Endocrinology

Edward Buckingham, M.D. Francis Quinn, M.D. F.A.C.S.

Pituitary - Embryology and Anatomy

posterior pituitary- neurohypophysis
outpouching floor 3rd ventricle nervous connection to hypothalamus octapeptides-oxytocin, vasopressin (ADH)

anterior pituitary-adenohypophysis
Rathkes pouch no direct nerve supply chemical hypophyseal-portal system ACTH, TSH, GH, PRL, FSH, LH

Pituitary - Embryology and Anatomy

Pituitary - Sella tercica, sphenoid bone

Pituitary - Relation to sphenoid sinus

Pituitary - Soft tissue boundaries

Pituitary - Vasculature

Pituitary - Embryology and Anatomy

Pituitary - Embryology and Anatomy

Pituitary - antidiuretic hormone (ADH) (vasopressin)

CNS osmoreceptors supraoptic, periventricular nuclei hypothalamus
plasma osmolality changes

baroreceptors, aortic arch, carotid sinus, left atrium

CN IX, X

renal action
ADH increases H2O permiability of DCT and CD

Pituitary - ACTH
proopiomelanocortin precursor melanotropins, lipotropins and B-endorphin circadian rhythm peaks am, stimulus, CRF- stress, hypoglycemia, CRF-feed back from glucocorticoids in circulation action- adrenal cortex secrete glucocorticoids, lesser aldosterone

Pituitary - TSH
glycoprotein hormone, thrytopic cells, level constant stimulus, TRH feedback free T3 c-AMP mediated action-early increased formation of colloid, uptake of iodine, formation of TH action-late increased volume and number of cells

Pituitary - GH
via somatomedins promotes longitudinal growth anabolic protein metabolism, lipolytic, stimulates insulin release, decreases peripheral tissue utilization of glucose

Pituitary - Prolactin
acts on prepared mammary tissue to initiate and maintain lactation

Pituitary - FSH, LH
Kallmanns syndromemaldevelopement olfactory lobes, related hypothalamic lesions, hyposmia, anosmia, isolated Gn-RH deficiency

Pituitary - Diabetes Insipidus

partial or complete absence of vasopressin tumor, inflammation, granuloma, trauma, vascular

Pituitary - Diabetes Insipidus

clinical features
polyuria- 3-15 L/day 4-5 L common, SG < 1.005, urine osmolality <200 mOsm/kg, plasma osmolality > 287 mOsm/kg polydipsia- compensatory mechanism, hypothalamic thirst center destruction disastrous associated features- visual field loss, optic atrophy, papilledema, other pituitary hormone abnormalities

Pituitary - Diabetes Insipidus

treatment
acute- liberal fluid replacement, shortacting aqueous vasopressin chronic- dDAVP intranasally BID

Pituitary - SIADH
continued secretion of antidiuretic hormone despite hypotonicity secreted by pituitary or ectopic source

Pituitary - SIADH
clinical features
fatigue, muscle weakness, dizziness, behavioral changes, drowsiness, Na < 120 stupor, convulsions, coma urine osmolality not maximally dilute despite hypotonicity

Pituitary - SIADH
diagnostic criteria
hyptonicity of plasma hyponatremia less than max dilute urine naturesis exclusion of other causes

treatment
water restriction 600800 ml/day demeclocycline 9001200 mg/day- blocks vasopressin at DCT hypertonic saline if sodium < 115 mEq/L

Pituitary - Tumor classes

Class 1 - microadenomas < 10mm diameter Class 2 - macroadenomas >10 mm diameter Class 3 - part of sellar floor involved Class 4 - all of the floor destroyed

Parathyroid- Embryology and Anatomy

third and fourth branchial pouches
third migrates with thymus aberrant in 15% to 20% ICA to AP window ant or post to arch usually 4 glands may be 6 or more

Parathyroid- Ectopic glands

Parathyroid- Blood supply

inferior/superior parathyroid arteries

branches of inferior thyroid artery occas. superior from sup. thyroid artery

Parathyroid- Calcium metabolism

actions of PTH
increases serum calcium level increases urine phosphate increases bone osteoclast and osteoblast activity increases bicarbonate excretion by kidney increase GI calcium and phosphate absorption through Vit D increases conversion of 25-OH Vit D to 1,25 di-OHVit D

Parathyroid- Calcium metabolism

calcitonin
parafollicular cells response to increased Ca inhibit bone resorption, increase phos excretion by kidney

vitamin D
absorbed through skin or GI tract liver 25 OH kidney 1,25 OH most active form increases calcium and phosphate absorption and retention

Parathyroid - Hypercalcemia

Parathyroid - Assoc. conditions

Parathyroid- Hypercalcemia

Parathyroid - laboratory evaluation

Parathyroid - definitions
primary hyperparathyroidism
single adenoma 85%, 12% hyperplastic glands, 3% multiple adenomas

secondary hyperparathyroidism
hyperplastic glands malfunction of another organ system usually renal failure

Parathyroid - definitions
tertiary hyperparathyroidism
similar to secondary PTH production now autonomous renal transplant

Parathyroid hyperparathyroidism
Laboratory values
low serum phosphorus (<2.5 mg/dL) hyperchloremia (>107 mEq/L) alkaline phosphatase elevated in 10%
indicates osteitis fibrosis cystica

subperiosteal bone resorption

Hyperparathyroidism - surgery
asymptomatic hyperparathyroidism
Kaplan
compared metabolic benefits 6 pt asymptomatic with 7 symptomatic before and after surgery concluded asymptomatic received same benefits

Hyperparathyroidism - surgery
Other pros
postmenapausal women Cogan psychologic function and EEG improved avoid hypercalcemia if sick or dehydrated cost effective

surgery indicated
hypertension, mildly reduced creatinine clearance, increased urine calcium, decreased bone density, clinical symptoms

Thyroid - Embryology and Anatomy

embryology
pharyngeal floor, foramen cecum decent with parathyroids lateral to TE groove assoc. with RLN

Thyroid - Embryology and Anatomy

vasculature
arterial
sup. thryroid artery ECA inf. thyroid artery TCT

venous
superior and middleIJV inferior BCV

lymphatics
pretracheal, paratracheal

Thyroid - Physiology
hormonogenesis
trapping - iodine oxidized organification - tyrosyl incorporation MIT, DIT, T3, T4 secretion 95.5% bound. 0.5% free biologically active TBG primarily, prealbumin, albumin T4 > T3 liver and kidney

Thyroid - Physiology
hormonogenesis
inhibited by
renal, hepatic disease acute or chronic illness drugs- propylthiouracil, glucocorticoids, propranolol, iopanoic acid

reverse T3

regulation
feedback of free T3 on TRH and TSH

action
metabolic rate, thermogenesis

Thyroid - TFTs
T4 radioimmunoassay
measures bound and unbound hormone

T3RU
determines TBG capacity radiolabeled T3 given bound to TBG open sites resin given 25-35% normally binds to resin increased TBG decreased T3RU

Thyroid - TFTs
FTI
product of T3RU and T4 good initial determination of hyper or hypo thyroidism

T3 radioimmunoassay
reflects peripheral metabolism not thyroid function T3 thyrotoxicosis

Thyroid - TFTs
TSH
hypothyroidism replacement therapy euthyroid goiters

Thyroid imaging
thyroid scans
radioactive isotopes of iodine one month to clear contrast agents indications
hot and cold nodules metastatic thyroid cancer ectopic tissue Hashimotos

Thyroid imaging
ultrasonography
solid vs. cystic FNA suppression

Thyroid - Hyperthyoidism

Thyroid - Hypofunction

Adrenal Gland
cortex
zona glomerulosa
mineralocorticoids- aldosterone

zona fasciculata
glucocorticoids- cortisol

zona reticularis
androgens- estrogen, progesterone, testosterone

medulla
norepinephrine, epinephrine

Adrenal Gland - Physiology

zona glomerulosa
renin JG cell
respond to Na, and volume

angiotensinogen > angiotensin I angiotnsin I > angiotensin II by ACE angiotensin II potent pressor > aldosterone hyperkalemia promotes independently hypokalemia inhibits ACTH

Adrenal Gland - Physiology

zona fasciculata
ACTH as discussed cortisol actions

zona reticularis
ACTH controls no feedback adrenarche

Hyperadrenocorticism
cushings sydndrome 3rd - 6th decade, 4 to1 females causes
pharmocologic pituitary adenoma 75-90% adrenal adenoma, carcinoma ectopic ACTH

treatment based on cause

Adrenocortical insufficiency
primary causes, ie. Addisons disease
autoimmune disease, tumors, infection, hemorrhage, metabolic failure,

secondary causes
hypopituitarism, suppression exogenous steroids

Adrenocortical insufficiency
symptoms, signs
fatigability, weakness, anorexia, nausea, weight loss, hyperpigmentation, hypotension, women loss of axillary and pubic hair can lead to severe volume depletion and shock

treatment
glucocorticoid replacement, mineralocorticoid replacement

Overproduction of aldosterone
primary causes, ie. Conns syndrome
adenoma, nodular hyperplasia zona glomerulosa

secondary
cirrhosis, ascites, nephrotic syndrome, diuretic use

symptoms, signs
headache, hypokalemia causing muscle weakness, nocturnal polyuria, hand cramping

Overproduction of aldosterone
treatment
surgical for adenoma medical for hyperplasia with sprionolactone

Pancreas
alpha cells- glucagon beta cells- insulin
stimulus
glucose, amino acids, glucagon, GI hormones, vagal nerve

inhibition
B-adrenergic blockers, sympathomimetics, somatostatin

Diabetes

Surgical care
120-250 mg/dL 1-2 hr checks 3 g/kg/day prevent catabolism and lipolysis
5% dextrose at 100 ml/hr

Ketoacidosis
ketone bodies metabolic acidosis-lipolysis IV insulin 12-20 u bolus .05 to 0.1 u/kg/hr IVF - 0.9 NS glucose approx. 200 add dextrose potassium electrolytes as needed monitor anion gap for endpoint

Hyperosmotic nonketotic coma

similar to above disagreement isotonic/hypotonic saline severe dehydration watch electrolytes closely

Case Presentation
45 year old with craniopharyngeoma now 24 hrs post-op from a transphenoidal approach to tumor excision Nurse notifies you patient urinated 3L over the last 8 hrs and 5L over the last 16 hrs

Case Presentation
PE
The patient is slightly somnolent, but arousable, oriented to person and place, but not to time or situation, this is new over last 4-5 hrs No polydipsia Neuro-exam is otherwise normal

Labs
CBC, Chem 7, plasma osmolality pending, urinalysis SG - 1.003, urine osmolality 185 mOsm/kg.

Case Presentation
CT Head
post-operative changes, otherwise normal

Labs
WBC 10.5, HGB 14.5, HCT 45.2, Plt 567K, Na-162, K-5.4, Cl-110, CO2-18, BUN-45, Cr.76, Glucose 120 Osmolality - 300 mOsm/kg

Case Presentation
Diagnosis
Diabetes insipidus with injury to hypothalamic thirst center

Therapy
Fluid boluses with isotonic saline aquous vasopressin