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CLASSICAL ALGORHYTHM
PITUITARY
ANTERIOR POSTERIOR
BETTER ALGORHYTHM
PITUITARY
ANTERIOR POSTERIOR
NON-NEOPLASTIC
HYPER-function HYPO-function
FEEDBACK SYSTEMS
CORTEX, SUBCORTEX? HYPOTHALAMUS ANTERIOR PITUITARY ENDOCRINE GLAND END ORGAN HYPOTHALAMUS
AntPitWiFi PostPitWired
HORMONES
POLYPEPTIDE (2nd MESSENGER) STEROID (DIRECT on NUCLEUS)
ACIDOPHILS
BASOPHILS CHROMOPHOBES
A
I
AXONS
ANTERIOR PITUITARY
ACIDOPHILS (growth)
GROWTH HORMONE PROLACTIN
BASOPHILS (trophs)
TSH ACTH LH, FSH
POSTERIOR PITUITARY
OXYTOCIN (contracts
uterine smooth muscle)
VASOPRESSIN (ADH)
(vasoconstriction, gluconeogenesis, platelet aggregation, release of Factor-VIII and vWb factor, concentrates urine, main effects on kidney and brain)
PITUITARY PATHOLOGY
CLINICAL FEATURES, mimic the endocrine effects, visual effects, or mass effects) FUNCTIONING ADENOMAS HYPO-PITUITARISM POSTERIOR PITUITARY SYNDROMES HYPOTHALAMIC (SUPRASELLAR) TUMORS
CLINICAL FEATURES
HYPER: growth(a), lactation(a), thyroid(b), adrenal cortex(b) HYPO: growth, thyroid, adrenal cortex MASS EFFECT: visual fields, brain
A
L A
C
T O R R
H
E A
GIGANTISM (excess
somatotropin [GH]
BEFORE
epiphyseal
closure)
BITEMPORAL HEMIANOPSIA
HYPO-pituitarism
Pituitary tumors, functional or not. NON-pituitary tumors, primary or metastatic Pituitary surgery, of course Radiation, of course Apoplexy, i.e., sudden hemorrhage Sheehans syndrome (Post-partum ischemic necrosis) Cysts (Rathkes cleft) Empty sella syndrome, (is NOT a disease) Genetic defects (pit-1 gene mutations)
POSTERIOR pituitary
DIABETES INSIPIDUS SIADH (Syndrome of Inappropriate AndiDiuretic Hormone)
DIABETES INSIPIDUS
ADH deficiency Head trauma, tumors, inflam. hypothal/pit Hyperdiureses with
LOW sp.gr.
Inappropriate ADH
ADH EXCESS (SIADH)
Hyponatremia (hypervolemia), cerebral edema, neurologic symptoms Neoplasms, esp. Small Cell CA. NON-neoplastic lung diseases Posterior pituitary injury
15-25 grams
HYPER-THYROIDISM
aka, thyrotoxicosis Diffuse (Graves disease) Nodular Adenoma Carcinoma Neonatal Secondary to TSH pituitary adenoma
HYPER-THYROIDISM
HYPERMETABOLISM Tachycardia, palpitations Increased T3, T4 Goiter Exophthalmos Tremor GI hypermotility Thyroid storm, life threatening
HYPO-THYROIDISM
1 Developmental 1 Surgery, I-131, external radiation 1 Auto-immune (i.e., Hashimotos) 1 Iodine deficiency 1 Li+, iodides, p-aminosalicylates 2 (pituitary) 3 (hypothalamic, rare)
HYPO-THYROIDISM
Cretinism
Severe retardation CNS/Musc-skel Short stature Protruding tongue Umbilical hernia Maternal iodine defic.
Myxedema (coma)
Sluggishness Cool skin, cholesterol
THYROIDITIS
Hashimoto (Auto-Immune) (Lymphoid
follicles with germinal centers), MOST COMMON cause of acquired hypothyroidism in USA Subacute Granulomatous (DeQuervain) Subacute Lymphocytic (just like Hashimotos but NO fibrosis and no germinal centers), often post-partum
GRAVES DISEASE
(aka, diffuse toxic goiter) HYPERTHYROIDISM EXOPHTHALMOS PRE-TIBIAL MYXEDEMA
Autoimmune, auto-antibodies to TSH receptors, thereby stimulating them
SCALLOPING
GRAVES DISEASE
(aka, diffuse toxic goiter)
PLUMMER DISEASE
(aka, nodular toxic goiter)
HARDER TO TREAT Surg PTU (Propyl Thio Uracil) I-131
GOITERS
(aka, thyromegaly, diffuse or nodular) IODINE deficiency Increased TSH Goitrogens, e.g., cabbage, Brussels sprouts, cauliflower, turnips, cassava) Associated with HYPO thyroidism eventually, NOT hyperthyroidism
G O I T E R
Thyroid Neoplasms
Nodules vs. true neoplasms Adenomas vs. Carcinomas
NODULES
Solitary vs. Multiple Younger vs. Older Male vs. Female Hx. neck radiation vs. NO Rx. Cold vs. HOT (really NOTcold)
NEOPLASMS
ADENOMAS CARCINOMAS
FOLLICULAR HRTHLE (oxyphilic)
FOLLICULAR PAPILLARY
MEDULLARY (AMYLOID) ANAPLASTIC (worst)
AMYLOID!!!
HYALINIZATION showing APPLE GREEN birefringence in CONGO RED stain, i.e., AMYLOID
BIOLOGIC BEHAVIOR
Papillary CA lymph nodes Follicular CA blood vessels, bone
35-50 mg
PTH
HYPOCALCEMIA is MAIN STIMULUS (9-10.5 mg/dl)
ANTAGONIZES CALCITONIN
PARATHYROID DISORDERS
HYPER PRIMARY (usually adenomas) SECONDARY (LOW CA++ of Renal Failure)
HYPER-PARATHYROIDISM
Bone pain, fractures Nephrolithiasis Constipation, ulcers, gallstones Depression, lethargy short QT interval and a widened T wave Weakness, fatigue
HYPO-PARATHYROIDISM
Neuromuscular irritability Mental status change Parkinsonism like effects Lens calcification* (paradox) Widened QT interval Defective, carious, teeth
ADRENAL CORTEX
Glomerulosa (Salt), mineralocorticoids
ALDOSTERONE
4 g.
SALT
SUGAR
SEX
STRESS
HYPERADRENALISM
HYPERALDOSTERONISM (g) CUSHING SYNDROME (CORTISOL) (f) (most common of the three) ADRENOGENITAL (VIRILIZING) SYNDROME (r)
CUSHING SYNDROME
CENTRAL OBESITY MOON FACIES WEAKNESS HIRSUTISM HYPERTENSION DIABETES OSTEOPOROSIS STRIAE
CUSHING SYNDROME
PITUITARY ACTH INCREASE TUMOR ACTH INCREASE HYPERPLASIA OF CORTEX ADENOMA OF CORTEX CARCINOMA OF CORTEX
PRIMARY HYPERALDOSTERONISM
CORTICAL NEOPLASM CORTICAL HYPERPLASIA FAMILIAL (rare)
SECONDARY HYPERALDOSTERONISM
DECREASED RENAL PERFUSION EDEMA (HEART, LIVER, KIDNEY)
PREGNANCY
ADRENOGENITAL SYNDROME
VIRILIZATION/feminization CORTICAL NEOPLASM CORTICAL HYPERPLASIA 21-Hydroxylase Deficiency, with buildup of 17-hydroxy progesterone
ADRENAL INSUFFICIENCY
PRIMARY ACUTE (ADRENAL CRISIS) PRIMARY CHRONIC (autoimmune ADDISON DISEASE) SECONDARY (PITUITARY)
PRIMARY ACUTE
RAPID WITHDRAWAL OF STEROIDS MASSIVE ADRENAL HEMORRHAGE (WATERHOUSE-FRIDERICHSEN, if it follows infection [meningo, staph, H. flu] and shock)
Newborns with DIFFICULT DELIVERY ANTICOAGULANT RX POSTSURGICAL DIC PATIENTS
PRIMARY CHRONIC
Most of Addison disease is auto-
GENETIC DISORDERS
NEOPLASMS
ADENOMAS of ADRENAL CORTEX
ADRENAL MEDULLA
PHEOCHROMOCYTOMAS, aka,
primary tumors of the adrenal medulla
10% arise in an MEN setting 10% are EXTRA-adrenal 10% are bilateral 10% are malignant 10% are in childhood You can only call them malignant if they metastasize, but this is no bad thing, because they are all removed anyway
PHEO
2. Benign adenomas may have extremely bizarre nuclei, but are most usually BENIGN!!!
chiefly hyperplasia
Pancreatic endocrine
tumors
MEN-2A (SIPPLE): Pheo, Medullary CA., Parathyroid hyperplasia MEN-2B: NO hyperparathyroidism, but neuromas present Familial Medullary Thyroid CA
MEN-2
PINEAL GLAND
PINEALOMAS
PINEOBLASTOMAS PINEOCYTOMAS
ENDOCRINE PANCREAS
DIABETES MELLITUS
16 Million in the USA 1 Million/yr 50K people die of it per year in the USA
TWO* Types of DM
2
Genetic, but diff. from Type 1 NOT autoimmune Adult, or maturity onset, e.g., 40s, 50s Insulin may be low, BUT, peripheral resistance to insulin is the main factor OBESE patients
Genetic Autoimmune Childhood (juvenile) onset Antibodies to beta cells, insulitis Beta cell depletion NON-OBESE patients
Dm
POLYPOLYPOLY-
FAT
INSULIN
MUSCLE
IN-creased glucose uptake IN-creased glycogen synthesis IN-creased protein synthesis
LIVER
DE-creased gluconeogenesis IN-creased glycogen synthesis IN-creased lipogenesis
PATHOGENESIS
1 2
Diet Life Style Obesity INSULIN RESISTANCE Beta cells UN-able to adapt to the long term demands of insulin resistance T-Lymphocytes reacting against poorly defined beta cell
PANCREAS in Dm
PANCREAS in Dm
COMPLICATIONS
MACRO-VASCULAR disease, i.e.,
ASCVD
COMPLICATIONS
ADVANCED GLYCATION
collagen, laminin, polypeptides, GBM (glomerular basement membrane), Hgb1c
ACTIVATION of PROTEIN KINASE C, VEGF, endothelin-1, increased ECM, decreased fibrinolysis, inflam. cytokines INTRACELLULAR HYPERGLYCEMIA
COMPLICATIONS MORPHOLOGY
Infections
ATHEROSCLEROSIS
ATHEROSCLEROSIS
RETINOPATHY in Dm
Shows microaneurysms, areas of hemorrhage, cotton wool spots, hard exudates, venous beading, neovascularization, retinal detachment, vitreous detachment, pre retinal hemorrhage
NEPHROPATHY
KimmelstielWilson (KW)
Kidneys IS
Nodular
glomerulosclerosis
NEPHROPATHY
NEPHROSCLEROSIS
NEPHROPATHY
GBM thickening
NEPHROPATHY
Diffuse Mesangial Sclerosis
INFECTIONS in Dm
SKIN TUBERCULOSIS PNEUMONIA PYELONEPHRITIS CANDIDA