1DDX: LECTURE 45 – APRIL 4TH, 2007

Endocrine (1), Hypothalamus and Pituitary

Page 1
GH stimulates prolactin, TRH stimulates Prolactin, GnRH stimulates prolactin. Somatostatin and Dopamine are inhibitory.

Distinct areas in Hypothalamus

Optic chiasm right next to pituitary. CN III, IV, VI.
Posterior pituitary only stores hormones.
PRL will be seen in pituitary adenoma

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Anterior pituitary hormones may have more dramatic impact when FSH and LH are low.
GH: glucagons-like effects.

GH: Acutely, GH has insulin-like activity to counter the glucagon released in hypoglycaemia.
Interfereing factors: argentine, insulin and glucagon are in large amounts.

Prolactin:
See nipple discharge

TSH:
Lesion at thyroid and TSH gets no response.
Thyrotoxicosis is a type hyperthyroidism

FSH and LH:

Most pituitary hormones have diurnal variation. Spike in early morning: this is why we do 24 hour urine sample.
PCOS = polycystic ovarian syndrome
Hematuria: interferes with 24 hour urine test.

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Emesis happens in sympathetic state. Body produces ADH in sympathetic state.
Trying to keep fluid in the system.
DM: different is that one is nephrogenic: lesion at level of KI or neurogenic, lesion is at level of brain.
SIADH: syndrome of inappropriate ADH.

Headaches: anything over 10mm (macro) starts pressing on structure

*Signs and symptoms of a mass lesion, such as headaches, visual field defects are the biggest clue to pituitary tumour.
If 1 hormone: it is at level of gland.
Bilateral hemianopia: loss of vision on outer halves of visual field

Sclerosis: change in skin texture (thickening/hardening)

Chronically high ACTH in Addison’s, Cushings.
Myxedema: hypothyroid

Hypothalamus mediates primitive functions. Endorphins and enkephalins are hypothalamus-mediated.

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Generalized Adult Hypopituitarism
Rare for pituitary lesion to only effect ECTH.
“pituitary dwarfism” is from birth
Loss of muscle mass and strength in isolated GH deficiency.

Panhypopituitarism normally results from Sheehan’s syndrome. Low anterior pituitary hormones across the board.
Pituitary apoplexy normally not panhypopituitary

Empty sella syndrome: visual problems are insidious.

Headache: chronic and increasingly severe

DDX LECTURE 45, APRIL 4TH, 2007 – PAGE 1

Replacement of hormones: for life.
Tumours and adenomas: outside pituitary

Primary hypopituitarism: lesion is at level of pituitary

Apoplexy = infarction

Generalized Adult Hypopituitarism

Anorexia nervosa: GH and cortisone are increased because you are in chronic sympathetic state.
Myotonia dystorphica: type of muscular dystrophy.

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Galactorrhea: because so many releasing hormones trigger prolactin. FSH/LH are decreased because they are inhibited
by prolactin.

Dopamine abnormalities: dopamine inhibits prolactin

Chest wall lesions: from trauma to breast.

Phenothiazines: diuretics

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Gigantism and Acromegaly:
Increased risk of malignancy in GI because rate of turnover is increased.
Chronically high GH has an anti-insulin, glucagon effect.

Non-functioning pituitary adenomas: impingement.

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Primariy DI: not producing ADH

Diagnosis:
No change in symptoms. Still excessive amount of urin in 24 hours (5-7 L)
Diuretics have negative feedback effect on ADH.

Vasopressin-sensitive: lesion at ADH

Info about Growth Hormone:

GH released in reponse to hypoglycaemia, starvation, anorexia
GH has insulin-like activity acutely
Low blood sugar, insulin decreases and GH is decreased. Sugar leaves cells and becomes available for brain function.

When you see more than 1 endocrine problem, keep hypopituitarism in mind.

DDX LECTURE 45, APRIL 4TH, 2007 – PAGE 2