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HYPERPARATHYROIDISM

HYPERPARATHYROIDISM

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HYPERPARATHYROIDISM

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  1. Shariati Thursday Conference • 86 12 16 HYPERPARATHYROIDISM

  2. ParaThyroid Hormone (PTH) • Biochemistry • Physiology • pathophysiology • Hyperparathyroidism • Clinical manifestation • Diagnosis • Lab finding • imaging • treatment

  3. Biochemistry • Parathyroid Glands (4 glands 6*3*2 mm.) • 84 aa protein (9500 D) • Receptor in target cell (osteoblast, osteoclast, renal tubules) • cAMP enzym release reaction catalysis

  4. Physiology Bone GI intake PTH Vit D Calcitonin Ca Urinary out put Sweat GI

  5. Physiology PTH 400-1000mg Vit D Bone 10-70% GI intake Ca 7g 98% Urinary out put Sweat 100-300mg >4mg/kg abn. GI

  6. Physiology Bone Ca 99%=1-2kg GI intake 1% Ca Pr.Bound Ca 40% Non-ionized Ca 10% Ionized Ca 40% Intra cellular Ca Exra-cellular 0.1% Urinary out put Sweat . GI

  7. In minutes Osteocyt&blast In days Osteoclast Bone Ca Kidney Ca GI Ca PTH

  8. Pathophysiology • Primary hyperpara • Secondary hyperpara • Tertiary hyperpara • pseudohyperpara

  9. Pathophysiology • Primary hyperpara • Diffiuse hyperplasia 10-40% • Single adenoma 50-80% • Multiple adenoma 10% • Carcinoma 1% • Secondary hyperpara • Tertiary hyperpara • pseudohyperpara

  10. Pathophysiology • Primary hyperpara • Secondary hyperpara • Secondary to hypocalcemia • Renal dysfunction P • Malabsorption P • Tertiary hyperpara • pseudohyperpara

  11. Pathophysiology • Primary hyperpara • Secondary hyperpara • Tertiary hyperpara • Autonomus hyperactivity after secondary hyperpara • pseudohyperpara

  12. Pathophysiology • Primary hyperpara • Secondary hyperpara • Tertiary hyperpara • pseudohyperpara • Hypercalcemia of malignancy without metastasis or primary hyperpara

  13. Pathophysiology • Primary hyperpara Ca / N • Secondary hyperpara Ca / N • Tertiary hyperpara • pseudohyperpara

  14. Pathophysiology • Osteoclast/Osteoblast • Osteoclast activity • Osteoblast activity • Remodeling activity

  15. Clinic • 100,000 new case / year in USA • 1/1000 • 4th and 6th decade • F/M = 2/1

  16. Clinical findings: • Renal • Gastrointestinal • Skeletal manifestation • CNS • Skin • Cardiovascular • hypercalcaemia common rare nowadays

  17. Renal • Urinary tract calculi • Nephrolithiasis • Gastrointestinal • Peptic ulcer • Pancreatitis • Skeletal 10-25% • Tenderness • Aching pain (peripheral joints & vertebrae) • Sever pain, swelling, deformity

  18. Rare manifestations: • CNS Personal disturbance, coma, fatigue • Skin Dry skin, itching • Cardiovascular Hypertension, CHF

  19. Lab exam, • Ca • P • Alk Ph. • Urin Ca

  20. Lab exam, • Ca • Primary Up-N • Secondary N-Low • Total Ca 50% ionic calcium (acidosis, hypoproteinemia) • P • Alk Ph. • Urin Ca • PTH

  21. Lab exam, • Ca • P • Primary Low • Secondary Up/Low • Alk Ph. • Urin Ca • PTH

  22. Lab exam, • Ca • P • Alk Ph. • Hyperphosphatesia • Urin Ca • PTH

  23. Lab exam, • Ca • P • Alk Ph. • Urin Ca. • Hypercalciurea • PTH

  24. Lab exam, • Ca • P • Alk Ph. • Urin Ca. • PTH • Up • Rarely N

  25. Radiologic findings, • Bone resorption • Bone survey • Bone resorption of hand is highly sensitive • If high quality macroradiography/digitalized radiograhy • Bone densitometry

  26. Radiologic findings, • Bone resorption • Bone survey • Bone resorption of hand is highly sensitive • If high quality macroradiography/digitalized radiograhy • Bone densitometry

  27. Bone resorption • Subperiosteal • Juxtaarticular • Intraarticular, (high turn over, hyperthyroidism) • Subchondral • Endosteal, (MM, Osteoporosis) • Subphysial • Trabecular • Sublig. And sub tendinous • Brown tumor

  28. Bone resorption • Subperiosteal • Juxtaarticular • Intraarticular, (high turn over, hyperthyroidism) • Subchondral • Endosteal, (MM, Osteoporosis) • Subphysial • Trabecular • Sublig. And sub tendinous • Brown tumor

  29. Subperiosteal resorption • Diagnostic (prominent) • DD: chronic renal disease • Radial aspect of the hand phalanx • Middle phalanx • Index & middle finger

  30. Subperioseal resorption • Progressive lace like appearance

  31. Subperioseal resorption • Progressive lace like appearance speculated contour

  32. Subperioseal resorption • Progressive lace like appearance speculated contour complete resorption of cortex

  33. Subperiosteal resorption • Other sites; • Phalanx tuft • Medial proximal tibia, femur,humerus • Upper and lower border of the rib • Lamina dura • Subperiosteal resorption • Other sites; • Phalanx tuft • Medial proximal tibia, femur,humerus • Upper and lower border of the rib • Lamina dura

  34. Subperiosteal resorption • Phalanx tuft, acro-osteolysis

  35. Subperiosteal resorption • Phalanx tuft, acro-osteolysis

  36. Subperiosteal resorption • Phalanx tuft, acro-osteolysis

  37. Trabecular resorption • Medullary bone • In advance stages • Granular appearance • In cranium is caractristic osteopenia+speckled appear=Salt and Pepper

  38. Trabecular resorption

  39. Brown tumor • Osteoclastoma • Specially in primary hyperpara • Fibrous tissue+giant cells • Radiologic app. • Single or multiple • Well defined • Axial or appendicular skeleton • Cortical or eccentric • Could be expansile • Common sites; face bones, pelvis, rib, femur

  40. Brown tumor • Usually after other signs • Occasionally as presenting finding

  41. Diagnosis • Lab exam • Ca • PTH • Preoperative study • Tc labeled Sestamibi

  42. Treatment • Surgery • Adenoma resection • Resection of 3.5 gland • Post operative care

  43. Thank you for your attention