Pathophysiology

Hypopituitarism
– hypofunction of the pituitary gland
– can result from disease of the pituitary
itself or disease of the hypothalamus
– can result from radiation therapy to the
head and neck area.
Total destruction of the pituitary gland results in:
• Extreme weight loss
• Emaciation
• Atrophy of all endocrine glands and organs
• Hair loss
• Impotence
• Amenorrhea
• Hypometabolism
• Hypoglycemia
• Coma and death – occur if missing hormones are
not replaced.
Anterior Pituitary

Cushing’s Syndrome – over secretion of the anterior

pituitary gland most commonly involves ACTH.

Acromegaly – an excess of GH in adults, results in

bone and soft tissue deformities and enlargement
of the viscera without an increase in height.

Dwarfism – generalized limited growth due to

insufficient secretion of GH during childhood.
Panhypopituitarism – undersecretion commonly
involves all of the anterior pituitary hormones.

Sheehan’s Syndrome – postpartum pituitary necrosis,

another uncommon cause of failure of the anterior
pituitary.

Posterior Pituitary

Diabetes Insipidus - a condition in which abnormally

large volumes of dilute urine are excreted as a
result of deficient production of vasopressin.
 Specific Disorders of the Pituitary Gland

PITUITARY TUMORS

Pituitary tumors are usually benign and may be

primary or secondary (Porth & Matfin, 2009).
Functionality is also important. Functional tumors secrete
pituitary hormones, whereas nonfunctional tumors do
not. The location and effects of these tumors on hormone
production by target organs can have life-threatening
effects. Three principal types of pituitary tumors
represent an overgrowth of (1) eosinophilic cells, (2)
basophilic cells, or (3) chromophobic cells (ie, cells with
no affinity for either eosinophilic or basophilic stains).
Clinical Manifestations

Eosinophilic tumors that develop early in life

result in gigantism. The affected person may be more
than 7 feet tall and large in all proportions, yet so
weak and lethargic thathe or she can hardly stand. If
the disorder begins during adult life, the excessive
skeletal growth occurs only in the feet, the hands, the
superciliary ridge, the molar eminences, the nose,
and the chin, giving rise to the clinical picture called
acromegaly.
 Basophilic tumors give rise to Cushing’s syndrome
with features largely attributable to hyperadrenalism,
including masculinization and amenorrhea in females,
truncal obesity, hypertension, osteoporosis, and
polycythemia.

Chromophobic tumors represent 90% of pituitary

tumors. These tumors usually produce no hormones
but destroy the rest of the pituitary gland, causing
hypopituitarism. People with this disease are often
obese and somnolent and exhibit fine, scanty hair;
dry, soft skin; a pasty complexion; and small bones.
Assessment and Diagnostic Findings

Diagnostic evaluation requires a careful history

and physical examination, including assessment of
visual acuity and visual fields. CT and MRI are used to
diagnose the presence and extent of pituitary tumors.
Serum levels of pituitary hormones may be obtained
along with measurements of hormones of target
organs (eg, thyroid, adrenal) to assist in diagnosis.
Medical Management

Surgical removal of the pituitary tumor

(hypophysectomy) through a transsphenoidal
approach is the usual treatment. Stereotactic
radiation therapy, which requires use of a
neurosurgery-type stereotactic frame, may be used to
deliver external beam radiation therapy precisely to
the pituitary tumor with minimal effect on normal
tissue
Surgical Management

Hypophysectomy is the treatment of choice in

patients with Cushing’s syndrome resulting from
excessive production of ACTH by a pituitary tumor.
Hypophysectomy may also be performed on occasion
as a palliative measure to relieve bone pain secondary
to metastasis of malignant lesions of the breast and
prostate.
DIABETES INSIPIDUS

Diabetes insipidus (DI) is a disorder of the posterior

lobe of the pituitary gland that is characterized by a
deficiency of ADH (vasopressin). Excessive thirst
(polydipsia) and large volumes of dilute urine
characterize the disorder. It may occur secondary to
head trauma, brain tumor, or surgical ablation or
irradiation of the pituitary gland. It may also occur
with infections of the central nervous system
(meningitis, encephalitis, tuberculosis) or with tumors
(eg, metastatic disease, lymphoma of the breast or
lung).
Clinical Manifestations

Without the action of ADH on the distal nephron

of the kidney, an enormous daily output of very
dilute, waterlike urine with a specific gravity of 1.001
to 1.005 occurs. The urine contains no abnormal
substances such as glucose or albumin. Because of
the intense thirst, the patient tends to drink 2 to 20 L
of fluid daily and craves cold water. In the hereditary
form of DI, the primary symptoms may begin at birth.
In adults, the onset of DI may be insidious or abrupt.
Assessment and Diagnostic Findings

The fluid deprivation test is carried out by

withholding flu-ids for 8 to 12 hours or until 3% to 5%
of the body weight is lost. The patient is weighed
frequently during the test. Plasma and urine
osmolality studies are performed at the beginning and
end of the test. The inability to increase the specific
gravity and osmolality of the urine is characteristic of
DI.
Medical Management

The objectives of therapy are (1) to replace ADH

(which is usually a long-term therapeutic program),
(2) to ensure adequate fluid replacement, and (3) to
identify and correct the underlying intracranial
pathology. Nephrogenic causes require different
management approaches.
Pharmacologic Therapy

Desmopressin (DDAVP), a synthetic vasopressin

without the vascular effects of natural ADH, is
particularly valuable because it has a longer duration
of action and fewer adverse effects than other
preparations previously used to treat the disease. It is
administered intranasally; the patient sprays the
solution into the nose through a flexible calibrated
plastic tube. One or two administrations daily (ie,
every 12 to 24 hours) usually control the symptoms
(Tierney, McPhee & Papadakis, 2005). Vasopressin
causes vasoconstriction; thus, it must be used
cautiously in patients with coronary artery disease.
Nursing Management

The nurse must teach the patient and family about

followup care and emergency measures and provide
specific verbal and written instructions, including the
actions and side effects of all medications. In addition
to demonstrating correct medication administration,
the nurse should observe return demonstrations.