pituitary

04/14/2015

Pituitary gland General

Surrounded by sphenoid bone
Sella turcicia
Hypothalamus and optic chiasm
Adenohypophysis (80%)
Neurohypophysis
a. ADH
b. Oxytocin
Hypothalamic pituitary axis
Galactorrhea case
32 yr old woman with milk like discharge.
What is next appropriate test
o TSH in hypothyroidism there is an increase in thyrotropinreleasng hormone increases prolactin levels
o Medication/drug history
o Grenancy test
o Prolactin levels
Pituitary: hyperprolactenemia
a. Excess prolactin
b. Most are micro-adenoma
c. Women: amenorrhea, galactorrhea most common microadenoma <1cm

d.
e.
f.
g.

Men: hypogonadism most common presentation erectile dysfunction

Bi-temporal hemianopia
Most common functioning adenomas
Etiology
a. Nursing, stress, stimulation
b. Drugs (haloperidol, reserpine, H2 blockers)
c. Hypothyroidism
G. work up
Exclude drugs and hypothyroidism
Exclude pregnancy
Check prolactin levels > 100 ng/mL probably pituitary adenoma
(level correlates to size like 200 ng/mL= 2 cm
o Basal, fasting morning PRL level >100 to 200 mg/L normal <
20 mg/L in a non-pregnant woman indicates a need for MRI
for pituitary
MRI
I. Treatment
Dopamine agonist: cabergoline, bromocriptine
Surgery
XRT
Pituitary: acromegaly
Excessive GH
Gigantism Vs acromegaly

Macro adenomas 75%--> can see bitemporal hemi

Clinically:
Enlargement: hands, feet, tongue, mandible
CHF
Carpal tunnel syndrome (bilateral)
o Bilateral carpal tunnel syndrome is seen in
Acromegaly
Hypothyroidism

Diabetes
Hemianopia (common)
Chronic disease: 9-10 yrs before diagnosis is considered
Diagnosis
IGF/somatomedins- made in the liver
Glucose load
o Give 100 g of glucose and normally GH goes down. In
acromegaly it remains high. GH >5ng/mL
MRI of pituitary
Treatment
Octreotide- somatostatin analog ( also seen in bleeding varices)
Dopamine agonist
Pegvisomant is a GH analogue that antagonizes endogeneic GH

Surgery (commonly used) highly efficacy

XRT

Hypopituitarism
Lesions in the pituitary-hypothalamic region
Craniopharyngiomas in children
TB, sarcoidosis
GH, gonadotropins(LH, FSH): lost early
ACTH: lost last
Diagnosis
Decreased GH levels after hypoglycemia or arginine
o After injection of 0.1u/kg of regular insulin, blood glucose
declines to <40mg/dL; in normal conditions that will stimulate
GH levels to >10 mg/L
Pituitary apoplexy
Prior adenoma
Headache
Altered mental status
Confusion
Mengismus (mengitits or subarchanoid hemorrhage)
Sheehans syndrome
Postpartum necrosis
Inability to lactate

Posterior pituitary: diabetes insipidus

Central vs Nephrogenic
Polyuria, polydipsia
Excessive, dilute urine
Low urine osmolality
Hypernatremia
Increased serum osmolality
Causes
Central DI
o Neoplastic or infiltrative lesions
o Sarcoid
o Surgery
o Radiotherapy
o Head injuries
Nephrogenic DI
o Hypercalcemia
o Sickle cell disease
o Drugs (lithium, demeclocycline, colchicine)
Treatment
Central DI
o Desmopressin in SQ

o Vasopressin SQ
Nephrogenic DI
o Diuretics: HCTZ, amiloride, Chlorthalidone
o NSAIDS

SIADH
Pearl: consider SIADH in all cases of euvolemic (no edema) hyponatremia
Hyponatremia<130
Plasma osm <270
Small amts. Conc. Urine
Urine sodium >20 mEq/L
Inappropriate natriuresis
Low BUN
Low uric acid
Normal thyroid, adrenal function
General
Free water retention
ECF volume expansion
Hyponatremia
NO edema or hypertension

Hyper
Situational syncope
should be considered in differential diagnosis fo syncopal episode.
The typical scenario would include a middle age or older male who
loses his consciousness immediately after unination ro a moan who
loses his consciousness during coughing fits

mamangement ofhyperkalemia
o IV bicarb
Alkalosis causes K to shift into the intracellular space
IV insulin
Activates the na/+/ K atpase
Add dextrose to prevent hypoglycemia
o Sodium polystyrene sulfate
Inhibits intestinal absorption of K+
o Hemodialysis

Atrial fibrillation tx
1. Rate control goals
60-80 at rest
90-110 at moderate exercise
2. Meds
A. Rate control
a. Diltiazem
b. Beta blocker
c. Verapamil
d. Digoxin
B. Rhythm control
d. amiodarone
e. dofetilidide
f. flecainide
g. ibutilide
h. propafenone

C. maintaining sinus rhythm

Flecaindie
Propafenone
Sotalol
Dofetilide
Amiodarone
D. Anticoagulation INR 2-3
Anticoagulation in cardioversion: electrical or pharm
Determine duration fo A-fib> 48 hrs
1. TEE to rule out existing clot for immediate cardioversion
or
2. administer Coumadin for 3 weeks prior to performing cardioversion
both option are followed by 6 weeks of Coumadin
CHAD2 Score rate control AV node and then decide if you need
anticoagulation
anticoagulation used in a non-valvular atrial fib ? NO
determine pharmacological intervention by using CHAD 2 score
1. point CHF, HTN, Age > 75 or DM
2 points stroke or TIA
CHAD 2 score 0= lone a fib A
Score
0
1
2

Treatment
Give asa
Asa or coumadin
Coumadin (warfarin)

Anticoagulation
1. Coumadin INR 2-3 FFP and vita k
2. dabigatran oral direct thrombin inhibitor
3. Rivaroxaban Factor xa inhibitor
4. apixaban oral factor x a inhibitor
A fib with CHF management
Antirrhmig sysotic hf with low ef
Rhythm control amiodarone or dofetilide
Rate control digoxin first then amiodarone
NEVER use verapamil
Use beta blocker and CCB cautiously CHF

wolff Parkinson white syndrome

A fib with wolff Parkinson white

DO NOT slow AV node conducation
CONTRAINDICATION for
- ca+2 blockers
-beta blockers
- digoxin
may induce ventricular tachycardia
use
procainamide, ibutilide flecanide or amiodarone