Parathyroids
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Parathyroids

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Parathyroids Parathyroids Presentation Transcript

  • PARATHYROIDS
    • Anatomy
  • Physiology
    • Secretes parathyroid hormone (PTH)
    • PTH produced by the chief cells
    • PTH secretion is controlled by a complex feed back mechanism dependent on serum Ca levels
    • PTH or its fragments can be measured by radio immunoassay
  • Actions of PTH
    • Stimulation of osteoclastic activity  bone resorption and mobilization of Ca &Phosphate
    •  Absorption Ca from the gut
    •  Reduces the urinary Ca by increasing the reabsorption Ca by renal tubules
    •  Reduces the renal tubular absorption of PO4  Phosphaturia
  • Calcitonin
    • Secreted by C cells of thyroid
    • Opposite action of PTH
    •  Serum Ca
    •  Ca storage in the bones
  • HYPERPARATHYROIDISM
    •  Secretion of PTH
    • One of the most common causes of hypercalcaemia
    • Large no. of patients are asymptomatic
    • In India a high proportion of patients presents with skeletal and renal disease
  • Classification
    • Primary Hyperparathyroidism(PHPT) – inappropriately  secretion of PTH
    • Secondary hyper parathyroidism – chronic hypocalcaemia  reactive hyperplasia of all four glands
    • Tertiary hyper parathyroidism – reactive hyperplasia, the glands become autonomous e.g, chronic renal failure pt. After transplantation
  • Pathology
    • Parathyroid adenoma
    • Usually single,5% multiple
    • Whole gland is enlarged, darker in color more vascular than usual
    • A rim of compressed normal tissues seen surrounding the adenoma
    • Predominance of chief or clear cells
  • Pathology(contd.)
    • Parathyroid hyperplasia – hyperplasia of all the glands
    • Parathyroid carcinoma – rare (<1%) – palpable swelling , very large swelling infiltrating to the thyroid or adjacent structures – distant metastasis & recurrence have been reported
  • Multiple Endocrine Neoplasia (MEN) Syndrome
    • Autosomal dominant disorder
    • APUD cells are involved
    • MEN Type I (Werner syndrome)  Hyperparathyroidism,pancreatic islet cell tumors,pituitary tumor
  • MEN Type II
    • MEN Type IIA(Sipple syndrome )
    • MedullaryCa.thyroid,Phaeochromacytoma,Hyperparathyroidism
    • MEN TypeIIB(MEN TypeIII)
    • Medullary Ca ,Phaechromocytoma ,and mucosal neuromas
  • Clinical presentation (contd.)
    • Skeletal - mild to crippling bone disease
    • Osteitis fibrosa cystica, Brown tumors , single or multiple bone cysts, pseudomotor & pathological fractures . Vague pain in the bone and joints
    • Renal stones, nephrocalcinosis
  • Clinical Presentation
    • Age  20 – 45
    • Females :Males = 2:1
    • Most common presentation in the western world  Asymptomatic hypercalcemia
    • Classical manifestations in the 3 rd world ,viz. “Bones,stones,abdominal groans & psychic moans”
  • Clinical presentation (contd.)
    • Gastro intestinal - nausea, vomiting,anorexia and weight loss, peptic ulceration, pancreatitis.
    • Nervous system – lethargy, listlessness,personality changes,irrational behavour and memory loss. Hyper calcemia  depression of nervous system  coma
  • Laboratory findings
    • Serum Ca -  most common finding PHPT. Normocalcemic PHPT not uncommon in India. Serum Ca level to be corrected with respect to serum albumin
    • Urinary Ca –24 hrs 
    • Serum alk. Phosphatase  in bone disease
    • Serum PTH – Normal – 65 pg/ml
  • Clinical presentation (contd.)
    • Other complications: Corneal calcification ,Itching
    • Hypertension is seen in many pts. Reason not clear
  • Common causes of hypercalcemia
    • a.Bony metastasis – breast, bronchus, prostate,kidney, thyroid
    • b.PTH secreting solid tumors
    • c.Haematological malignancies –multiple myeloma
    • d.Vit D intoxication
    • e.Sarcoidosis
    • f.Immobilisation,medications like lithium, thiazide etc
  • Imaging investigations
    • Radiology  Useful for skeletal lesions
    • Ultrasound  Adenoma or multiple enlarged glands may be detected
    • CT Scan  Lesions in the chest
    • Thallium Technetium subtraction scan
    • 99 Tc Sestambi scan
    • Selective angiography & venous sampling
  • Treatment
    • Surgery is the treatment of choice
    • Parathyroid adenoma  Excision of the adenoma
    • Parathyroid hyperplasia  If more than one gland is involved,3 ½ gland can be removed or total parathyroidectomy with auto transplantation
    • Parathyroid Ca  Hemithyroidectomy + involved gland