This document provides information on parathyroid glands and parathyroid hormone (PTH). It discusses the anatomy and blood supply of the parathyroid glands. It describes PTH, its functions, and how it regulates calcium levels. It outlines primary hyperparathyroidism, including causes, clinical features, investigations, and treatment via parathyroidectomy. It also briefly discusses secondary and tertiary hyperparathyroidism, acute hyperparathyroidism, MEN syndrome, apudomas, and hypoparathyroidism.

1. Dr. Ritesh Dhanbhar

2. ANATOMY
 Endocrine glands situated behind thyroid gland.
 Four in number.
 Weight: (40-50)gms
 Secrete: Parathormone.
 Superior glands:
Develop from 4th pharyngeal pouch.
Behind RLN.

3. ANATOMY
 Inferior glands:
Develop from 3rd pharyngeal pouch.
Front of RLN.
Variable positions:
1.Tracheo-oesophageal groove.
2.Behind oesophagus.
3.Carotid sheath.
 Blood supply: Inferior thyroid artery (End artery).

4. PARATHORMONE
 84 amino acids.
 Secretion not dependent on pituitary gland.
 Half life: 4 minutes.
 Functions:
1.Converts vitamin D into 1,25-dihydrocholecalciferol in
kidney.
2.Absorption of calcium from gut.
3.Mobilises calcium from bone.
4.Reabsorption from renal tubules.

5. CALCIUM
 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.

6. CALCIUM
 Functions:
1.Blood coagulation.
2.Neuromuscular activity.
3.Cellular activity.
4.Bone integrity.

7. HYPERPARATHYROIDISM (HPT)
 Types:
1.Primary.
2.Secondary.
3.Tertiary.

8. PRIMARY HPT
 3rd most common endocrine disease.
 Causes hypercalcaemia.
 Etiology:
Parathyroid adenoma.
Familial/ genetic causes.
MEN I syndrome.
Therapeutic ionizing radiation.
Lithium: no bone or renal problems.

9. CLINICAL FEATURES
 Clinical vignette: “Bones, stones, abdominal organs
and psychiatric moans”.
 Middle aged women (3:1).
 Incidence: 1: 1000.
 Asymptomatic >50% cases.

10. CLINICAL FEATURES
 Bones:
Raised PTH
Increased osteoclastic activity
Extensive decalcification of bone
Bone pain, subperiosteal erosions.
Osteitis fibrosa cystica: Single/ multiple cysts/
pseudotumours in the jaw, skull or phalanges.
Osteopenia, osteoporosis and pathalogical fractures.

11. CLINICAL FEATURES
 Stones:
Renal stones in 25% patients.
Recurrent stones.
Calcium phosphate and oxalate type.
Metastatic calcification, nephrocalcinosis, renal
failure.
Calcification in renal vessels: renal hypertension.

12. CLINICAL FEATURES
 Abdominal organs:
Stimulates gastrin release: peptic ulceration.
Precipitate acute pancreatitis.
Increases gall stone disease (Calcium bicarbonate).
 Psychic moans:
Behavioural and neurotic problems: Depression and
anxiety.

13. 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.

14. Acute hyperparathyroidism (Crisis)
 Clinical Presentation:
1.Abdominal pain.
2.Vomiting.
3.Dehydration.
4.Oliguria.
5.Muscular weakness.
6.Death.
 Serum Calcium:>12mg%.

15. Acute hyperparathyroidism (Crisis)
 Treatment:
Forced diuresis: 3-5 litres of saline with frusemide.
Rehydration: normal saline 300ml/hour.
Steroids: Inhibit effects of vitamin D.
Dose: 400mg/day iv for 5 days.
Bisphosphonate:
Clodranate Sodium, Pamidronate
Inhibits mobilization of calcium from bone.
Dose: 4mg iv followed by 8mg.

16. Investigations
Parameters Primary HPT Secondary HPT
Parathormone High High
Calcium High Normal
Phosphate Decreased Increased
•Increased serum PTH level: specific and diagnostic
>0.5.
•Bone density assessment.
•Vitamin D estimation.
•Increased urinary calcium level >250mg/24 hours.
•Raised alkaline phosphatase level.

17. Investigations
 X-Ray features:
Skull: salt and pepper appearance.
Phalanges: subperiosteal bone resorption.
Jaw: osteitis fibrosa cystica.
Spine: rugger jersey spine.
 USG abdomen.
 Thallium- Technetium scan: hot spots (diagnostic of
parathyroid adenoma).

18. Treatment
 Parathyroidectomy.
 Indications for parathyroidectomy:
1.Severe symptoms.
2.Young age group.
3.Markedly reduced bone density.
4.Serum calcium >11mg%.
5.Urinary calculi.
6.Urinary calcium >400mg/24 hours.

19. Parathyroidectomy
 Preoperative preparation:
 Vocal cords assessed.
 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: 7.5mg/kg slow iv
infusion for 3 days.
6.Mithramycin: 25microgm/kg single dose.

20. Parathyroidectomy
 Total parathyroidectomy:
For parathyroid hyperplasia.
All four glands removed.
1/3rd of one gland autotransplanted into forearm
muscle (brachioradialis) or sterniocleidomastoid with
marker stitch.
Transplanted gland sliced in 1mm pieces.
18 pieces embedded.

21. Parathyroidectomy
 Adenoma in gland with normal other glands: removal
of single gland.
 Carcinoma: Parathyroidectomy plus
hemithyroidectomy with post operative radiotherapy.
 All 4 glands diseased: Transcervical thymectomy
added.

22. Parathyroidectomy
 Surgical approaches:
Classical approach.
Minimally invasive parathyroidectomy.
Median sternotomy extension.
Video-assisted parathyroidectomy.
Endoscopic parathyroidectomy.
Remedial parathyroidectomy.
Subtotal parathyroidectomy.
Total parathyroidectomy with parathyroid
autotransplantation.

23. 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.

24. Parathyroidectomy
Hypoparathyroid with severe hypocalcaemia: 10
ampoules Calcium gluconate with one liter Normal
saline (continuous infusion at 30ml/hour).
Hungry Bone Syndrome:
In patients with preoperative hyperthyroidism.
Increased bone breakdown in hyperthyroid state.

25. Parathyroidectomy
Patient’s thyroid hormone level drops acutely after
surgery, stimulus to brake down bone is removed.
Bones remove calcium from plasma rapidly.
 Presentation: Hypocalcaemia.
Hypophosphatemia.
Hypomagnesemia
Hyperkalaemia.

26. Parathyroidectomy
Vitamin D supplementation and elemental calcium:
for 6 months.
Calcitriol with 2gm calcium supplement.

27. MEN Syndrome
 Autosomal dominant.
 Types:
Type I (Werner’s syndrome):
Parathyroid hyperplasia/Adenoma.
Pituitary tumour.
Pancreatic tumour.
Chromosome 11

28. MEN Syndrome
 Type II (Sipple syndrome):
 Type II A:
Medullary carcinoma thyroid
Pheochromocytoma
Pararthyroid hyperplasia
Chromosome 10.
 Type II B:
Medullary carcinoma thyroid
Pheochromocytoma
Neuroma.

29. APUDOMAS
 APUD (Amine precursor uptake decarboxylation)
 Derived from endoderm.
 Neuron specific enolase enzyme: specific for cells.
 Synthesize peptides:
Endocrine action
Paracrine action
Neurocrine action
Neuroendocrine action.

30. APUDOMAS
 Present like syndromes:
Insulinoma
Glucagonoma
Gastrinoma
VIPoma
 Entopic type: Secrete hormones normal to tissue, like
insulinoma/ glucagonoma.
 Ectopic type: Produce hormones not normal to tissue
of origin, like gastrinoma/VIPoma.

31. APUDOMAS
 Associated with MEN syndrome (Type I).
 Investigation: Radioimmunoassay
MRI abdomen
CT neck

32. Hypoparathyroidism
 PTH level <10pg/ml.
 Types:
1.Temporary:
More common (2-50)%
Lasts for 2months maximum upto 6 months.
Decrease in calcium.
Increase in phosphorous.

33. Hypoparathyroidism
2.Permanent:
Less common (0.4-13)%
Continues beyond 6 months.
Decrease in calcium.
Increase in phosphorous.
3.Hungry bone syndrome:
Common (5-13)%

34. Hypoparathyroidism
 Causes:
Direct trauma to parathyroid glands.
Devascularization of glands.
Removal of gland during surgery.

35. Hypoparathyroidism
 Clinical features:
Circumoral tingling, numbness and paraesthesia.
Carpopedal spasm, laryngeal stridor.
Respiratory muscle spasm, suffocation.
Convulsion.
Cataract formation.

36. Hypoparathyroidism
 Treatment:
 IV calcium gluconate: 10ml in 10% solution over 10
min.
Symptoms not resolve: Calcium infusion at 1-2
mg/kg/hr.
1-2 gm oral calcium per day.
(Calcium carbonate: 1250mg = 500mg elemental
calcium)
Vitamin D supplementation: 0.25-1 microgm/day.

37. THANK YOU !!!