1 / 35

Naif Bawazeer

Naif Bawazeer. Case presentation. History. This 40 yr old female, past medically free, para 2+0. patient cant speak or hear. She complain of headache especially in the morning mainly frontal associated with blurred vision, amenorrhea and enlargement in hand and foot since 7 years.

majed
Télécharger la présentation

Naif Bawazeer

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. NaifBawazeer

  2. Case presentation

  3. History • This 40 yr old female, past medically free, para 2+0. patient cant speak or hear. • She complain of headache especially in the morning mainly frontal associated with blurred vision, amenorrhea and enlargement in hand and foot since 7 years. • Past 6 month symptoms progressed out of proportion and associated with lower limb weakness. • Otherwise unremarkable.

  4. Physical Examination • Conscious, alert, with dysmorphic features including: protruded jaw, macroglossia, big hands and feet. • Otherwise unremarkable.

  5. Investigation • CBC and chemistry: with normal range • Glucose: 126 mg/dl • Alk pho:154 U/L (high) • Urea and creatinie: with normal range. • Growth hormone: 40mcg/L (very high) • Prolactin : 23.6 ng/mL (high) • FSH: 6.3 mIU/ml • ECG: Sinus rhythm.

  6. MRI scan Measuring 2.8 x 3.6 x 1.7 cm

  7. MRI scan Measuring 2.8 x 3.6 x 1.7 cm

  8. CT scan

  9. Diagnosis • Pituitary macro-adenoma with acromegaly

  10. Management • Surgical removal of tumor by: Endoscopic TranssphenoidalPituitary Surgery • Post- Operative: • no cerebrospinal fluid leak or seizure • Hormonal replacement therapy. • Follow up.

  11. Intra-Operative

  12. Anatomy 101

  13. Phases of the Operation • Nasal stage (approaching tumor). • Sellar stage (resection of tumor). • Reconstruction phase (closure).

  14. Video demonstration • See Attachment

  15. Bone + Mucosal Graft

  16. Navigation System

  17. Acromegaly

  18. Definition • Excessive growth hormone (GH) after epiphyseal plate closure at puberty. Causing enlargement of hands, feet, and facial features

  19. Epidemiology • Incidence about 3-4 per million per year. • Mean age at presentation 44 years. • Extrapolation: Prevalence in Saudi Arabia Incidence in Saudi Arabia

  20. Epidemiology in Saudi Arabia:

  21. Causes • Endogenous sources: 1- pituitary adenoma (90%). 2- familial syndromes: multiple endocrine neoplasia (MEN) type I, McCune-Albright syndrome, Carney's syndrome. 3- pituitary carcinoma . 4- peripheral neuroendocrine tumors. • Exogenous sources.

  22. History and Physical In case of pituitary adenoma: • Mass effect: headaches, cranial nerve palsy, visual field defects + • Hormonal effect: GH: increase in soft tissue, CTS (60%) Prolactin: Amenorrhoea. TSH: Hyperthyroidism. ACTH: Cushing's syndrome Apoplexy: sudden deterioration.

  23. History and Physical Other causes of acromegaly: • according on underlying cause will give us the clinical picture. + • Hormonal effect: GH: increase in soft tissue, CTS (60%)

  24. Diagnosis • Clinical suspicion • Biochemical marker: • elevated insulin-like growth factor 1 (IGF-1) • elevated growth hormone (GH < 1 ng/mL ) • Radiology: MRI of pituitary gland to detect tumor and evaluation.

  25. Treatment • After searching the literature through:

  26. Treatment • American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Acromegaly-2011 Update http://aace.metapress.com/content/5h1427154k550851/?id=5H1427154K550851

  27. Treatment • The Journal of Clinical Endocrinology & Metabolism May 1, 2009 vol. 94 no. 5 1509-1517

  28. Treatment Enclosed pituitary tumor: • Primary trans-sphenoidalsurgery

  29. Treatment In case of unresectablepituitary tumour (with neural or vascular impingement/invasion): • Medical therapy: • somatostatin analogs • dopamine agonists • growth hormone-receptor antagonist (GHRA) • Debulking surgery • Radiotherapy

  30. Treatment In case of non-pituitary adenoma etiology: • Medical VS surgical for underlying pathology

  31. Follow up: • Hormonal replacement therapy. • blood investigation for hormones levels. • MRI (evaluate recurrence). • Colonoscopy.

  32. References • 1- Cook DM, Ezzat S, Katznelson L, et al (AACE Acromegaly Guidelines Task Force). AACE medical guidelines for clinical practice for the diagnosisAnd treatment of acromegaly [published correctionsAppear in EndocrPract. 2005;11:144 and EndocrPract. 2008;14:802-803]. EndocrPract. 2004;10:213-225. • Javer, A., Marglani, O., Lee, A., Matishak, M., & Genoway, K. (2008). Image-guided endoscopic transsphenoidal removal of pituitary tumours. Journal Of Otolaryngology - Head & Neck Surgery = Le Journal D'oto-Rhino-Laryngologie Et De ChirurgieCervico-Faciale, 37(4), 474-480. • 2- Johnson N. New approaches to the development and use of treatment guidelines. Formulary. 1998;33:665-678. • 3. Mechanick JI, Bergman DA, Braithwaite SS, Palumbo • PJ (American Association of Clinical Endocrinologists • Ad Hoc Task Force for Standardized Production of • Clinical Practice Guidelines). American Association of Clinical Endocrinologists protocol for standardized production of clinical practice guidelines [published correction appears in EndocrPract. 2008;14:802-803]. EndocrPract. 2004;10:353-361. • 4. Alexander L, Appleton D, Hall R, Ross WM, Wilkinson R. Epidemiology of acromegaly in the Newcastle region. ClinEndocrinol (Oxf). 1980;12:71-79. • 5. Daly AF, Rixhon M, Adam C, Dempegioti A, Tichomirowa MA, Beckers A. High prevalence of pituitary adenomas: a cross-sectional study in the province of Liege, Belgium. J ClinEndocrinolMetab. 2006;91:47694775. • 6. Avagnina P, Martini M, Terzolo M, et al. Assessment of functional liver mass and plasma flow in acromegaly before and after long-term treatment with octreotide. Metabolism. 1996;45:109-113.

More Related