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Year 2 Endocrine > Pituitary Pathology > Flashcards

Pituitary Pathology Flashcards

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1
Q

Microadenoma

A

<1cm

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2
Q

Macroadenoma

A

> 1cm

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3
Q

What is a prolactinoma?

A

Prolactin producing tumour

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4
Q

What happens as a result of raised prolactin levels?

A

Galactorrhea (milk produced outside of pregnancy)

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5
Q

What can result in raised prolactin levels?

A 
Breast feeding (nipple stimulation)
Stress 
Dopamine antagonist 
Stalk Lesions (severance of connection)
Hypothyroidism 
Prolactinoma
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6
Q

Why do dopamine antagonist result in raised prolactin levels?

A

Dopamine inhibits prolactin production, by reducing dopamine levels you increase prolactin levels.

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7
Q

Give an example of a dopamine antagonist?

A

Metaclopramide

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8
Q

Why does a stalk lesion result in raised prolactin?

A

Prevents dopamine transmission to the pituitary so prolactin levels are not inhibited

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9
Q

Why does hypothyroidism often result in a raised prolactin ?

A

As TRH stimulate prolactin

Hypothyroidism there is negative inhibition so TRH levels are raised.

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10
Q

How does a patient with a prolactinoma present?

A 
Galactorrhea
Menstrual irregularity
Infertility
Impotence
Visual field disturbances
Headaches
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11
Q

What is the first line investigation in a suspected prolactinoma?

A

Serum prolactin levels

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12
Q

If the prolactin levels are found to be high in a suspected prolactinoma what should be undertaken?

A

MRI to determine the cause
Tumour extent and size
Stalk lesion
Optic chiasm compression

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13
Q

In pituitary tumours what is a common side effect if they are large?

A

Bitemporal Hemianopia

Compression of the optic chiasm

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14
Q

What should also be undertaken alongside an MRI in any suspected pituitary tumour?

A

Visual field test

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15
Q

After an MRI has diagnosed the tumour what should also be taken?

A

Pituitary function tests- look for other hormones affected

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16
Q

What is the treatment of choice for a prolactinoma?

A

Dopamine agonists

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17
Q

Name dopamine agonists

A

Cabergoline 1st line less side effects

Bromocriptine

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18
Q

Cabergoline in prolactinomas

A

Causes tumour shrinkage
Very successful in fertility restoration
Taken 1 or 2 times a week

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19
Q

Side effects of cabergoline

A

Low mood
Nausea
Vomiting

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20
Q

What is acromegaly?

A

Growth Hormone excess in later life

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21
Q

What s gigantism ?

A

Growth Hormone excess since birth

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22
Q

What is the difference between gigantism and acromegaly?

A

Acromegaly occurs after the growth plates have fused

Epiphyseal fusion

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23
Q

What is the appearance of someone with acromegaly?

A 
Large protruding jaw
Round doughy face
Large Hands
Prominent nasolabial folds
Thickened soft tissue
Enlarged brow
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24
Q

What are the clinical features associated with acromegaly?

A 
Sleep apnoea
Hypertension 
Headaches
Diabetes Mellitus
Visual field defects
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25
What are the risks associated with acromegaly?
Early Cardiovascular death | Colonic polyps
26
Why are patients with acromegaly more likely to die from cardiovascular disease?
Increased risk of heart failure due to Left ventricular hypertrophy
27
Whilst acromegaly doesn't directly cause colonic cancer what risks are there?
By inducing colonic polyps they increase the likely one of these polyps, by pure chance, could become cancerous.
28
What is the screening test for acromegaly?
Measuring IGF-1 levels | Results are age and sex matched
29
Why is IGF-1 not GH used in acromegaly screening?
IGF-1 is present in peripheral tissues for a longer time, as it has a longer stable half life.
30
What is the diagnostic test of choice for acromegaly?
Glucose tolerance test
31
What is a glucose tolerance test?
75g of glucose is taken orally | GH checked at 0 30 60 90 120 mins
32
In a healthy patient what should happen to the GH levels in a glucose tolerance test?
Suppressed to 0.4 ug/L
33
What happens to a patient with acromegaly in a glucose tolerance test?
GH levels are unaffected or increase
34
Once tests are done what should happen next in a patient with acromegaly?
MRI and CT | Check other hormone level
35
In acromegaly when checking the other pituitary hormones what should be measured in regards to TSH?
Free T3/4 not TSH
36
Is surgery curative in acromegaly?
90% if micro | 50% if macro
37
What can be used to shrink a tumour for surgery? Acromegaly
Somatostatin analogue | Dopamine agonist
38
Why do dopamine agonists work in acromegaly?
10/15% of patients with acromegaly also secrete prolactin
39
Somatostatin analogues
Sondostatin LAR
40
What are the effects of somatostatin analogues?
Tumour shrinkage | Reduces GH levels
41
Side effects of somatostatin analogues?
Flatulence Diarrhoea Diffuse abdo pain Increased risk of gall stones
42
How are somatostatin analogues administered?
Injected once a month
43
What is the last line therapy for acromegaly due to a tumour?
GH antagonist
44
GH antagonist?
Peguisomal
45
Do GH antagonist affect the tumour?
There is no reduction in tumour size
46
Affects of GH antagonists?
IGF-1 and GH reduced | 85% response rate
47
What surveillance is undertaken in those with acromegaly?
Colonoscopy CV risk - BP lips and glucose levels Sleep apnoea studies
48
What is cushings syndrome?
Excess cortisol production
49
What is cushings disease?
Pituitary adenoma - producing ACTH
50
Pan hypopituitarism
Posterior and anterior pituitary glands are completely non functional
51
List some common causes of pan hypopituitarism?
``` Pituitary tumour Iatrogenic TB Sarcoidosis Trauma Meningitis ```
52
What could be some local brain tumours that could cause hypopituitarism?
Meningioma | Glioma
53
Anterior symptoms of pan hypopituitarism
``` Menstrual irregularity Inferitility Impotence Abdominal obesity Loss of facial hair Dry skin Growth retardation ```
54
What hormone tests would be undertaken in a suspected pan hypopituitarism?
TSH IGF-1 LH FSH
55
Why is ACTH not regularly tested for in pan hypopituitarism?
As ACTH levels fluctuate throughout the day
56
What tolerance test would be undertaken in pan hypopituitarism?
SynACTHen | Insulin
57
What is the treatment for someone with pan hypopituitarism?
``` Thyroxine Hydrocortisone ADH GH Oestrogen and progesteron (female) Testosterone (male) ```
58
What is the dose of thyroxine in someone with pan hypopituitarism?
100-150mg
59
What is the dose of steroids in someone with pan hypopituitarism?
10mg morning 5 mg midday 5 mg dinner
60
What is the dose of ADH in someone with pan hypopituitarism?
Nasal spray
61
What is the does of Growth hormone in someone with pan hypopituitarism?
Injection nightly
62
When is oestrogen and progesterone replacement used in women?
Used only in pre menopausal women
63
What is the dose of testosterone in someone with pan hypopituitarism?
Intramuscularly every 3-4 weeks
64
What is the testosterone used in IM injections?
Sustanon
65
What is the topically applied form of testosterone?
Testogel
66
What are the benefits of using growth hormone in adults with pan hypopituitarism?
``` Improves quality of life Reduces abdominal fat Increases muscle mass and strength Increases cardiac function Increases bone density ```
67
What are the risks associated with testosterone replacement?
Prostate enlargement - not cancerous Polycythaemia - increased risk of MI Hepatitis - only in oral tablet
68
What is polycythaemia?
Increased number of red blood cells increases the viscosity of the blood
69
What is the main symptom due to posterior pan hypopituitarism?
Cranial diabetes insipidus
70
What is the diagnostic test for cranial diabetes insipidus?
Water deprivation test Nil by mouth for 8hrs Urine osmolarity should be >2 greater than normal Diabetes insipidous if lower
71
Treatment for cranial diabetes insipidus?
Desmospray nasally | Desmopressin oral tablets
72
What tumour can spread to the pituitary and is a remnant of Rathkes pouch?
Craniopharyngioma
73
Symptoms of craniopharyngioma?
Headaches Visual disturbance Growth retardation
74
What ages are affected by craniopharyngioma?
5-15 | 6th and 7th decade
75
What is the prognosis for a craniopharyngioma?
excellent
76
Cushings Disease
Excess ACTH secretion from the pituitary results in High Cortisol levels
77
Physical sign of Cushings disease
``` Proximal Myopathy Abdominal Obesity Easy bruising Purple Striae Hirsutism/Virilisation Acne Moon face ```
78
Clinical manifestations of Cushings disease
``` Diabetes Mellitus Hypertension Oedema Periorbital Psychosis depresson Testicular atrophy Oligo/amenorrhea ```
79
How can you differentiate between an obese person with and without cushings?
Obesity protects against osteoporosis, | Cushings results in obesity with osteoporosis
80
What suppression test should be undertaken if cushings is suspected?
Exogenous high dose oral steroid | Should produce a low serum cortisol level
81
What oral steroid is used in a cortisol suppression test?
Dexamethasone
82
What are the screening tests for cushings?
1mg of dexamethasone at midnight -cortisol checked at 8am Urine free cortisol - 24hr collection
83
In the screening test involving dexamethasone what is the dosage and what is the expected level of cortisol?
1mg Dexamethasone < 50nmol/l is normal > 130nmol/l is abnormal
84
In free cortisol urine sampling what is the expected values?
Total <250 is normal
85
What is the definitive test for cushings?
Low dose dexamethasone test - 0.5mg every 6 hours for 2 days - 6 hours after last dose cortisol is measured
86
What cortisol level indicates cushings 6 hours post final dose of dexamethasone?
>130nmol/l
87
If the low dose dexamethasone test is positive what else should be undertaken?
A ACTH test
88
In a +ve low dose dexamethasone with a V.High ACTH what does this indicate?
Ectopic ACTH
89
In a +ve low dose dexamethasone with a normal ACTH what does this indicate?
Pituitary pathology
90
What tumours can cause ectopic ACTH secretion?
Lung Thymus Pancreas Carcinoid Small Cell lung cancer
91
What is the most common cause of cushings?
High dosage steroid use

Year 2 Endocrine (21 decks)

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