NCM 116 LEC

SECOND SEMESTER / First Term

SATURDAY
7:30-12:30
PITUITARY GLAND
ANATOMY AND PHYSIOLOGY Insulin

o Ipapababa yung glucose sa bloodstream, key para

makapasok yung glucose sa loob ng cell (no insulin = high
blood sugar)
o To store fat in adipose tissue
o Pag nastore na sa liver, bababa na blood level

Fasting

o Beta cells = more on insulin

o Alpha = glucagon
o Si akpha cells magrerelease ng glucagon pupunta kay liver
para itrigger na maglabas ng glycogen (stored glucose)
para mag increase yung blood level sugar -> homeostasis
pa rin
o Kahit wala kang kinain = tuloy tuloy pa rin si pancreas
maglabas ng insulin

(NEGATIVE FEEDBACK MECHANISM = pag may tumataas = pinipilit

pataasin [vuce versa])

POSITIVE FEEDBACK MECHANISM – childbirth = pag may mataas

= itaaas pa lalo

*Pancreas lang ang may duct

*Others secrete through vascular and bloodstream

Ferguson reflex = pag nagtouch na yung ulo ni baby sa cervix

trigger posterior pituitary gland to secrete oxytocin – travel form
bloodstream to uterus – oxytocin will contract para lumabas yung
ulo ni baby

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 NCM 116 LEC
SECOND SEMESTER / First Term
SATURDAY
7:30-12:30
ASSESSMENT o Result is extreme weight loss, emaciation, atrophy of all
o Health history endocrine glands and organs, hair loss, impotence,
o Physical assessment (head to toe) – acromegaly, amenorrhea, hypometabolism, and hypoglycemia
gigantism, dwarfism, cushing’s syndrome, addison’s o Coma and death occur if the missing hormones are not
syndrome replaced.
o Diagnostic evaluation PITUITARY TUMORS
o Stimulation test o Pituitary tumors are usually benign
o Suppression test o Although their location and effects on hormone
production by target organs can cause life-threatening
effects.
o Three principal types of pituitary tumors represent an
overgrowth (eosinophilic cell, basophilic cell,
chromophobic cells)
EOSINOPHILIC
o Acromegaly
o Severe headaches; visual disturbances
o Eosinophilic tumors that develop early in life result in
gigantism
o The affected person may be more than 7 feet tall and
large in all proportions, yet so weak and lethargic that
he or she can hardly stand.
o If the disorder begins during adult life, the excessive
skeletal growth occurs only in the feet, the hands, the
superciliary ridge, the molar eminences, the nose, and
the chin, giving rise to the clinical picture called
acromegaly
o Many of these patients suffer from severe headaches
and visual disturbances because the tumors exert
pressure on the optic nerves (Sachse, 2001)
o Assessment of central vision and visual fields may
HYPOPITUITARISM
indicate loss of color discrimination, diplopia (double
o Hypofunction of the pituitary gland (hypopituitarism) can
vision), or blindness of a portion of a field of vision.
result from disease of the pituitary gland itself or of the
Decalcification of the skeleton, muscular weakness, and
hypothalamus o may result from destruction of the
endocrine disturbances, similar to those occurring in
anterior lobe of the pituitary gland.
patients with hyperthyroidism, also are associated with
SHEEHAN’S SYNDROME
this type of tumor
o Postpartum pituitary necrosis
o Uncommon cause of failure of the anterior pituitary. It is BASOPHILIC
more likely to occur in women - postpartum secondary to o Give rise to Cushing’s syndrome with features largely
with severe blood loss, hypovolemia, and hypotension at attributable to hyperadrenalism, including masculinization
the time of delivery and amenorrhea in females, truncal obesity, hypertension,
osteoporosis, and polycythemia
SIMMOND’S DISEASE
o Panhypopituitarism
o Absence of all pituitary secretions

o A complication of radiation therapy to the head and neck

area.
o Total destruction of the pituitary gland by trauma, tumor,
or vascular lesion removes all stimuli that are normally
received by the thyroid, the gonads, and the adrenal
glands.

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 NCM 116 LEC
SECOND SEMESTER / First Term
CHROMOPHOBIC
o Chromophobic tumors represent 90% of pituitary tumors.
o Tumors usually produce no hormones but destroy the rest
of the pituitary gland, causing hypopituitarism
o People with this disease are often obese and somnolent
and exhibit fine, scanty hair, dry, soft skin, a pasty
complexion, and small bones. They also experience
headaches, loss of libido, and visual defects progressing to
blindness
o Other signs and symptoms include polyuria, polyphagia, a
lowering of the basal metabolic rate, and a subnormal
body temperature
ASSESSMENT
o Diagnostic evaluation requires a careful history and
physical examination, including assessment of visual acuity
and visual fields
o Computed tomography (CT) and magnetic resonance
imaging (MRI) are used to diagnose the presence and
extent of pituitary tumors
o Serum levels of pituitary hormones may be obtained along
with measurements of hormones of target organs (eg,
thyroid, adrenal) to assist in diagnosis if other information
is inconclusive
MEDICAL MANAGEMENT
o Surgical removal of the pituitary tumor through a
transsphenoidal approach is the usual treatment.
o Stereotactic radiation therapy, which requires use of a
neurosurgery-type stereotactic frame, may be used to
deliver external-beam radiation therapy precisely to the
pituitary tumor with minimal effect on normal tissue
o Treatments include conventional radiation therapy,
bromocriptine (dopamine antagonist), and octreotide
(synthetic analog of growth hormone).
o These medications inhibit the production or release of
growth hormone and may bring about marked
improvement of symptoms.
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SATURDAY
7:30-12:30
o Octreotide (Sandostatin) (Somatosatin) may also be used
preoperatively to improve the patient’s clinical condition
and to shrink the tumor.
HYPOPHYSECTOMY
o Hypophysis – other term for pituitary gland
o Removal of the pituitary gland, may be performed to
treat primary pituitary gland tumors
o It is the treatment of choice in patients with Cushing’s
syndrome due to excessive production of ACTH by a
tumor of the pituitary gland.
o May also be performed on occasion as a palliative
measure to relieve bone pain secondary to metastasis
of malignant lesions of the breast and prostate
o Several approaches are used to remove or destroy the
pituitary gland: surgical removal by transfrontal,
subcranial, or oronasal– transsphenoidal approaches or
irradiation or cryosurgery
o Even if surgery succeeds at removing the tumor, many
of the features or symptoms of acromegaly will be
unaffected (Sachse, 2001).
o Absence of the pituitary gland alters the function of
many body systems
 Menstruation ceases and infertility occurs after
total or near-total ablation of the pituitary
gland
 Replacement therapy with corticosteroids and
thyroid hormone is necessary.
ENDOSCOPIC TRANSNASAL TRANSPHENOIDAL SURGERY
o The pituitary gland is a pea-sized structure located at the
base of the brain. It functions by producing hormones that
control or regulate various functions of the body such as
growth, metabolism, sexual development and
reproduction.
o Pituitary adenomas are noncancerous tumors that form in
the pituitary gland. These tumors cause hormonal
imbalance in the body by either secreting excessive levels
of a particular hormone or more than one type of
hormone. They can also grow in size and compress
important arteries and nerves at the base of the skull.
Endoscopic transnasal transsphenoidal surgery is a
minimally invasive procedure where the pituitary tumor is
removed by working through the nose. This surgical
technique can also be used to remove tumors located in
other regions of the skull base.
o Transnasal transsphenoidal surgery is a minimally invasive
technique performed to remove pituitary adenomas by
inserting an endoscope through the nose. An endoscope
is a long tube with a camera attached at the end that sends
images to a computer screen for the surgeon to view
inside the body.
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 NCM 116 LEC
SECOND SEMESTER / First Term
Indications
o Endoscopic transnasal transsphenoidal surgery can be
utilized to remove pituitary tumors which are compressing
critical brain structures or are over secreting certain
hormones.
o Surgical procedure.
o The surgery is performed general anesthesia.
o You will lie on your back on the operating table and your
nasal cavity will be prepared with antibiotic and antiseptic
solution.
o An image-guided device is placed on your head which
creates a 3D map on a computer screen. This map assists
your surgeon in navigating through the nose.
o A thin endoscopic tube attached to a lighted device and a
video camera at its end is inserted through one nostril and
moved up to the back of the nasal cavity. A small portion
of the nasal septum separating the two nostrils and the
wall of the sphenoid sinus is opened.
o The surgeon then makes an opening in a thin bone
overlying the pituitary gland called the sella, to view the
dura (the covering of the brain). The dura is then opened
to view the tumor and pituitary gland.
o Your surgeon uses special instruments called curettes
through the other nostril to remove the tumor.
o At the conclusion of the procedure your surgeon will
usually take a fat graft from your abdomen which is used
to repair the opening into the skull base and to prevent
any CSF fluid leakage. Sometimes bone graft may be used
to close the opening made in the skull base.
o Your surgeon will apply biologic glue over the graft to
promote healing and prevent leakage of cerebrospinal
fluid into the nasal cavity.
Post-Operative Care
o After the surgery, medications are prescribed to control
nausea, pain and nasal congestion. Your doctor will check
to see if the pituitary gland is functioning normally.
Hormonal medications may be prescribed if the pituitary
gland fails to produce the required level of hormones.
o Avoid coughing, sneezing, blowing your nose, and
straining during bowel movements for a few weeks after
surgery. Resume normal activities gradually. If a fat graft
has been obtained from the abdomen, keep the wound
open to air and prevent contact with water. Consult your
doctor immediately if you experience continuous nasal
drainage, excessive swallowing, nasal bleeding, high fever,
frequent urination or weight loss.
Recovery
o Crusts can form in your nose, causing nasal congestion.
These can be removed safely by spraying local anesthetic
in the nasal cavity. Nasal saline rinses may be
recommended to remove the crusts and promote healing
of the wounds.
o Risks and complications.
o As with any surgery, endoscopic transnasal
transsphenoidal resection of pituitary adenoma can be
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SATURDAY
7:30-12:30
associated with certain risks and complications, which
include:
o Loss of vision due to damaged optic nerves.
o Pituitary gland damage.
o Diabetes insipidus.
o Nasal deformity and bleeding.
o Stroke.
o Cerebrospinal fluid leak and meningitis (tissue layers
covering the brain).
Benefits
o The resection of the pituitary adenoma through
endoscopic transnasal transsphenoidal surgery has several
benefits over open surgery, which include
o No external incisions and no visible scars.
o Minimal loss of blood.
o Removes large tumors.
o Faster healing and recovery time.
o Shorter hospital stay.
o Endoscopic transnasal transsphenoidal surgery is an
effective technique for removing pituitary tumors. It is a
safe, minimally invasive procedure which confers
numerous benefits.
COMPLICATIONS
o Bleeding
o Congestion
o Stroke
o Transient DI
o CSF leak
o Meningitis
(HALO Sign – di nagmimix sa csf)
TRANSIENT DIABETES INSIPIDUS
o Diabetes insipidus is a disorder of the posterior lobe of the
pituitary gland characterized by a deficiency of antidiuretic
hormone (ADH), or vasopressin.
 Great thirst (polydipsia) and large volumes of
dilute urine characterize the disorder
 May be secondary to head trauma,
brain tumor, or surgical ablation or
irradiation of the pituitary gland.
 It may also occur with infections of the
central nervous system (meningitis,
encephalitis, tuberculosis) or tumors
(eg, metastatic disease, lymphoma of
the breast or lung
 Another cause of diabetes insipidus is failure of the renal
tubules to respond to ADH; this nephrogenic form may be
related to hypokalemia, hypercalcemia, and a variety of
medications (eg, lithium, demeclocycline [Declomycin])
A
JCDM
 NCM 116 LEC
SECOND SEMESTER / First Term
SATURDAY
7:30-12:30
SYNDROME OF INAPPROPROATE ANTIDIURETIC HORMONE SIADH DI
SECRETION ADH Increased Decreased or none
o Excessive growth hormone (ADH) secretion from the (decreased UO)
pituitary gland even in the face of subnormal serum UO Decreased Increased
osmolality.
o Patients with this disorder cannot excrete a dilute urine Specific gravity = Specific gravity =
o retain fluids and develop a sodium deficiency known as >1.025 < 1.010
dilutional hyponatremia (oliguria) (polyuria)
o SIADH is often of nonendocrine origin; for instance, the S/sx Edema (inc BP) Dehydration, wt. loss
syndrome may occur in patients with bronchogenic (dec BP)
carcinoma in which malignant lung cells synthesize and Serum Decreased (kasi Increased
release ADH. Osmolality diluted)

o SIADH has also occurred with severe pneumonia,

Diluted Concentrated
pneumothorax, and other disorders of the lungs, in
hyponatremia hypernatremia
addition to malignant tumors that affect other organs
Management Furosemide Vasopressin (mas
(Terpstra & Terpstra, 2000).
↓ OFI, ↓IV fluids potent – pwede siya
o Disorders of the central nervous system, such as head magkaroon ng effect
injury, brain surgery or tumor, and infection, are thought sa blood vessel)/
to produce SIADH by direct stimulation of the pituitary Desmopressin
gland. (synthetic - preferred)
 Some medications (vincristine, phenothiazines, DI – Daming ihi
tricyclic antidepressants, thiazide diuretics, and
others) and nicotine have been implicated in
SIADH they either directly stimulate the pituitary
gland or increase the sensitivity of renal tubules
to circulating ADH.
 Eliminating the underlying cause, if possible, and
restricting fluid intake are typical interventions
for managing this syndrome
 Because retained water is excreted slowly
through the kidneys, the extracellular fluid
volume contracts and the serum sodium
concentration gradually increases toward
normal
 Diuretics (eg, furosemide [Lasix]) may be used
along with fluid restriction if severe
hyponatremia is present.
 Close monitoring of fluid intake and output, daily
weight, urine and blood chemistries, and
neurologic status is indicated for the patient at
risk for SIADH.
 Supportive measures and explanations of
procedures and treatments assist the patient to
deal with this disorder (Terpstra & Terpstra,
2000).
Triggered by:
o Medications
o Tumor or surgery
o Infection

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JCDM