Pituitary Parathyroid Adrenals (1) (1)

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Endocrine System–
Pituitary, Parathyroid and Adrenal
Conditions

PGNC5

Aim

• Overview

• Pituitary gland

• Parathyroid glands

• Adrenal glands

Recap…

• The pituitary is known as…

• Disorders are associated with hyposecretion or hypersecretion depending on the impact on the pituitary gland.

• Hypersecretion-can affect the adrenal glands (Cushing’s syndrome) or cause syndrome of inappropriate anti-diuretic hormone (SIADH) or acromegaly.

• Hyposecretion (due to damage) can affect the adrenal glands (Addison disease, diabetes insipidus (DI) or dwarfism).

Pituitary Gland Hormones

• Anterior 

• TSH

• PRL

• FSH

• LH

• ACTH (adrenocortropic hormone) 

• GH

• Posterior

• ADH

• Oxytocin

Hypersecretion of the Anterior Pituitary Hormones

Gigantism / Acromegaly

Cause: prolonged hypersecretion of GH -tumour.

Can compress nearby tissue leading to hyposecretion of other pituitary hormones and due to its location it may press on the optic nerve causing visual disturbance. It can be caused by hypothalamus dysfunction causing excessive GHRH.

The effects of excessive growth hormone is

• Excessive growth of bone, cartilage

• Excess protein synthesis

• Organ enlargement

• Hypertension

• Reduce glucose tolerance and therefore a predisposition to DM

Gigantism: occurs in children when there is excessive GH while the epiphyseal cartilage of long bone are still growing

Acromegaly: occurs in adults when there is excessive GH secretion after ossification is complete resulting in abnormally thick bones and soft tissue, coarse features and excessively large hands and feet. Gradual onset, Condition usually develops age 30-50

Gigantism
https://www.ncbi.nlm.nih.gov/books/NBK279155/

• Complications

  • Adrenal insufficiency

  • Diabetes insipidus 

  • Hypogonadism 

  • Hypothyroidism

  • Fertility complications

  • Erectile dysfunction

  • Cardiac abnormalities e.g. cardiomyopathy, cardiac arrhythmias

  • Hypertension

  • Arthritis/arthralgia

  • Colon polyps / colon cancer

  • Psychological problems associated with body image

• Treatment

  • Remove the cause (pituitary tumour) hypophysectomy

  • Medication: Somatostatin analogues

Acromegaly

• Bones become excessively thick

• Excessive growth of lower jaw and forehead

• Enlarged tongue, enlarged nose, thickened lips, excessively large hands and feet

• Headache, insomnia, muscle pains.

• Coarse, oily, thickened skin,

• Excessive sweating and body odour,

• Skin tags, fatigue and muscle weakness

• Treatment may include removal of the tumor, radiation therapy, and injection of growth hormone blocking drugs e.g. Somatostatin analogues

Acromegaly

Hyposecretion of the Anterior Pituitary Gland

• Pituitary Dwarfism –

  • caused by under secretion of growth hormone most commonly occurring in the childhood years, causes stunting of growth.

  • Children with growth hormone deficiency have a slow rate of growth, usually less than 2 inches per year. The slow growth may not appear until a child is 2 or 3 years old. Or defined as an adult height of less than 4 feet 10 inches

  • Somatropin- SQ injection

  • Stops after epiphysial closure

Hyperprolactinaemia

• Hyperprolactinemia-normal during pregnancy and breastfeeding.

• Outside of this-caused by a benign tumour of the anterior pituitary (prolactinoma).

• Excessive production of the hormone prolactin which can affect both men and women. It leads to galactorrhoea (inappropriate milk secretion), amenorrhoea in females and impotence / erectile dysfunction in males.

• Other causes may include:

  • Antidepressants (SSRI's and MAOI's, tricycles)

  • Antipsychotics (Haldol, Zyprexa, Risperdal)

  • Antiemetics (metoclopramide)

• Diagnoses

  • Symptoms: as above+ obstetric hxt/ if tumor cause visual disturbances, headache

  • Serum prolactin

  • MRI

Management Hyperprolactinaemia 

• Médication - Parlodel (bromocriptine) and Dostinex (cabergoline) to reduce prolactin levels and shrinking pituitary tumors.

• Review of medications

• Surgical treatment: Transsphenoidal surgery

• Watch for CSF leak-?halo sign; headache; “sweet” taste to drainage reported by patient; test for glucose-needs review.

• Avoid anything that could increase ICP-coughing; sneezing; bending down, straining-stool softeners.- 4 weeks

• Decreased sense of smell

• No brushing teeth - 2/52

Hyposecretion of the pituitary hormones

• Causes of Hyposecretion include

  • Tumours of the hypothalamus or pituitary or structures adjacent to them

  • Trauma e.g. fracture base of skull

  • Infection e.g. meningitis / encephalitis

• Sheehan’s syndrome-anterior pituitary gland is damaged due to significant blood loss during or after delivery.

  • The diagnosis of Sheehan syndrome is not always clear immediately after childbirth.

    • Signs and symptoms may not present until months after childbirth or significant trauma.

    • The first and most common symptom -is the absence of lactation

    • Mostly anterior pituitary affected= deficiencies in cortisol release (ACTH), thyroxin (TSH), regulation of menstrual cycle (LH/FSH)

    • Adrenal insufficiency can also occur with symptoms of fatigue and weight loss.

    • Laboratory values that may support secondary adrenal insufficiency due to Sheehan syndrome could include hyponatremia, anaemia, and hypoglycaemia.

Disorders of the posterior pituitary

Diabetes Insipidus (Neurogenic Vs Nephrogenic)

A pituitary disorder - the most common disorder related to the posterior lobe. Caused by lack of secretion of ADH, causing the kidneys (renal tubules) to fail in reabsorption of fluid most commonly caused by injury or hypercalcemia or lithium toxicity if nephrogenic

• Presentation:

  • Frequent urination(polyuria)

  • Dilute pale urine

  • Extreme Thirst (polydipsia)

  • greater than 3 L per day & excessive thirst

    • Interference with sleep; weakness, weight loss.

• Complications:

  • Dehydration, Electrolyte Imbalance

• Management

  • Restricted fluids; water deprivation test; vasopressin test.

  • Synthetic ADH hormone called Desmopressin. Administer IV/intra-nasally via spray/oral. Antidiuretic effect - It acts on the kidneys to reduce the flow of urine.

Syndrome of Inappropriate ADH (SIADH)

• Excess ADH

  • Water retention

  • Small amounts of concentrated urine

  • Tachycardia

  • Distended neck veins

  • Muscle cramps

  • Confusion; seizures; LOC (hyponatremia)

• Treatment:

  • Diuretics

  • Vasopressin antagonist- tolvaptan

  • Hypertonic saline –3% NaCL draw water extracelluar + increase NA

  • Daily weights

  • Electrolyte replacement

  • Monitor for pulmonary oedema

Disorders of the Parathyroid Glands
Hypoparathyroidism

• Commonly caused by atrophy or traumatic injury

• This can occur as a result of accidental removal or destruction of parathyroid tissue during a thyroidectomy, irradiation of the thyroids or parathyroids, neck trauma, or idiopathic  atrophy of the glands. 

• Drop in serum CA levels + increase phosphorus levels

• S&S of hypocalcemia= mild tingling, numb, muscle cramp, mental changes ie irritability, Chvostek sign (muscle irritability when facial nerve gently tapped), trousseau sign (carpel spasm BP >20mmHg then systolic)

• If CA continue to decrease = convulsions, dysrhythmias

• Treatment for acute hypoparathyroidism: IV  Calcium gluconate, magnesium and vitamin D

• Treatment for chronic hypoparathyroidism-maintain normal calcium levels 

Disorders of the Parathyroid Glands
Hyperparathyroidism

• High blood calcium levels (hypercalcaemia) usually caused by a benign tumour of the parathyroid causes excessive secretion of PTH (parathyroid hormone) resulting in release of calcium from bones

  • Tumour

  • Congenital

  • Trauma

  • Radiation

  • Vit D deficiency 

  • Chronic renal failure

  • Some cancers

Disorders of the Parathyroid Glands
Hyperparathyroidism

Signs and symptoms

• Dehydration 

• confusion 

• lethargy

• arrhythmias 

• anorexia 

• nausea

• Vomiting

• Weight loss

• constipation 

• thirst

• frequent urination

• hypertension 

• skeletal changes -calcium being pulled out of the bone by parathyroid hormone- Excessive bone reabsorption 

• osteoporosis

• formation of bone cysts. 

• bone fracture 

Hyperparathyroidism

• Management –

• Cardiac monitoring

• I/O chart

• Hydration

• Loop diuretics- promotes excretion of excess calcium

• Calcium Restricted Diet

• Vitamin D supplements

• Surgery to remove abnormal parathyroid tissue (parathyroidectomy)-perioperative care

• Assess for hypoparathyroidism 24hours after surgery.

Adrenal insufficiency 

• Adrenal glands – reduced cortisol

• 2 adrenal glands above kidneys

• Work with hypothalamus and pituitary glands

• Cortisol helps break down fats, proteins, and carbs. Controls BP and effects immune system

• Primary adrenal insufficiency: Addisons disease, adrenal glands damaged. Insufficient cortisol and aldosterone.

• Secondary adrenal insufficiency. This starts when the pituitary gland doesn’t make enough of the hormone ACTH (adrenocorticotropin). As a result the adrenal glands don’t make enough cortisol.

Disorders of the Adrenal Cortex
Glucocorticoid – Hypersecretion

• Hypersecretion of the glucocorticoids (Cushing’s Syndrome) – cortisol is the main glucocorticoid hormone secreted by the adrenal cortex

• Caused by overproduction of ACTH, or by excess steroidal drugs.

• More common in women

• Signs and Symptoms 

  • Progressive obesity

  • A fatty hump between the shoulders (buffalo hump),

  • A rounded face (moon face),

  • Pink/purple stretch marks on the skin, fragile thin skin that bruises easily,

  • Hirsutism.

  • Cushing syndrome can also result in high blood pressure, bone loss and, on occasion, type 2 diabetes.

  • Due to excessive tissue protein breakdown, diminished protein synthesis, loss of calcium and excessive gluconeogenesis resulting in hyperglycaemia

  • Increased risk of infection

  • Emotional instability

Investigations

• Elevated glucose

• Elevated sodium

• Decreased potassium

• Decreased calcium

• Elevated cortisol

• Dexamethasone suppression test (synthetic cortisol)

• CT MRI; US

• Treatment

• Hypophysectomy; adrenalectomy; - inhibits cortisol synthesis

• Restrict fluid and sodium

• Replace electrolytes in deficit

• Watch for S&S of fluid overload

• Nursing care re integumentary system

• No NSAIDs

• Infection prevention measures 

Hyperaldosteronism

• Primary aldosteronism=Conn’s syndrome

• Overproduction of aldosterone -BP balance

• Adenoma in adrenal gland

• Aldosterone (reabsorption of sodium and water + excretion of potassium)

  • Hypernatremia

  • Hypokalaemia-dysrhythmias

• Treatment: Surgical :Adrenalectomy. Medication: aldosterone blocking meds: Spironolactone Potassium-sparing diuretic

• Monitor BP- HTN

• Monitor electrolytes

• Low sodium and high potassium diet

Disorders of the Adrenal Cortex: Hyposecretion

• Adrenocortical insufficiency (Addison’s Disease-autoimmune)

• Most commonly caused by a destruction of the adrenal cortex most commonly due to autoimmune conditions, metastases and infections; stopping corticosteroids abruptly

• Underproduction of aldosterone by adrenal cortex acts on the kidneys causing high potassium (hyperkalaemia), high calcium and low sodium (hyponatremia), low cortisol and low glucose levels.

• Metabolic acidosis

  • Person is easily fatigued, loses weight, may have problems with dehydration, has low blood pressure and low blood sugar, may be easily susceptible to infection due to decreased activity of immune system, confusion, muscle weakness, N&V, hypoglycaemia, chronic dehydration, menstrual disturbance.

• Diagnosis:

  • ACTH stimulation test –IM/IV

  • Treatment: Hormone replacement therapy-hydrocortisone and fludrocortisone; tx hyperkalemia

• Sick day rules + at home emergency dose of hydrocortisone

Acute Adrenal Crisis- Addisonian crisis

• (severe) Hypotension

• Hyponatremia

• Hyperkalaemia

• Hypoglycaemia

• Addisonian crisis=severe dehydration; hypotension and shock

• Tx the underlying cause 

• Vital signs

• S&S of shock

• Steroids

• Cardiac monitoring

• Electrolyte replacement

• Sufficient nutrition (query GI disturbances) and rest post-acute

• Correct planning prior to interventions

• Stress management-coping mechanisms

Disorders 

Links to Further Reading

• Stromberg, H. 2023., Care of Patients With Pituitary, Thyroid, Parathyroid, and Adrenal Disorders, Medical-Surgical Nursing (Fifth Edition), edited by Stromberg, H. pp. 858-881, ISBN 978-0-323-81021-0, http://dx.doi.org/10.1016/B978-0-323-81021-0.00036-X.

• (https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B978032381021000036X)

• https://www.ncbi.nlm.nih.gov/books/NBK470458/

• https://www.ncbi.nlm.nih.gov/books/NBK538261/#:~:text=Gigantism%20occurs%20when%20growth%20hormone,large%20extremities%20and%20characteristic%20facies.

• https://www.ncbi.nlm.nih.gov/books/NBK537331/

• https://www.ncbi.nlm.nih.gov/books/NBK563282/

• https://www.ncbi.nlm.nih.gov/books/NBK441899/

• https://www.ncbi.nlm.nih.gov/books/NBK441895/

• https://www.statpearls.com/ArticleLibrary/viewarticle/23170

• https://www.ncbi.nlm.nih.gov/books/NBK470218/

• https://www.ncbi.nlm.nih.gov/books/NBK441994/

• https://www.statpearls.com/articlelibrary/nursingarticle/17183

• https://www.statpearls.com/ArticleLibrary/viewarticle/20047

• https://www.ncbi.nlm.nih.gov/books/NBK499968/