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Pituitary Pathologies Simplified
1. “Simple can be
harder than
complex:
You have to work hard to
get your thinking clean to
make it simple. But it’s
worth it in the end
because once you get
there, you can move
mountains.”
- Steve Jobs
Friday, March 21, 14
2. Iris Thiele Isip Tan MD, MSc
Assoc. Prof. 4, UP College of Medicine
Chief, Medical Informatics Unit
GPs as
Pituitary
Stalkers
Pituitary
Pathologies
Simplified
David and Goliath by Robert Temple Ayres
Friday, March 21, 14
4. to be a
PituitaryStalker
How
“The world is full of obvious
things which nobody by any
chance ever observes.”
- Sherlock Holmes
optical_illusion_tshirt by Kevin
https://flic.kr/p/a573df
Have a
questioning
mind!
Ask
Friday, March 21, 14
7. David and Goliath
Painting by Giovan Francesco Nagli
Height “6 cubits and a
span” (2.5-3 meters)
Slow-moving and
ponderous
Goliath saw “sticks”
Stone sunk into forehead
Goliath fell forward
Did
Goliath
acromegaly
have
Friday, March 21, 14
11. Menses stopped
6 mos ago
followed by the
headaches
Gynecologist?
No
galactorrhea
Endocrinologist?
headache by beermug
http://www.sxc.hu/photo/1413980
Friday, March 21, 14
12. Who makes the initial
diagnosis of a pituitary lesion?
Diagnostic
Source
Total percentage (n=404)Total percentage (n=404)Total percentage (n=404)Diagnostic
Source Prolactinoma Non-functioning Acromegaly
Internist/Family Med 16 23 39
Endocrinologist 34 14 25
Gynecologist 34 10 <1
Ophthalmologist/
Optometrist
6 25 6
Relatives/ self 2 1 6
Neurologist 0 3 5
Dentist 0 0 5
Other 8 24 14
Drange et al JCEM 85:168–174, 2000
Friday, March 21, 14
13. Pituitary adenomas
come to clinical attention
mass
effects
hormone
excess
hormone
insufficiency
Friday, March 21, 14
15. Key Elements of the Clinical
Diagnostic Reasoning Process Bowen J. NEJM
2006;355:2217-2225
Patient’s story
Data acquisition
Accurate “problem representation”
Generation of hypothesis
Search for and selection of illness script
Diagnosis
Knowledge
Context
Experience
Friday, March 21, 14
16. Expert clinicians store and
recall knowledge as
diseases, conditions, or
syndromes - “illness
scripts” - that are
connected to problem
representations.
These representations trigger
clinical memory, permitting the
related knowledge to become
accessible for reasoning.
A room lamp without lampshade by Mattox
http://www.sxc.hu/photo/1120345
Bowen J. NEJM 2006;355:2217-2225
Friday, March 21, 14
17. Illness Script - Structure Bowen J. NEJM 2006;355:2217-2225
Predisposing
conditions
Pathophysiological
insult
Clinical
consequences
Rare
17% of population
Equal sex incidence
Incidence increases with age
Tumor growth
Compression of optic nerve
Extension to cavernous or sphenoid sinus
Compression of normal pituitary
Non-functioning
pituitary adenoma
Friday, March 21, 14
18. By OpenStax College [CC-BY-3.0
(http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons
andThe Pituitary
Optic Chiasm
Friday, March 21, 14
22. Illness Script - Structure Bowen J. NEJM 2006;355:2217-2225
Predisposing
conditions
Pathophysiological
insult
Clinical
consequences
Most common pituitary tumor
F:M ratio 10:1
Neoplastic transformation of anterior
pituitary lactrotrophs resulting in excess
synthesis and secretion of prolactin
Prolactinoma
Oligo- or amenorrhea
Galactorrhea
Erectile dysfunction or decreased libido
Hypopituitarism (compression from large tumor)
Friday, March 21, 14
24. Patient presenting with secondary amenorrhea;
negative pregnancy test
Check TSH and prolactin levels
Both
normal
Normal TSH
Abnormal prolactin
Progestogen challenge test
No withdrawal bleed
Estrogen/progestogen
challenge test
Withdrawal bleed
Normogonadotropic
hypogonadism
No withdrawal bleed
Outflow obstruction
Withdrawal bleed
Check FSH and LH
FSH >20 IU/L
LH >40 IU/L
Hypergonadotropic
hypogonadism
FSH & LH <5 IU/L
Perform MRI to evaluate
for pituitary tumor
Normal MRI:
hypogonadotropic hypogonadism
Normal prolactin
Abnormal TSH
Thyroid disease
Prolactin <100 ng/mL
(100 mcg/L)
Consider
other causes
Prolactin >100 ng/mL
Perform MRI to evaluate
for prolactinoma
Negative MRI
Friday, March 21, 14
25. What happens when
you can’t match an
illness script?
59/F with dizziness,
vomiting and
weakness ...
Rounadabout by ColinBroug
http://www.sxc.hu/photo/1265027
Friday, March 21, 14
26. Third time admitted
for vomiting, dizziness
and general weakness
Previous admissions
also with hypoglycemia
and pneumonia or UTI
Normal endoscopy
end to end ...
What to do?!
Photo by Ashley Webb
https://flic.kr/p/5u36oV
Friday, March 21, 14
27. Adrenal
insufficiency?!
31 years ago
Postpartum bleeding
needing BT
Delivered twins at home
Retained placenta
Screaming by ralaenin
http://www.sxc.hu/photo/579286
Friday, March 21, 14
28. Illness Script - Structure Bowen J. NEJM 2006;355:2217-2225
Predisposing
conditions
Pathophysiological
insult
Clinical
consequences
5.1 per 100,000 women
Severe postpartum vaginal bleeding
Severe hypotension or shock requiring fluid
replacement or blood transfusion
Sheehan’s
syndrome
Friday, March 21, 14
30. Illness Script - Structure Bowen J. NEJM 2006;355:2217-2225
Predisposing
conditions
Pathophysiological
insult
Clinical
consequences
5.1 per 100,000 women (Iceland)
Severe postpartum vaginal bleeding
Severe hypotension or shock requiring fluid
replacement or blood transfusion
Pituitary enlargement
Lactotroph hyperplasia
Pituitary gland susceptible to ischemia
Postpartum pituitary necrosis
Failure of postpartum lactation
Failure to resume regular menses
Varying degrees of hypopituitarism
Empty sella on CT scan or MRI
Sheehan’s
syndrome
Friday, March 21, 14
31. Sheehan’s
Syndrome
Presentation
At ER following a
stressful event
Coma of hypothyroidism
Adrenal insufficiency
Hypoglycemia
Hyponatremia
http://www.sxc.hu/photo/65898Ozkan& Kolac, Neuroendocrinol Lett 2005;26(3):257-60
Friday, March 21, 14
32. GH deficiency
Reduced energy and vitality
Reduced muscle mass and
strength
Decreased sweating and impaired
thermogenesis
Increased central adiposity
Increased CV risk
Decreased BMD
Prabhakar & Shalet, Postgrad Med J 2006;82:259–66
Friday, March 21, 14
33. ACTH deficiency
Fatigue, weakness, anorexia,
weight loss
Nausea, vomiting, abdominal pain
Hypoglycemia
Circulatory collapse if acute onset
Loss of axillary and pubic hair in
women
Prabhakar & Shalet, Postgrad Med J 2006;82:259–66
Friday, March 21, 14
34. Gonadotrophin
deficiency
Men: erectile dysfunction, soft
testes, reduced muscle mass and
energy
Women: oligo/amenorrhea,
dyspareunia, breast atrophy
Both: loss of libido, flushes,
infertility, regression of sexual
characteristics, reduced BMD
Prabhakar & Shalet, Postgrad Med J 2006;82:259–66
Friday, March 21, 14
35. TSH deficiency
Fatigue, apathy, psychomotor
retardation
Cold intolerance, dry skin
Constipation
Weight gain
Prabhakar & Shalet, Postgrad Med J 2006;82:259–66
Friday, March 21, 14
36. 45/M
referred to
surgeon for
colon CA
Referred by
surgeon
to me for coarse
facial features
http://www.cinemainsomnia.com/lobo-
loves-rondo-does-rondo-love-lobo/
Friday, March 21, 14
37. Illness Script - Structure Bowen J. NEJM 2006;355:2217-2225
Predisposing
conditions
Pathophysiological
insult
Clinical
consequences
40-70 cases per million population
Mean age of onset 30 y
Onset to diagnosis 5-15 y
Mean age at diagnosis:
40 y in men and 45 y in women
GH excess
GH-secreting pituitary adenomas
Inc incidence of colonic polyps & colon adenoCA,
diabetes, hypertension and CVD
Soft tissue swelling & enlargement of extremities
Increase in ring and/or shoe size
Hyperhidrosis
Coarsening of facial features
Prognathism, macroglossia
Acromegaly
Friday, March 21, 14
38. Rondo Hatton
American Actor
Acromegaly attributed to exposure
to German mustard gas attack in World War I
http://i1139.photobucket.com/albums/n545/travislouie37/Rondoisgoodwiththeladies.jpg
Friday, March 21, 14
40. At rounds more than a decade ago with MALA ...
How much does a
human pituitary gland weigh?
Seagull in front of sea by cobrasoft
http://www.sxc.hu/photo/1437851
Friday, March 21, 14
41. “But what physician
has not had patients
who don’t make
any sense at all? To
tell the truth, they’re
our stock-in-trade.
We talk and write
about the ones we
can make sense of.”
- Walker Percy
Dr. House MD Caricature Hugh Laurie by Nelson Santos
https://flic.kr/p/46tXvx
Friday, March 21, 14