, should be low here but it wont be) Salivary cortisol Urine cortisol ACTH levels FBC U+Es MRI pituitary CXR (lung. Cancer) Abdo x-ray (adrenal tumour) Petrosal venous sampling (then PET scan if negative)
75
What is the treatment for Cushings disease/syndrome?
Transphenoidal surgery for pituitary adenoma Surgical removal of ectopic ACTH tumours Adrenal tumour removal Bilateral Adrenalectomy (not really used) Medications
76
What medications can be given for Cushing’s disease/syndrome?
Metyrapone
77
How does metyrapone work to treat Cushings?
Inhibits production of cortisol by the adrenal glands (inhibits CYP11B1)
78
Why is Adrenalectomy avoided when treating Cushing’s syndrome?
Can lead to Nelsons syndrome Will need adrenal hormone replacement therapy
79
What is Nelsons syndrome?
Removing both adrenal glands leads to an anterior pituitary tumour developing that produce ACTH to try and increase cortisol levels
80
How does a non functioning pituitary adenoma presetn?
Just mass effects Headache Optic chiasm involvement (Bitemporal hemianopia) Apoplexy
81
How do you investigate a non functioning pituitary adenoma?
MRI pituitary Pituitary function tests
82
How do you treat a non functioning pituitary adenoma?
Non if microademona <1cm Surgical (Transphenoidal) if macroadeoma or radiotherapy
83
How does a gonadotropinoma present?
Mass effect (headache, Bitemporal hemianopia) Rarely macroorchidism
84
How do you investigate a gonadotropinoma?
MRI Pituitary function test
85
How does a thryotropinoma present?
Hyperthyroidism: -agitation -sweaty -weight loss -diarrhoea Mass effects
86
What investigations are done if you think a patient has a thryotropinoma?
Free T3, T4, TSH MRI Pituitary function tests
87
How do you treat a thryotropinoma?
Surgical removal (Transphenoidal)
88
How does a pituitary carcinoma present?
VERY RARE Mainly mass effect (Headache, bilateral temporal hemianopia)
89
What investigations are done for pituitary carcinoma?
MRI Pituitary function
90
How is a pituitary carcinoma treated?
Surgery if possible Extremely poor prognosis
91
What is the main issue with the posterior pituitary that can occur?
Lack of ADH production / Diabetes Insipidus
92
What are the 2 types of diabetes Insipidus?
Cranial diabetes Insipidus Nephrogenic diabetes Insipidus
93
What is cranial diabetes Insipidus?
Posterior pituitary doesn’t produce sufficient ADH
94
What is Nephrogenic diabetes Insipidus?
When the kidneys (collecting ducts) dont respond to ADH but the posterior pituitary produces sufficient ADH
95
What can cause cranial diabetes Insipidus?
Brain tumours Brain injury Brain surgery Brain infections (meningitis, encephalitis) Genetic mutation Vasculitis Infiltration
96
What can cause Nephrogenic diabetes Insipidus?
Medications Genetic mutations in ADH receptor gene Hypercalcaemia Hypokalaemia CKD (PKD)
97
What is the presentation for diabetes Insipidus?
Polyuria Polydipsia Dehydration Postural hypotension
98
What is the volume of urine to classify Polyuria for diabetes Insipidus?
3L or more in 24hrs
99
What investigations would you do if you suspect diabetes Insipidus?
Urine output (>3L) Urine Osmolality should be low (DILUTE < 300mOsm/kg) Serum Osmolality high WATER DEPRIVATION TEST MRI Pituitary
100
What would expect the urine Osmolality and serum osmolality to be like in diabetes Insipidus?
Urine osmolality = low because it’s dilute Serum osmolality = high or normal due to lack of fluid
101
What is the process of the water deprivation test?
Patient doesn’t drink water 8hrs before test Desmopressin then given and the urine osmolality is then measured
102
Following a water deprivation test, What will the urine osmolality be for a patient with primary Polydipsia (drinks too much water)?
Serum osmolality will be measured high due to urine being concentrated from the ADH production
103
Following a water deprivation test, What will the urine osmolality be for a patient with primary Cranial Diabetes Insipidus?
Urine osmolality will be low indicating pathology (dilute when shouldn’t be) After giving desmopressin the urine osmolality becomes high since the kidneys can respond to the exogenous ADH/desmopressin
104
Following a water deprivation test, What will the urine osmolality be for a patient with primary Nephrogenic Diabetes Insipidus?
Urine osmolality will be low indicating pathology (dilute when shouldn’t be) After giving desmopressin the urine osmolality stays low since the kidneys are unable to respond to the exogenous ADH/desmopressin
105
What electrolyte changes can happen with diabetes Insipidus?
Hypernatraemia.
106
How is cranial diabetes Insipidus managed?
Desmopressin Sodium levels need monitoring since Desmopressin might be too effective causing dilutional hyponatraemia
107
How is Nephrogenic diabetes Insipidus managed?
Thiazides Indomethacin (an NSAID) High dose desmopressin Lots of water

Y3(M) - Endocrinology (9 decks)

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