Internal Medicine Review Core Curriculum, Book 4: Endocrinology

150 Pages·2014·19.819 MB·English

by  Robert A. Hannaman (ed.)

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MedStudy®
INTERNAMLE DICINREE VIEW
RE
SIXTEENTH EDITION
CURRIG CULUM
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Topicisnt hivso lume:

Endocrinology
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Hematology
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Oncology
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Allerg&y Immunology
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RoberAt.H annamanM,D
EditionrC hief
Disclaimers
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Endocrinology
HELPFULG ENERALITI.E.S. ..................7.-.1. ..........E.V.AL.U.A.T.I.O.N.O .F. H.Y.P.E.R.L.I.P.I.D.E.M..I..A.. ..... ......7.-.2.9. ...................
PRJMARYvsS.E CONDARYvsT.E RTIAR.Y. ..........7-.1. ..........T.R.E.A.T.M.E.N.T.O F HYPERLIPIDEM.I.A. ..........7.-.2.9. ...................
POSTERJOPRI TUITARY ...................7.-.1. ...........G.e.n.e.r.Ca.ol.n .c.e.po.tf.Ps .r .i.m.a.Pr.ry.e .v.e.n.t..i...o..n.. ........ ..7.-.2.9. ................
ANTERIORP ITUITARGYL AND. .................7.-.1. ...........N.C.E.P.A .T.Pl. l.Gl.u .i.d.e.l.i..n..e..s.. ... .............7.-.3.0. ................................
PITUITARTYU MORS. .....................7.-.2. ............2.0.1.A3.C .C. IA. H.A. .C.l.i.n.iP.cr.aa.lc. t.Gi.uc.ie.d .e.l.oi.nnB. el. o od
HyperprolactainndPe rmoilaa ctin.o..m.a.s. ......7.-.3. .............C.h.o.l.e.s.tt.eo Rr eodlu cAet herosclerotic Cardiovascular
Acromeg.a.l.y. .......................7.-.4. ............D.i.s.e.a.(s.Ae.S .C.V.D.R).i .si.kn. A .d.u.l..t..s.. ......................7..-..3..1.. ... ....................
OthePri tuiTtuamroyr .s. ...................7.-.4. ...........N.L.A. R.e.s.p.o.nS.st.ea. t.e.m.o.en.n2 .t0. 1.A3.C .C. I.A .H.A Clinical
PITUITARY INCIDENTA.L.O.M.A. ............7.-.5. ............P.r.a.c.tG.i.uc.ie.d .e.l.i..n..e..s.. ... ...............7.-.3.2. .....................................
ApopleaxnydS heehSaynn dro.m.e. ............7.-.5. ............D.i.e.t.aT.rh.ye. r.a..p..y.. ...... ..................7.-.3.2. ..........................................
DIABETEISN SIPID.U.S. ....................7.-.5. ...........D..r.u.gf.so. Dr.y .sl.i.p.i.d.e..m..i..a..s.. .......................... ..7.-.3.2. .................................
SIADH... ............................................................................................. 7-6 TreatmSecnetn ar.i.o.s. ..................7.-.3.4. ......................................
THYROIDG LAND. .........................7.-.6. .........L.I.P.I.D.IS.N .A .C.U.T.E. .C.O.R.O.N.A.R.Y. G.S.Y.N.D.R.O..M..E.. ..........7..-..3. 5. ..........
NORMAL PHYSIOLOG.Y. ..................7.-6. ...........G.O.A.L. L.E.V.E.L.SO. F. .L.D.LI. .NP. A.T.I.E.N.T.WS.I .T.H C HD .....7.-.3.5. ....
THYROIDF UNCTIONT ESTS. .................7.-.6. ........D.I.A.B.E.T.E.MS.E .L.L.I.T.U.S.. ............... .............7.-.3.5. .......................................
OTHERT HYROIDT EST.S. ..................7.-.7. ..........D.I.A.G.N.O.S.IA.SN. D. .S.C.R.E.E.RN.I.N..G.. ........... ........7.-.3.6. ..........................
Uptakaen dS ca.n. .......................7.-.7. .........P.R.E.D.I.A.B.E.T..E..S.. ..............................................7..- .3.7. .............................................
Ultrasou.n.d. .........................7.-.7. ...........G.o.a.la.sn. d.T .y.p.eo.sf. T .r.e.a.t.m..e..n..t.. ..........................7..-..3..7.. ..... ........................
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Biop.s.y. ..........................................7..-..7.. ....................T..Y.P.E.I .D .M. ......................... .................................7..-..3.7. .........................
HYPOTHYROIDIS.M. .....................7.-.8. ...........T.r.e.a.t.m.oe.fnT.t!.O . M. ....................................... ..7.-.3.7. ......................................
Findi.n.g.s. .........................7.-.8. ...........N.o.t.e.fs.o d.Tr.l O. M. ................................................7..-..3..8.. ........... ....................................
DiagnoosfiH sy pothyro.i.d.i.s.m. ............7.-.8. .........T.Y.P.E.2.D.M. ............................. .............7.-.3.9. .................................................
TreatmoefnH ty pothyroi.d.i.s.m. ............7.-.8. ............E.te.i.o.l..o..g..y.. ............................ ..............7.-.3.9. ...........................................
MyxedemCao ma. .......................7.-.9. ...........T.r.e.a.t.m.oe.fnT.t.2D .M. ........................................... 7.-.3.9. ......................................
HYPERTHYROIDIS..M. ...................7.-.1.0. ...........S.e.q.u.e.no.cf.De .r .u.gR. e.g.i.m.e..n..s.. ................ ......7.-.4.2. .............................
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Findi.n.g.s. ........................7.-.1.0. ..........G.L.Y.C.E.M.I.CT. R.E.A.T.M.E.N.TG. O.A.L.S. ............................7..-..4..2.. ....... ..................
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GraveDsi sea.s.e. ......................7-. I0. ...........A.N.C.I.L.L.A.R.YM. A.N.A.G.E.M.E.N.T.. ................................7 .-.4.3. ...........................
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ThyroSitdo r.m. .......................7.- .II. ............H.y.p.e.r.t.e.n..s..i..o..n.. ..........................................7. -.4.3. .............................................
THYROIDIT.I.S. .......................7.-.1.1. ...........D.y.s.l.i.p.i.d..e..m..i..a.. .........................................7..-..4. 3. .............................................
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EUTHYROIDS ICKS YNDROME. ..............7.-.1.2. ...........A.s.p.i.r..i..n.. .............. ...................7.-.4.3. ....................................................
NODULESA ND GOITER.S. .................7.-.1.3. .........D.I.A.B.E.T.I.CC.O .M.P.L.I.C.A.T.I.O.N..S.. ....... ...........7.-.4.3. ............................
RisFka ctofrosTr h yroNiodd ul.e.s. ............7.- .1.3. ...........M.o.n.i.t.o.r..i..n..g.. ..... ....................7.-.4.4. ................................................
NodulWeo rku.p. ......................7.-.1.3. ..........H.Y.P.E.R.G.L.Y.C.E.M.IS.CT. A.T.E.S.. ................................. 7.-.4.4. ..............................
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BenigNno dular Di.s.e.a.s.e. ..............7.-.1.4. ..........K.e.t.o.a.c..i.d..o..s..i..s.. ..................... ..........7.-.4.4. ..............................................

ToxiAcd enom.a. ......................7.-.1.4. ...........H.y.p.e.r.g.l.y.c.He.ym.pi.ec.r .o.s.m.oS.lt.aa.r(t. He.H .S..).. .............. .7.-.4.5. .............
ThyroCiadr cino.m.a. ...............9....7.-1.4. ...........G.E.S.T.AT.I.O.N.A.LD. I.A.B.E.T.E..S.. ........................ .....7.-.4.5. ...............................
Goit.e.r. ..........................7.-..1.5. .......H.Y.P.O.G.L.Y.C.E.M.I.A.. ................................................7..-..4..5.. ............. ......................................
MultinodGuoliatreN ro:n toxaincdT oxi.c. 9.........7.-.1.5. .........R.E.A.C.T.I.V HEY POGLYCEMIA. ................7.-.4.6. ...........................
ADRENALG LAND. ........................7.-.1.5. .........N.O.N.R.E.A.C.T.I.V.E. .H.Y.P.O.G.L.Y.C.E..M..I..A.. ....................7 .-.4.6. .....................
STEROIDS YNTHESI.S. .......r............7.-.1.6. ........B.O.N.E. I.C .A.L.C.I.U.M. .D.I.S.O.R.D.E.R.S. ............ ........7.-.4.7. ................................
CONGENITAALD RENALH YPERiPLASI.A. ........7.-.1.7. .........N.O.R.M.A L CALCIUMP HYSIOLOG.Y. ...........7.-.4.7. ....................
CUSHINGS YNDROME. ....h................7.-.1.7. ...........I.n.c.r.ei.an.sS .ee. r.u.Cm.a .l.c.i..u..m.. .............. ........7.-.4.7. ...............................
CushiSnygn droWmoer ku.p. ................7.-.1.8. ...........D.e.c.r.e.ai.sn.Se .e .r.uC.ma. l.c..i..u..m.. ... .............7.-.4.7. ..............................
ADRENALI NSUFFICIaEN.C.Y. ...............7.-.1.9. .........H.Y.P.E.R.C.A.L.C.E.M.I..A.. .............. ..............7.-.4.7. ........................................
MINERALOCORTICOI.D.S. ................7.-2.0. ............P.r.i.m.a.Hr.yy.p .e.r.p.a.r.a.t.h.y..r..o..i..d..i..s .m. .........7.-.4.7. ...........................
Aldostero.n.i.s.m. ....................7.-.2.0. ...........O.t.h.eC.ra. u.s.eo.fs.H .y.p.e.r.c.a.l.c..e..m..i..a.. ......................7. -.4.8. .........................
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Hypoaldoste.r.o.n.i.s.m. ...............7.-.2.1. ...........T.r.e.a.t.m.oe.fn.H t.y p.e.r.c.a.l.c..e..m..i..a.. ................ .....7.-.4.8. .............................
PHEOCHROMOCYTOMA.. ..................7.-.12. ..........H.Y.P.O.C.A.L.C.E.M.I.A.. ....................... ...........7.-.4.9. .........................................
OTHERA DRENALM ASSES. .................7.-.2.2. ...........O.s.t.e.o.m.a.l..a..c..i..a.. ............. ..............7.-.4.9. .............................................
HORMONES OF REPRODUCTIO.N. ..............7.-.2.3. .........R.E.V.I.E.W.O .F. C.A.L.C.I.U.MR.-E.L ATEDL ABS. .........7.-.5.0. ...............
NORMAL PHYSIOLOG.Y. ..................7.-.2.3. .........M.U.L.T.I.P.L.EE. N.D.O.C.R.J.N.E. .N.E.O.P.L.A..S..I .A... .......7.-.5.0. .................
Amenorr.h.e.a. ......................7.-.2.3. ........F.O.R.F .U.R.T.H.E.RR. E..A.D.I.N.G.. .......................................7..-..5..1 . ...................................
Hirsut.i.s.m. ........................7.-.2.4. .................................................
MEN ...............................7.-..2.5. .........................................................
LIPOPROTEI.N.S. ........................7.-.2.6. ...............................................
REVIEW. ............................7.-.2.6. .....................................................
Chylomic.r.o.n.s. ....................7.-.2.6. .............................................
VLDL. ............................7.-.2.7. .....................................................
IDL... ............................7..-.2.7. .......................................................
LDL. .............................7.-.2.7. .......................................................
HDL. .............................7.-.2.8. .......................................................
HEREDITARDYY SLIPIDEMI.A.S. ............7.-.2.8. .........................
LDL-AssociDaytsepldii demi.a.s. .............7-.2.8. ..........................
OtheDry slipide.m.i.a..s. ................7.-.2.9. .....................................
HDL-AssociaDtyesdl ipid.e.m.i.a.s. ..........7.-.2.9. .........................
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HELPFUGLE NERALITIES
HELPFULG ENERALITIES POSTERIOPRI TUITARY
Ify ouw antt ot esfto rh ypsoecretoifao nh ormonter,y Thep ttuttgalrayn ids c onsidetrheedm astegrl and.
tos timuliattE.ex amplIen:c aseosf s uspecatderde nalF unctioniatli lscy o,m prisoefdt hea nterpiiotru itary
insufficietnhcAeyC ,T Hs timulatteisiotspn e rformteod andt hep osterpiiotru iteaarcyoh,f w hicpha rticiipna tes
stimulcaotret ipsroold uction. diffehroerntm onaaxle sE.a cha xihsa sa differesneottf
hormonoault pauntd c ontrols.
Ify ouw antt ot esfto hry pesrecretoifao hno rmonter,y
tos uppreistEs.x amplIen:c aseosfs uspecCtuesdh ing The hypothalacmounst roolust puotf thea nterior
syndromteh,e d examethassounpep resstieosnti s pituibtyam reya nosf h ormon.eI stc ontrtohleos u tpouft
perfortmoes du pprpersosd uctoifco onr tisol. thpeo sterpiiotru i(tnaeruyr ohypopbhyyd siirsen)ce tr ve
stimulaTthieop no.s terpiiotru itsatroyra ensd r eleases
Importcahnatr actertioks ntoiwac bso uath ormone:
oxytocainnda ntidiuhroertmiocn( e[ ADH]a;l scoa lled
• Whati si tfusn ction? vasopresTshiean n)t.e rpiiotru itcoanrtyGa oisnmso recep­
• Wheries i tp roducaendds ecreted? torwsh,i ccho ntrAoDlH releaasneda rer esponsfiobrl e
• Whats timulaantdei sn hibiitrtses l ease? these nsatoifto hni rst.
R
• Wheraer et hesceo ntrols? Abovaec erttahirne shoofsl edr uoms molal(irteyl atively
• How isi ts ecretIesid td? i urnaolrt onic? leswsa tetrh asno lutteh)ek, i dnehyasv aec ompensatory
V
andp roportiroensaptoen osfec oncentratthieun rgi ne
NoteM:a nye ndocrgilnaen adrse r esponstiorv eeg u­la
inr espontsote h es ecretoifAo DnH .T het hreshsoeltd
torfye edbamcekc haniswmhsi,c dhe termtihneee xtent
poinitsd ecrea(sAedDdH i sr eleaastea d l oweors mo­
ofh ormonsee cretbiyo eni thneerg atifveee dbaocrk
lalibtyyp )r egnanacnydp re-menstehses; e tp oinits
positifveee dbacNke.g atifveee dbadcekc reastehse
increabsyec dh eronhiycp ervoleamciuath,ey pertension,
deviatfiroonma ni deanlo rmavla luaen di si mportant
andc orticostVeorlouimdceso .n tracbtoitoihnn creases
inm aintaihnoimnego staMsoisste. n docrgilnaen adrse t
thea mounotfA DH releaasneddd ecreatshetesh reshold
undetrh ec ontroofnl e gative femeedcbhaacnki sms. i
septo int.
n
Seruoms molaclainbt yee stimaRteemde.m betrhf eo rmula:
PRIMARvYs .S ECONDARYv s.T ERTIARY OUsmola=l i2t[yNa++] ( Gluco1s8e)+/ (BUN/2.8).
ADH alsiosr eleaisner de spontsone o n-osmotic factors;
Withr egatrodg landualbanro rmalities:
them ospto teonftt hesiesn aus,ew ahicihn creaAsDeHs
Primarrye fetrosd iseaisnte h eg lantdh aste cre-tthees levetloss everhauln dretdi menso rmaTlh.i rbsetg ins
hormonEex.a mplPer:i mahryyp othyroimde iasntmsh e whens erumo smolality e2x9c5em eOdssm /La nd
thyrogilda nidsd iseaasneddn otp roductihn9ygr oxine.b ecomes more aisns teernusomes molaliintcyr eases.
Secondarrye fetrosd iseaosfet heg land ctohnattr olDse hydratainodhn y povoleamlisaio n creatshei rasntd
9
thep rimagrlya nEdx.a mplSee:c ondahryyp othyroiditshme reibnyc reatshees ecretoifoA nD H, buto nlyi n
meantsh ep ituiitsad riys eaasneddn otp roducTiSnHgt o extrecmier cumstasnuccaehss s hock.
r
stimultahtteeh yrotiomd a ket hyroxine.
i
Tertiarreyf etrosd iseaosfte hh eg lantdh acto ntrtohles ANTERIOPRI TUITAGRLYA ND
glantdh acto ntrtohleps r imagrlya nEdx.a mplTee:r tiary
a
hypothyromiedainstsmh hey pothaliasmd uiss eaasnedd OVERVIEW
notp roducTiRngH tos timulate thet orp eilteuaistea ry
TSHt os timultahttteeh yrotiomd a ket hyroxine. Thea nterpiiotru ictoanrtya 6ihn osr mones:
Let'doso nem oree xample: I)A drenocortichootrrmoopn(ieAc C TH)
2)G rowthho rmon(eG H)
Primahryyp eraldostemreoanntishs amtt h ed iseaissie n
3)L uteinizing (hLoHr)m one
theg lantdh amta keasl dosterwohnieci,hs t hea drenal.
Thiwso ulbde a na ldosterone-secreting tu4m)Fo orl.l icle-sthiomrumloant(eiF nSgH )
5)P rolac(tPiRnL )
Secondary hyperaldmoesatnestr hoanttih sedm i sease
6)T hyroid-stimhuolramtoin(neTg S H)
isi nt heg lantdh acto ntraolldso sterreolneea Tshee.
kidnerye learseensi wnh,i csht imulattheeas d rentaol Theh ypothalamuasr-yp-ittauorirgtgealtn o opsst imulate
produacled osterSoon,ie ns. e condhayrpye raldostehroornm­onper oductwihoenn s eruml evealrse l owa nd
ismd,i seaissae tt hel eveolft hek idneTyh.i wso ulbde
inhibhiotr monsee cretwihoenns eruhmo rmonlee vels
renovascduilsaerao srae r enin-sectruemtoirn.g
arhei gThh. eh ypothalsatmiumsu lpaitteusi htoarrmyo ne
secretwihoinc,th h esnt imulattaergsoe rtg ahno rmone
productTiarogne.ot r gahno rmonneesg atifveeelbdya ck
tob otthh ep ituiatnadrt yh hey pothalamus.
© 2014 MedStudy
7-2
ANTERIOR PITUITARYG LAND
Theraer e2 typeosfs ignatlhsac to ntrtohler eleaosfe • Somatotro--p->h shypersecroefGtHi orne sulting
anterpiiotru ihtoarrmyo nes: ina cromegaly
I)Th es timulahtoorrmyo nperso ducbeytd h hey pothalamu•s C orticotr-o-p-hh>ys p ersecroefAt CiToHn resulting
inC ushidnigs eea s
(e.gt.h,y rotropin-hroerlmeoansei)n g
2)T argoertg ahno rmofnee edba(cek.t gh.y,r oxcionret,i sol•) T hyrotro--p->h hsy perthyro= ildeiascsmot m mon
ACTH hasa d iurnavla riatwiiotanhp eaakt 3 -4a .ma.n d • Mixedc eltly pe( somatotr+ olpahcst otr--o->p hs)
featuorfeb so tahc romegaanldhy y perprolactinemia
an adiart1 0-1p1. mA.C TH stimultahtaeed sr enal gland
top roduccoer ticostaenrdao niddrso geannsdi, t h asa Iti si mporttaonc th ecpkr olacitnsi onm atotrtoupmho rs
regulateoffreyco tn productoifom ni neralocortiacnodiI dGsF.-i 1n l actottruompohr s.
ACTH increaisner se spontsoce o rticotropin-rCeolmemaosnim nags esff etcs ymptoimnsc luhdeea daches, diplo­
hormon(eC RH)a ndp hysiocrap ls ycholosgtirceasls es.
piaor v isufaile dledf ec(tbsi temphoermaila nopmsoisat,
GH iss ecretienad p ulsatfialseh iaonnd i sr egulatecdo mmonlayn)d,s eizurLeessc.so mGmonlayd,e nomcaasn
by 2 hypothalamic-rheolremaosn-iengsgr owthho r­ exteanndd c ausCeS Fr hinorrAhceuath.ee morrhiangteo
mone-releahsoirnmgo n(eG HRH)a nd somatostatainn adencoamuas aepso plexy.
(alskon owna sg rowthho rmone-inhhiobrimtionnoger Especiaslulsyp eac pti tuRitary awdheennao pmaat ient
GHIH)G.H RH causes reGlHe afrsoem t hoefp i tuitarpyr,e sewnittsm hu ltiphloer monaeb normalistuiceahss ,
ands omatostatin/GHIrHe lienaohsfiGe bH i ftrso mt he am ixtuorfeh ypotVhyraondia dd renal inssuyffimc­pient
pituitSaormya.t ostatina/lGshHoaI sHt hec apabitloi tyt oms( i.er.e,fl exewsi thd elayerde turns, confusion,
inhitbhiert e leaosfeT SHf rotmh pei tuitary. alopeccioan,ds tipamteinoonr,r haograi mae norrphleuas
LH andF SHa rpe roducbeydg onadotroapnhdps r,o duc­hyponatrenmaiuas,e a/vomiltoiwn-gg,r afdeev earn,d
tioinsr egulabtyep du lsatsieclree toifgo onn adotropipno­stuhreyaplo tension).
releashionrgm on(eG nRH)f romt heh ypothalamuWsh.e n giveFnS H andL H levelasl,w aydse termine
lnhib(ipnr oducetdh eoi vna rayn dt estiinsh)i bointlsy whetthetrh el evealrse a pproprfioartt eh er eproduc­
FSHs ecretion. i
tivset agoeft hef emal(ep rev-sp.o stmenopaFuosra l).
n
PRL isd ifferefnrto mt heo thehro rmonbeesc auistie s examplIefa: p ostmenopafuesmaallp ea tiehnatsi nap­
undetro niicn hibibtyih oynp othaladompiacm ineU sepnrto prialtoewlo yrn ormaFlS H andL H leve(lssh ould
downt hpei tuisttaarlyk . havea n elevatFeSdH levelt)h,e riesa disruptiino n
productoifgo onn adotropins.
TSH secretiiosn s timulatbeyd hypo thalamic
thyrotropin-hroerlmeoans(eiT nRgH )a ndi -nhibibtye d DiagnosIifas p:a tienhti'sst orys/uPgEg esat psi tuitary
T4 ,T 3 ,a nds omatos/tGaH tIiH.n tumo(ro ri fa ni maginsgt uddyo nef oro therre asons
9 showsa n incidenptiatlu itmaarsys )t,h ei nitgioaall
ist od etermiwnhei cche ltly peh ase xpandiendt ao
PITUITATRUYM ORS
9 massS.t arbtyi magitnhge t umowri tahn M RI (info t
Overview alreaddoyn ea)n,d a ssesstihnefg o llowhionrgm onfeosr
r excessoerds e ficiencies:
Pituittaurmyo rasr em osto ftenf ounidn cidentoarl ly
i
followiimnagg ionfgt hheb rain sectoona d paartyi ent'•s P rolactin
symptomactoimcp laiPnittsu.i ttaurmyo rasr ed uet o • IGF-t1os crefeonar c romegaly
the abnoprrmoaalli feroafct eiloolnfs t hea nterpiiotru ­ • 24-houurri nfree ec orticsoonlc entroartI im ogn
itarTyh.e f irsstte ipn e valuatai pnigt uitary ist umoorv ernigdhetx amethassuopnper essi(oinsf u tsepsetc t
tod etermtine wihtei tsfh uenrc tionaablnloyr mal andc ortiesxocle sosrA) C THs timula(tiisfou ns pect
whethietir s s ecretainan bgn ormaamlo unotfa nyo ft he cortidseofli ciency)
variohuosr mones. • TSHa ndf reteh yrox(iFnTe4 )
Iff unctioanbanlolrym aanly,o ft hfeo llowcienltgly pes • as ubunFiStH,,a ndL H
canb er esponsfiobtrlh eet umogrr owtahn dm ayh ave
a subunitasr ei nactipviee ceosf g lycoproatnedi,n
anyo ft hfeo lloweiffnegc ts:
whenf ounidn i ncreaasmeodu nttsh,e syu ppoar dti ag­
• Lactotro(pphsr olacti-n-o-hm>ya pse)rprolactinenmoisaio;sf g onadotraodpehn o.mF ainditnhge sseu bunits
tiewdi tgho nadotraospt hhsme o stc ommont ype indicattheaast p ituitmaarsysi sd efiniptietluyi tianr y
ofm acroadenomas orig(ivns n.o n-pituistuacrha ysc, r aniopharyngioma).
• Gonadotrop--h->s v ariapbrlees entation: On MRI,c raniopharynpgrieosmeaanssct a lcicfyisetdi c
suprasellelsairo annsd a rec onsidetroeb de benign.
o Masse ffec+t clinicsaillleyn t
Howevetrh,e mya yc aussey mptosmesc ondtaorm ya ss
o Masse ffe+c/-tgonadotrdoepfiinc iency/
effecatn di mpingemoennt th eo ptince rve.
partpiaanlh ypopituitarism
o Masse ffec+t/-gonadotrhoyppienr secretion;W hena ndh owt op ropeorrlyd etrh esheo rmontee sitss
tiewdi tlha ctotrfoopmrho ss ct ommont ype discusisnte hde rierp resensteacttiivteoh nafsto llow.
ofm acroadenomas
© 2014M edStudy-PiReeapsoerC to pyriIgnhftr ingetmoec notpsy [email protected]
ANTERIOR PITUITARYG LAND 7-3
Prolactinaormteah sme o scto mmonfu nctiopniatlu itary
tumorT.h eya reu sualmliyc raodenoma(<s 1 em in
uiz
diametebru)tt ,h ecya na lsboe s pace-occumpayci­ng
roadenom(a2:s I e m ind iametaesrs)o ciwaittevhdi sual
• Whati sm eantb yp ositainvden egative fieldd efecTthse.e levatPeRdL levedle creatshees
feedbarcekg ulatiineo nnd ocridnies eases? releaosfGe n RH,t herecbayu sian dge creaisnLe H and
Whichi sm ostc ommonp:o sitoirvn ee gative FSH. Ad ecreaLseHda ndF SH mayr esuilnte rectile
feedback? dysfunctiionmn e na nda menorrhaenadh irsutiins m
womenP.R Ll eveglesn eraclolryr elwaitteth u mosri ze
• Whata ret hed efinitoifpo rnism arsye,c ondary, (>1 0J0l gf/oLmr a croadenoimfatsh)te;u moirs2: 1 e m,
andt ertihaorrym ondei seases?
and tPhReL l eveils< 0I0J.i g/Lt,h etnh et umoirs n ot
• Whata ret heh ormoneosft hep osterior ap rolactinoma.
pituitary?
Due toa menorrhperao,l actinaormefa osu neda rlier
G
• Whati st hef ormutloae stimasteer um inw oment hainn m en.D ecreasleidb iidsot h ee arliest
osmolality?
symptoomf a prolactiinonmm aal esa ndi so ften
• Whata ret heh ormoneosft hea nterpiiotru itary?i gnoresdom; e nt entdo p reselnRatt weirt vh isufaile ld
defecBtyst .h et immeo stm ens eecka reth,e t umohra s
• Whata ret ypicsailg nasn ds ymptomosfa
growcno nsiderGaabllayc.t ororchceuair nsm oswto men
pituittaurmyo r? V
withp rolactinboumtra asr eilnym en.L ong-standing,
• Asidfer oma prolactinwohmaata, r et heo ther unrecognidziesde aissea ssociawtietdh d ecreased
causeosf h yperprolactinemia? skelebtoanlem inerdalizianbt oitomhne na ndw omen.
Treatmefnotrt e hesteu morisss tartwehde nt hes izoef
Radiologists may roecpcoaarsnti" oenmapltslyey l la."
thet umorc ausense urolosgyimcp tom(sh eadaches,
An appareenmtp tsye lmlaay b ec ausebdyl ososf t he
visufiaell tddi sturbaonrcw ehse)nh ypogonadeixsims ts.
pitui,tb aurtiy tm aya lsboe n orma9l0.% o ft hep atients
i
withe mpty sellsay ndromaer em ultiparwooumse n Micrnoadenoumsausa ldloyn oti ncretaos> e eIm ,s o
whospei tuithaarsby e end isplaacneddc ompresbsye d observatmiaoyn b e an approproipattieo fno rt hese
CSFb utfu nctionnosr ma.lN loy treatmiesnn ete defdo r pUatiehnotwse;v esre,r iMaRli ss houlbedd onet oa ssess
emptsye llsay ndroimfen o hormone deficaireen caineycs h angien s izeF.o rp atiewnhtos do requiarne
associaOtfce odu.r steh,se e lmlaay a ctuablel" ye mpty,"i nterventthieorna,p eoupttiico ns imnecdliucdaaeln d

andt hpe atiemnatyh avhey popituitarism-. surgitcraela tment.
Form ostp atienmtesd,i catlh erawpiyt hd opamine
HyperprolacatnidnP ermoilaa cti9nomas agonisstusc ha sc abergoalnidnb er omocripitsti hnee
besitn itoipatli oDno.p aminaeg onists broetdthuh cee
A serump rolacctoinnc entratthiaotin s r epeatedly
9 PRLl eveanld t umosri zCea.b ergoilsib neet tteorl erated
>2 0n g/miLse levaatnedid st erm"ehdy perprolactinemia."
(twice-wedeoksliyan ng dl esnsa useaan)di sn owa vail­
A leveofl2 1-40ng /mLi sc onsirdear seldi gehlte vatioanb laes a generfiocr mulatCiaobne.r goliisan ses ociated
andc anb ec ausebdym anyf acitors: witihn creased cardiac wvhaelnav dumlionpiasttheyr ed
h
atv erhyi gdho sagaessi nt het reatmoefnP ta rkinson's.
• Drugtsh aatr ed opamiannet agonii.set.s,; Cabergoliiscn oen traindiincp aatteide wnittskh n own
metoclopravmeirdaaep,a mainldc, e rtaanitni psychotics
lungh,e arvta lvaen,dr etroperifitbornoetdaiilcs ease.
(phenothiahzailnoepse,r riidsople,r idone)
• Diseasoefts h hety pothalaanmdu/spo irt uisttaarlyk Transsphensouirdgaelr iysu sedw hent hep atient
thaitn terwfietrpher oductoirt orna nspoofd rotp amine;c annotto lerdartuetg h eraopryw ,h eni ti si neffective.
e.gs.a,r coidaonsdti rsa uma Postoperatainve elleyv,a tPeRdL l eveilsi ndicaotfi ve
ar ecurrepnacret,i cuilnta hrecl ays oef m acroadenomas.
• Pregnanocre ys trougseen( Estroignehni bits
Radiatiisou ns ualrleys ervfeodrp ostsurgciacsaetlso
dopamionuet flow.)
eradicaantyre e maintiunmgo r.
• Nipple stimiunll aacttiaotwnio nmge n
• Cheswta liln juries When a patieonnt d rugt herafpoyr a prolactinoma
becomepsr egnatnhtde,r uigs s toppaendd, tphaet ieinst
• Hypothyroidism
observuesdi nagg oodr evioewfs ystepmhsy,s iecxaalm ,
• Chronkiicd nedyi sease
andv isufiaell dtse stiAnbgo.u tl /3o fm acroadenomas
• Prolactinomas enlardguer ipnrge gnanIcfty h.et umoern laregneosu gh
• Foodi nta(kSeop rolacsthionu bledc heckfeads ting.t)o c aussey mptombsr,o mocripctainnb ee restarted.
A serupmr olacctoinnc entr>at 2i0o0nn g/mLa lmost Ifv isiiosnt hreatesnuerdg,e irsya therapeoupttiico n.
alwayissc ausbedya p rolactinoma. Botbhr omocripatnidcn aeb ergoalriFenD eA pregnancy
categoBr dyr ugs.
© 2014M edStudy
ANTERIOR PITUITARY GLAND
7-4
Acromegaly Screebny checkifnogr a higha ge-adjuIsGtFe-d1
leveClo.n firtmh ed iagnobsyid se monstraatf ianigl ure
Growth hor(mGoHn)ei sr equirfeodrn ormaglr owth.
ofG H tos uppreasfst ear 7 5-gmo ragll ucolsoea d
GH iss uppresbsyeh dy perglycseommiaat,o staantdi n,
(OGTT)A. p ost-OGGTHT leve> l1 ng/mLi sd iag­
chronciocr ticosutseear nodis dt imulbayth eydp oglyce­
nostoifca cromelgyDa.o noto rdear r andoGmH level.
miaa nde strogens.
Alsoc hecpkr olactin (deuleet voca ot-esde cretion in
A single voaflG uHe i sn otu sefuli nd iagnosin2g5 % ofG H tumorLsa)r.g teu mordsi srutphty roaindd
acromegbaelcya uistess e cretiispo unl sataindll ee velsg onadotrroepliena ssoet ,h eslee vemlasy a lsnoe edt o
int heb loocda nv argyr eatilnay healtihnyd ividuablea. s sessed.
Insuling-rloiwktfeha cto(rGI-F!- )1i sp roducbeydt he
Treaatlp la tienttsr wainstshp hesnuorigd,eae rlvy einft hey
liver and mtehdegi raotwetsh -promeoffteicontfg G H.
area symptomaGtiviecs .o matosatantailno(o g cst reo)t,i de
UnlikGeH ,I GF-l1e vealrses tabtlher oughtohuedt a y.
+/-dopaa goni(sbtrso mocrioprtc ianbee rgo)l,oi rGn eH
IGF-i1s t he1 5t1e sdto nei nt hew orkuopf a cromegaly.
recepatnotra gon(piesgtvsi somaansat d)j uvatnrte atment
Normalle veallsm osatl wayesx clutdheed iagnoIsfi s. G
top atiewnittsrh e sidtuuamlo orr t ot hosweh oa rep oor
theI GF-l1e vealrsee levatpeedr,f oar mG H suppr­es
surgiccaaln didaStoemse.e xperrtesc ommenmde di­
siotne s(tf ollowainno gr agll ucolsoea dI)n.a dequate
calt herawpiyt sho matosR tatina sai nnailttoihgaeslr apy.
supprescsoinofinr mtsh de iagnoosfai csr omegaly.
Radiatiisuo sne odn lays a djuvtarneta tmenpta.t iAelnlt s
Gigantiisds ume t oG H exceisnsc hildhood, whichw irteahsd uilatgsn oosfai csr omegsahloyu hladv ae s creening
V
ina bnormahlilgylh i negarro wtwhh ilteh ee piphyseaclo lonoscaonpdey c hocardiorgergaamr dolfea sgse .
growtphl atoefst hle onbgo neasr eo penA.c romegailsy
d
the sdaimseo rodfeGrH exceshso;w eveirot,c cudrusr ing
OthePri tuitary Tumors
adulthaoftoedtr h ger owtphl actaer tifulsaegseE. x cessive
e
softt issgureo wtihs c haracteorfia sctriocm egaanldy We discusgsoenda dotrtoupmho risn t heO verview.
mayr ecedfeo llowtirnega tmLeontn.gb onecsh anges,R ecatlhle ayr tei ewdi tphr olactifnoobrme aisn tgh em ost
t
howevedron, o tr ecefdoel lowtirnega tment. commont ypoef m acroadenoGmoansa.d otrotpuhm ors
i
cnanp resevnatr iaabsl:y
Greattehra n9 9% ofa cromegcaalsye asr ed uet oa
benigwne,l l-deafdienneodm tah aitse asirleyc ogniozne d • masse ffecatn dh ormonally osri lent,
U
CTorMRI. • masse ffecwti tshy mptoomfsh ypogonadism/partial
panhypuoiptiatriosrm ,
Acromegahlays a n insidioonusse ats sociawtietdh
an increamsoerdt alwihteyn u ntreaatneddi s u sually• masse ffecwti tshy mptoomfsg onadotropin
-
diagnolsaetdie nt hec ourosfed iseaAsffee.c tepda tientse xce(srsa re).

typicaarlsel yym ptomaitnti hce liart 3e0 st om id4 0s.
9 A diagnoosfig so nadotraodpehn omias s upporbteyd
Signasn ds ymptoomfsa cromegianlcyl ude: findinagn i ncreians e far eseu bunoitrhs i glhe veolfs
9 FSHa nd/LoHr.
• Enlarghianngd asn df eet
• Coarsenoiftn hgfe a cifaerla tures Transsphensouirdgaelir syi ndicaftoersd y mptomatic
nonfunctioorng ionnga dotrtoupmho rs.
• Deepenionftg h ev oicie
• Carpatlu nnseyln drhome Fora symptompaattiice wnittsph r eserevneddo crine func­
• Acanthonsiigsr icans tioann dn om asesn croachomnev nitt satlr uctoubrseesr,­
a vatiwoint she riiamla gisntgu dmieasyb ea ppropriate.
• Skitna gs
• Pronoutnjcaewdg rowt(hw hiclhe adtsom ultiple Radiatiisao nno ptifooncr e rttayipne osft umorbsu tp ri­
dentparlo blems) mariliysu sepdo stsurgitcoca olnltya in rteusimdoura l
• Excesssiwveea tibnogd,yo dor massP.a tiewnhtosh aveh adp ituitraardyi ation need
theainrt erpiiotru iftuanrcyt mioonni toirnedde finitely.
• Sleeapp nea
Withs everper imarhyy pothyroi(ddiissme aosfe
Them osti mportant long-tearsms ocpirawotibetldhe m
thet hyrogilda ndt)h,ep ituittahryyr otrboepchosm e
acromegiascl ayr diovasdciusleaairsn ec,l uding:
hyperplaansdtm iacys imulaat tuem or-imagsihnogw s
• Ischemhieca rdti sease a pituitmaarsysF .r eTe4 i sl owT,R H andT SH levels
• Cardiomyopathy increaasnedt, h ee levaTtReHd suppresdsoepsa mine,
• Diastodlyiscfu nction whicihn creaPsReLs;t hust,h ep atiemnatyb em istak­
• Hypertension enlyd iagnosweidt ha prolactinTormeaa.t mewnitt h
thyroxrienpel acemceanutst ehse t hyrotrtoops hhsr ink,
• Leftv entrichuylpaerr trophy
andP RLl evetlons o rmalize.
• Increased strokes
Metastactaincc ecra nb e seeni nt hep ituitary-the
Associadtiesde asiensc luodbes trucstlieveeap p nea,
posterpiaorrot f t heg lanids m osto fteni nvolved.
insurleisni staannddc iea beatnedsc ,o lopno lytphsa hta ve
Posteripoirt uitamreyt s presenats diabetes
ani ncrearsiesodkf m alignancy.
© 2014M edStudy-PieRaespe ort CopyIrnifgrhitn gemteonc tosp [email protected]
DIABETEISN SIPIDUS 7-5
On stimulation witthh ec ocrotsiysnotlr oplienv,e l
incresaisntechseae d rerneamlasii nnt Tahcmeto .s dta n­
gerosuist uaitsai nao cnu ltief,e -thrheyaptoetneinnsgio n
fromc entorrsa elc onaddarreyin naslu fficcyi.e n
Howd oy out esftoa rc romegaly?
• Thes ymptmoamyso cciumrm edi(a"tmeulklyie ci kn
Whiccha ncmeertsa statost ihpzeie t uitary? thhee ado"rm) a yd eveolvoep1-r 2 d ayDsi.a bewtietsh
•
microvasculatruardei otchhaeanrncdago penysc,,u rrent
Whaitst hweo rkfuopar p ituiitnacriyd entaloma?
• warfaursaiern re i fsakc tPoartsi.me anytp sr esweintth
• Whaitst hcel inpirceasle ntoafpt iitouni tary ana cuotnes aentdc omplaoif"n tthwseo rhseta dache
apopleTxhyet? r eatment? ofm yl ifAep.o"p laenxSdyh eehsaynn drmoamyeb e
diffictuold ti stinfgruosimus bha rachhenmooirdr hage.
insi.pB irdeuaasnsldtu ncga ncmeerta srm eo scto mmon.P ituihtoarrmyo naersea bnorimnaa lp oplaenxdy
Lymphoamnald e ukecmaipnar esaespn rti mcaarnyc eSrh eeshyannd rome.
G
oft hpei tuitary.
DiagnwoisteCh T / MRJ( "high-dmeansissni t thye
sellaand"di) ff erefnrtoiamla etaek ainnegu rysm.
R
PITUITAIRNYC IDENTALOMA TreatmItfehnsety :m ptaormmesi lodn,lc yo rticosteroids
Somep ituittuamroyar rsie n cidefnotuanlwdlh ye n arnee cessEadreymm.aa yc ausae m asesff ecatn d
braiimna giinspg e rforfmooertd h reera s(otnesr merde quire deemceorgmV epnrteC sosnisoaun nl.et u rosur­
an" incidentaloma"). geotnom akteh cea olnlw hetthoeu rsc eo rticosteroids
ort aktehp ea titeosdn utr gery.
Formatlelvsyit s fuiaelol fpd ast iwehnoth sa vteu mors
thaitm pinognte h oep tniecr voera butth ceh iasmS.he ehasny ndrom(e 1110d,e0l0i0v iespr oisetsp)a rtum
e
Worku pt hep atifeonhrty pearn-dh ypo-secrheytpioopni tuciatuasrbeiydis smc henmeiccr odsuiets o
ofh ormones: blooldo sasn dh ypovolsehmoicdcku rianngda fter
t
childIbtia rltwha.y s itnhvaeon ltveersi ora npdi tuitary
MeasuPrReLb ecapursoel actairnceoo mmamso n. i
•
somnetiamlesasoff ectthpseo stepriitou,rib turatar ryely
ChecIkG Ft-o1s crefeoanrc romegaly.
• causes dcieanbtierntaselis p idus.
Ordeeirt ah2 e4r- huoruirfrn eece o rtoirasl oolw ­
• U
dosoev ernidgehxta methsauspopnreet sesisiyftoo nu Inm ilcda setshs,ey ndrpormees ewnittpsho stpartum
suspecte cxocre(tseis.Hs gTo.Nl,h, y perglycemaimae,n orarnhdfe aai ltuolr aec tSaetveec.ra es perse sent
assocpihaytsecidhc aarla cteAr riasntdAioCcmTs H) . witshy mptoomfas d reinnaslu ffici(ewnecayk ness,
levienslo rte commeanttdi emodefi nistcira-ele nilnegt.h aarngoyr,ea xnifdaa )i ltuolr aec tate.
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ChecLkH F,S Ha ntde stosterone. tioann,di nfiltprraotcievsseus ceahsss , a rcoiodro sis
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Gonadal ifunpn rcetmieonno wpoamuescnaa lbn e histioXc.y tosis
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assebsyshe ids taonrpdyh yseirxcaaamll one.
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Ift hteu moirsn onfunchdtoieonsno iatml p,i nongt eh e DIABETEISN SIPIDUS
optcihci aasnmtd,h eirnseo h yposecorfhe otrimoonn es,
thetnht eu mcoarbn e r eimaignae bdo 6um to ntahnsd Diabeitnessi p(iDdIcu)as bn e n eugreon(idce creased
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ora cquiTrheead c.q uinreeudr ogfeonriimcsc aused
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ord iscoovfae crryo meogrCa ulsyh diinsge ase.
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recepotrio nar n a quaporin [aarqdeui aspcourssiends
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ApopleaxnydS heehaSny ndrome
imporctaaunostfeD le,s pecliiatlh.lAi ynu ycm auosfe
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byh emorrihnaatgp oei tumiatsaSsru.ys paepcotp lienx y
canc ause acqAulisrkoen do twDh IaS.tj ograennd' s
thpea tiwehnot prewsietanhv t asr ioanbsloeefst e vere
sickle ceclaclna udDsiIes. e ase
headaNcNh,em, e ningivsemrutsvi,ig sou,da elf ects,
Understthaanetdx presosfiD oIn,w hethceern tral
andf luctcuoantsicnigo Tuhsensseeysm sp.t moamysb e
(neurogoernn eipch)r ogiesvn airci,aw biltsehu bsets
superimopnco hsreodsn yimcp toofhm osr moenxec eosrs
deficiifte hnecirysae nu nderlaydienngoL maab.o ratoofrd yi sebaesienn agm e"dp arcteinatlra anld"" p artial
nephrogDeInK.in coh"wo wt od istincgeunitfrsroham l
valusehso uslhdod we creAaCsTeHad n cdo rtliesvoell s.
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