Parathyroid

Dr. S K Gupta
Professor,
Department of General Surgery
JIMSH
ANATOMY
• Endocrine glands situated behind thyroid gland
• Four in number
• Weight: 40-50 grams
• Secrete: Parathormone
• Superior glands:
• Develop from 4th pharyngeal pouch
• Behind RLN
• Inferior glands
• Develop from 3rd pharyngeal pouch
• Infront of RLN
• Variable in position: Tracheo-oesophageal groove, Behind esophgus, Carotid
sheath
• Blood supply- inferior thyroid artery (End artery)
Parathormone
• 84 aminoacids
• Secretion not dependent on pitutary gland
• Half life- 4 minutes
• Functions :
• Converts vitamin D into 1,25- dihydrocholecalciferol in kidney
• Absorption of calcium from gut
• Mobilises calcium from bone
• Reabsorption from renal tubules
Calcium metabolism

• Normal value: 8.5-10.2 mg/dl

• Commonest protein part of bound calcium is Albumin (80%)
• Level controlled by
• PTH
• Calcitonin
• Vitamin D- Acts on bone, kidney and GIT
• Functions
1. Blood coagulation
2. Neuromuscular activity
3. Cellular activity
4. Bone integrity.
Hyperparathyroidism
(HPT)
Hyperparathyroidism
• Types
1. Primary
2. Secondary
3. Tertiary
PRIMARY HPT
• 3rd most common endocrine disease
• Causes hypercalcemia
• Etiology
- Parathyroid adenoma
- Familial/ genetic causes
- MEN 1 syndrome
- Therapeutic ionizing radiations
- Lithium: parathyroid hyperplasia and HPT with no bone or renal
problems
Clinical features of HPT
• Clinical vignette: “Bones, stones, abdominal groans and psychic
moans”
• Middle aged women( 3:1)
• Incidence: 1:1000
• Asymptomatic > 50% cases
Clinical feature contd.
• BONES
- Raised PTH
- Increased osteoclastic activity
- Extensive decalcification of bone
- Bone pain, subosteal erosions
- Osteitis fibrosa cystica: single/ multiple cysts/ pseudotumours in the
jaw, skull or phalanges
- Osteopenia, osteoporosis and pathological fracture
Clinical feature contd.
• STONES:
- Renal stone in 25% patients
- Recurrent stones
- Calcium phosphate and oxalate type
- Metaststic calcification, nephrocalcinosis, renal failure
- Calcification in renal vessels: renal hypertension.
Clinical feature contd.
• ABDOMINAL GROANS
- Stimulates gastrin release: peptic ulceration
- Precipitate acute pancreatitis
- Increases gall stone disease ( calcium bilirubinate)
• PSYCHIC MOANS:
- Behavioural and neurotic problems: depression and anxiety
Acute hyperparathyroidism (Crisis)
• Causes
- Sudden increase in PTH due to rupture of parathyroid cyst or bleeding
in parathyroid tumour
- Severe dehydration precipitates crisis
- Secondaries in bone.
Acute hyperparathyroidism (Crisis)

• Clinical presentation
1. Abdominal pain
2. Vomiting
3. Dehydration
4. Oliguria
5. Muscular weakness
6. Death
• Serum calcium: >12mg%
Acute hyperparathyroidism (Crisis)

• Treatment
- Forced diuresis: 3-5 litres of saline with furosemide
- Rehydration: normal saline 300ml/hr
- Steroids: inhibit effects of vitamin D
Dose: 400/ day iv for 5 days
- Bisphosphonate:
Clodronate sodium, pamidronate
Inhibits mobilization of calcium from bone
Dose: 4mg iv followed by 8mg
Investigations
Parameters Primary HPT Secondary HPT
parathormone High High
Calcium High Normal
Phosphate Dcreased Increased

• Increased serum PTH level: specific and diagnostic, > 0.5

• Bone density assessment
• Vitamin D estimation
• Increased urinary calcium level: >250 mg/24 hours
• Raised alkaline phosphate level
Investigations
• X-ray features:
- skull: salt and pepper appearance
- Phalanges: supperiosteal bone resorption
- Jaw: osteitis fibrosa cystica
- Spine: rugger jersy spine
• USG abdomen
• Thallium- technetium scan: hot spotes ( diagnostic of parathyroid
adenoma)
Treatment
• Parthyroidectomy
• Indications
1. Severe symptoms
2. Young age group
3. Markedly reduced bone density
4. Serum calcium > 11mg%
5. Urinary calculi
6. Urinary calcium > 400 mg/24 hours
Parathyroidectomy
• Preoperative preperation:
- Vocal cords assesed
- Treatment of high calcium levels preoperatively
1. Diuresis
2. Steroids: prednisolone 20mg TDS for 5 days
3. Phosphate infusion: 100mmol infusion in 6 hours
4. Calcitonin subcutaneous injection: 200 units BD for 5 days
5. Biphosphate- Etiodronate disodium: 7-5 mg/kg slow iv infusion for 3 days
6. Mithramycin: 25 microgram/kg single dose.
Parathyroidectomy
• Total parathyroidectomy
- For parathyroid hyperplasia
- All four glands removed
- 1/3rd of one gland autotransplanted into forearm muscle
(brachioradialis) or sternocleidomastoid with marker stitch
- Transplanted gland slice in 1mm pieces
- 18 pieces embedded
Parathyroidectomy
• Adenoma in gland with normal other glands: Removal of single gland
• Carcinoma: parathyroidectomy plus hemithyroidectomy with
postoperative radiotherapy
Parathyroidectomy & its variants
• Surgical approaches;
1. Classical approach
2. Minimally invasive parathyroidectomy
3. Median sternotomy extension
4. Video- assisted parathyroidectomy
5. Endosopic parathyroidectomy
6. Remedial parathyroidectomy
7. Subtotal parathyroidectomy
8. Total parathyroidectomy with parathyroid autotransplantation.
Parathyroidectomy
• Complications:
- Haemorrhage, RLN palsy, hypocalcaemia.
- Persistent HPT: Serum calcium does not normalise immediately after surgery.
- Recurrent HPT: Serum calcium after surgery becomes normal but again
increases in 6-12 months.
- Hypoparathyroidism with severe hypocalcaemia- when all glands are removed
- Hungry bone syndrome: In patients with preop hyperthyoidism, Thyroid
hormone level drops acutely after surgery, stimulus to break down bone is
removed,
Bones remove calcium from plasma rapidly
Parathyroidectomy
- Presentation
Hypocalcaemia
Hypophosphatemia
Hypomagnesemia
Hyperkalaemia
• Vitamin D supplementation and elemental calcium: for 6 months
• Calcitriol with 2gm calcium supplement.
MEN Syndrome
MEN Syndrome
• Autosomal dominant.
• Types
- Type 1 (Werner’s syndrome)- 3P’s
1. Parathyroid hyperplasia/ adenoma
2. Pitutary tumour- Prolactinoma
3. Pancreatic tumour- Gastrinoma, Insulinoma,Glucoganoma,VIP’oma
Chromosome 11
MEN syndrome
• Type II A ( Sipple syndrome): chromosome 10
- Medullary carcinoma thyroid
- Pheochromocytoma
- Parathyroid hyperplaisa
• Type II B or Type III
- Medullary carcinoma thyroid
- Pheochromocytoma
- Mucosal Neuroma
- Marfanoid habitus
Hypoparathyroidism
Hypoparathyoidism
• PTH level < 10pg/ml
• Types
1. Temporary:
• More common (2-50%)
• Lasts for 2 months maximum upto 6 months
• Decrease in calcium
• Increase in phosphorous
Hypoparathyoidism
2. Permanent:
• Less common (0.4%)
• Continues beyond 6 months
• Decreased calcium
• Increase in phosphorous.
3. Hungry bone syndrome:
• Common (5-13%)
Hypoparathyoidism
• Causes-:
- Direct trauma to parathyroid glands
- Devascularization of glands
- Removal of gland during surgery
Hypoparathyoidism

• Clinical features:
- Circumoral tingling, numbness and paresthesia
- Carpopedal spasm, laryngeal stridor
- Respiratory musckle spasm, suffocation
- Cataract formation
- Convulsion.
Hypoparathyoidism

• Treatment :
- IV calcium gluconate: 10ml, 10% solution oveer 10 minutes
- Ssymptoms not resolve: Calcium infusion at 1-2 mg/kg/hr
- 1-2 gm oral calcium per day.
(Calcium carbonate: 1250 mg= 500mg elemental calcium)
- Vitamin D supplementation: 0.25- 1 microigram/day.
Thank you