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DISORDERS OF THE PARATHYROID GLANDS
Содержание
- 1. DISORDERS OF THE PARATHYROID GLANDS
- 2. Disorders of the Parathyroid Glands Maintenance of calcium,
- 3. Disorders of the Parathyroid Glands These hormones regulate
- 4. Disorders of the Parathyroid Glands The PTH acts
- 5. Disorders of the Parathyroid Glands Calcitonin is released
- 6. Disorders of the Parathyroid Glands Calcitonin is therefore
- 7. Слайд 7
- 8. Disorders of the Parathyroid Function Primary hyperparathyroidismis due
- 9. Disorders of the Parathyroid Function The cause of
- 10. Disorders of the Parathyroid Function The incidence of
- 11. Disorders of the Parathyroid Function The two major
- 12. Disorders of the Parathyroid Function In skeleton a
- 13. Disorders of the Parathyroid Function Now a days
- 14. Disorders of the Parathyroid Function Other symptoms include
- 15. Differential DiagnosisPrimary hyperparathyroidismSolitary adenomasMultiple endocrine neoplasiaLithium therapyFamilial
- 16. Differential DiagnosisSolid tumor with metastases(breast)Solid tumor with
- 17. Diagnosis The presence of established hypercalcaemia in more
- 18. Diagnosis Serum phosphate is usually low but may
- 19. Other Diagnostic tests The heypercalcaemic of non-parathyroid origin
- 20. Other Diagnostic tests The response is unusual in
- 21. Other Diagnostic tests Plain X-ray of hands can
- 22. Other Diagnostic testsUltrasonographyMRICTThallium 201 – Tehcnichum99m scan (subtraction study)Pre-operative localization of the abnormal parathyroid gland(s):
- 23. Treatment A large proportion of patients have “biochemical”
- 24. Medical Treatment of the hypercalcaemia In acute severe
- 25. Other agentsGlucocostiroidsIn hypercalcaemia associated the hematological malignant
- 26. Other agentsCalcitoninAlso inhibit osteoclast activity and prevent
- 27. Other agentsPhosphateOral phosphate can be used as
- 28. SurgerySurgical treatment should be considered in all
- 29. Other ComplicationsDeterioration of renal functionMetabolic disturbance e.g. hypomagnesia, pancreatitis, gout or pseudogout
- 30. Secondary hyperparathyroidism An increase in PTH secretion which
- 31. Major causes of chronic hypocalcemia other than
- 32. Major causes of chronic hypocalcemia other than
- 33. Hypoparathyroidism Deficient secretion of PTH which manifests itself
- 34. HypoparathyroidismSurgical hypoparathyroidism – the commonestAfter anterior neck
- 35. HypoparathyroidismIdiopathic hypoparathyroidismA form occuring at an early
- 36. HypoparathyroidismIdiopathic hypoparathyroidismCirculating antibodies for the parathyroid glands
- 37. HypoparathyroidismIdiopathic hypoparathyroidismThe late onset form occurs sporadically
- 38. HypoparathyroidismNeuromuscularThe rate of decrease in serum calcium
- 39. HypoparathyroidismNeuromuscularParathesiaTetanyHyperventilationAdrenergic symptomsConvulsion (More common in young people
- 40. HypoparathyroidismOther clinical manifestationPosterio lenticular cataractCardiac manifestation: Prolonged QT
- 41. HypoparathyroidismOther clinical manifestationDental Manifestation Abnormal enamel formation with
- 42. Hypoparathyroidism In the absence of renal failure the
- 43. Hypoparathyroidism The mainstay of treatment is a combination
- 44. Emergency Treatment for Hypocalcaemic Calcium should be given
- 45. Emergency Treatment for Hypocalcaemic In patients with hyperparathyroidism
- 46. Pseudohypoparathysoidism and Pseudopseudohypoparathyroidism A rare familial disorders with
- 47. Pseudohypoparathysoidism and Pseudopseudohypoparathyroidism In pseudopseudohypoparathyroidism they have the
- 48. Скачать презентанцию
Disorders of the Parathyroid Glands Maintenance of calcium, phosphate and magnesium homeostasis is under the influence of two polypeptide hormones; parathyroid hormone(PTH), and calcitonin (CT), as well as a sterol hormone, 1,25
Слайды и текст этой презентации
Слайд 3Disorders of the Parathyroid Glands
These hormones regulate the flow of
minerals in and out of the extracellular fluid compartments through
their actions on intestine, kidneys, and bones.
Слайд 4Disorders of the Parathyroid Glands
The PTH acts directly on the
bones and kidneys and indirectly on the intestine through its
effect on the synthesis of 1,25 (OH)2D3. Its production is regulated by the concentration of serum ionized calcium. Lowering of the serum calcium levels will induce an increased rate of parathyroid hormone secretion
Слайд 5Disorders of the Parathyroid Glands
Calcitonin is released by the “C”
cells (parafollicular cells in the thyroid gland) in response to
small increases in plasma ionic calcium. It acts on the kidney and bones to restore the level of calcium to just below a normal set point which in turn inhibits secretion of the hormone.
Слайд 6Disorders of the Parathyroid Glands
Calcitonin is therefore the physiological antagonist
of PTH. The two hormones act in concert to maintain
normal concentration of calcium ion in the extracellular fluid.
Слайд 8Disorders of the Parathyroid Function
Primary hyperparathyroidismis due to excessive production
of PTH by one or more of hyperfunctioning parathyroid glands.
This leads to hyprcalcemia which fails to inhibit the gland activity in the normal manner.Hyperparathyroidism
Слайд 9Disorders of the Parathyroid Function
The cause of primary hyperparathyroidism is
unknown. A genetic factor may be involved. The clonal origin
of most parathyroid adenomas suggests a defect at the level of the gene controlling the regulation and/or expression of parathyroid hormone.Hyperparathyroidism
Слайд 10Disorders of the Parathyroid Function
The incidence of the disease increases
dramatically after the age of 50 and it is 2-4
folds more common in women.A single adenoma occurs in about 80% of patients with primary hyperparathyroidism. Four glands hyprplasia account for 15-20% of cases. A parathyroid carcinoma could be the etiology in a rare incidence of less then 1%.
Hyperparathyroidism
Слайд 11Disorders of the Parathyroid Function
The two major sites of potential
complications are the bones and the kidneys.
The kidneys may have
renal stones (nephrolithiasis) or diffuse deposition of calcium-phosphate complexes in the parachyma (nephrocalcinosis). Now a days such complications are seen less commonly and around 20% of patients or less show such complications.Clinical Features:
Слайд 12Disorders of the Parathyroid Function
In skeleton a condition called osteitis
fibrosa cystica could occur with subperiosteal resorption of the distal
phalanges, distal tappering of the clavicles, a “salt and pepper” appearance of the skull as well as bone cysts and brown tumors of the long bones. Such overt bone disease even though typical of primary hyperparathyroidism is very rarely encountered.Clinical Features:
Слайд 13Disorders of the Parathyroid Function
Now a days almost 90% of
diagnosed cases in the developed countries are picked up by
routine screening for calcium level using the new automated machines.Clinical Features:
Слайд 14Disorders of the Parathyroid Function
Other symptoms include muscle weakness, easy
fatigability, peptic ulcer disease, pancreatitis, hypertension, gout and pseudogout as
well as anemia and depression have been associated with primary hyperparathyroidism.Clinical Features:
Слайд 15Differential Diagnosis
Primary hyperparathyroidism
Solitary adenomas
Multiple endocrine neoplasia
Lithium therapy
Familial hypocalciuric hypercalcemia
Vitamin D
intoxication
1,25(OH)2D; sarcoidosis and other granulomatous diseases
Idiopathic hypercalcemia or infancy
Causes
of HypercalcemiaParathyroid - related
Vitamin D – related
Слайд 16Differential Diagnosis
Solid tumor with metastases(breast)
Solid tumor with humoral mediation of
hypercalcemia (lung kidney)
Hematologic malignancies (multiple myeloma, lymphoma, leukemia)
Hyperthyroidism
Immobilization
Thiazides
Vitamin A intoxication
Assocated
with Renal Failure:Severe secondary hyperparathyroidism
Aluminum intoxication
Milk alkali syndrome
Causes of Hypercalcemia
Malignancy - related
Associated with high bone turnover
Слайд 17Diagnosis
The presence of established hypercalcaemia in more than one serum
measurement accompanied by elevated immunoreactive PTH is characteristic (iPTH)
Слайд 18Diagnosis
Serum phosphate is usually low but may be normal. Hypercalcaemia
is common and blood alkaline phosphatase (of bone origin) and
the urinary hydroxyproline concentrations are commonly elevated when the bones are involved. Nephrogenous CAMP is elevated in about 80% of patients but the test is rarely used because of technical difficulties
Слайд 19Other Diagnostic tests
The heypercalcaemic of non-parathyroid origin e.g., vitamin D
intoxication, sarcoidosis and lymphoproliferative syndromes generally respond to the administration
of prednisolone in a dose of 40-60 mg daily for 10 days by a decrease in serum calcium level.The Glucocortisoid suppression test:
Слайд 20Other Diagnostic tests
The response is unusual in hypercalcaemia secondary to
primary hyperparathyroidism and ectopic PTH production.
A positive test result i.e.
significant decrease in serum calcium is a contraindication to neck exploration and signals the need for investigation for a non-parathyroid cause of the hypercalcaemia. The Glucocortisoid suppression test:
Слайд 21Other Diagnostic tests
Plain X-ray of hands can be diagnostic showing
subperiosteal bone resorption usually on the radial surfacy of the
distal phalanx with distal phalangeal tufting as well as cysts formation and generalzed osteopenia.Radiograph:
Слайд 22Other Diagnostic tests
Ultrasonography
MRI
CT
Thallium 201 – Tehcnichum99m scan (subtraction study)
Pre-operative localization
of the abnormal parathyroid gland(s):
Слайд 23Treatment
A large proportion of patients have “biochemical” hyperparathyroidism but with
prolonged follow up they progress to overt clinical presentation. Resection
of the parathyroid lesion is curative with recurrences observed mainly in the multiple glandular disease.
Слайд 24Medical Treatment of the hypercalcaemia
In acute severe forms the main
stay of therapy is adequate hydration with saline and forced
diuresis by diuretics to increase the urinary excretion of calcium rapidly along with sodium and prevent its reabsorption by the renal tubules.
Слайд 25Other agents
Glucocostiroids
In hypercalcaemia associated the hematological malignant neoplasms
Mythramycin
A toxic antibiotics
which inhibit bone resorption and is used in hematological and
solid neoplasms causing hypercalcaemia.
Слайд 26Other agents
Calcitonin
Also inhibit osteoclast activity and prevent bone resorption
Bisphosphonates
They are
given intravenously or orally to prevent bone resorption.
Слайд 27Other agents
Phosphate
Oral phosphate can be used as an antihypercalcaemic agent
and is commonly used as a temporary measure during diagnostic
workup.Estrogen
It also decrease bone resorption and can be given to postmenopausal women with primary hyperparathyroidism using medical therapy
Слайд 28Surgery
Surgical treatment should be considered in all cases with established
diagnosis of primary hyperparthyroidism.
During surgery the surgeon identifies all four
parathyroid glands (using biopsy if necessary) followed by the removal of enlarged parathyroid or 3 ½ glands in multiple glandular disease.
Слайд 29Other Complications
Deterioration of renal function
Metabolic disturbance e.g. hypomagnesia, pancreatitis, gout
or pseudogout
Слайд 30Secondary hyperparathyroidism
An increase in PTH secretion which is adaptive and
unrelated to intrinsic disease of the parathyroid glands is called
secondary hyperparathyroidism. This is due to chronic stimulation of the parathyroid glands by a chronic decrease in the ionic calcium level in the blood
Слайд 31Major causes of chronic hypocalcemia other than hypoparathyroidism
Dietary deficiency of
vitamin D or calcium
Decreased intestinal absorption of vitamin D or
calcium due to primary small bowel disease, short bowel syndrome, and post-gastrectomy syndrome.Drugs that cause rickets or osteomalacia such as phenytoin, phenobarbital, cholestyramine, and laxative.
Слайд 32Major causes of chronic hypocalcemia other than parathyroprival hypoparathyroidism
States of
tissue resistance to vitamin D
Excessive intake of inorganic phosphate compunds
Psudohypoparathyroidism
Severe
hypomagnesemiaChronic renal failure
Слайд 33Hypoparathyroidism
Deficient secretion of PTH which manifests itself biochemically by hypocalcemia,
hyperphospatemia diminished or absent circulating iPTH and clinically the symptoms
of neuromuscular hyperactivity.
Слайд 34Hypoparathyroidism
Surgical hypoparathyroidism – the commonest
After anterior neck exploration for thyroidectomy,
abnormal parathyroid gland removal, excision of a neck lesion. It
could be due to the removal of the parathyroid glands or due to interruption of blood supply to the glands.Causes:
Слайд 35Hypoparathyroidism
Idiopathic hypoparathyroidism
A form occuring at an early age (genetic origin)
with autosomal recessive mode of transmission “multiple endocrine deficiency –autoimmune-candidiasis
(MEDAC) syndrome”“Juvenile familial endocrinopathy”
“Hypoparathyroidism – Addisson’s disease – mucocutaneous candidiasis (HAM) syndrome”
Causes:
Слайд 36Hypoparathyroidism
Idiopathic hypoparathyroidism
Circulating antibodies for the parathyroid glands and the adrenals
are frequently present.
Other associated disease:
Pernicious anemia
Ovarian failure
Autoimmune thyroiditis
Diabetes mellitus
Causes:
Слайд 37Hypoparathyroidism
Idiopathic hypoparathyroidism
The late onset form occurs sporadically without circulating grandular
autoantibodies.
Functional hypoparathyroidism
In patients who has chronic hypomagesaemia of various causes.
Magnesium
is necessary for the PTH release from the glands and also for the peripheral action of the PTH.Causes:
Слайд 38Hypoparathyroidism
Neuromuscular
The rate of decrease in serum calcium is the major
determinant for the development of neuromuscular complications.
When nerves are exposed
to low levels of calcium they show abnormal neuronal function which may include decrease threshold of excitation, repetitive response to a single stimulus and rarely continuous activity.Clinical Features:
Слайд 39Hypoparathyroidism
Neuromuscular
Parathesia
Tetany
Hyperventilation
Adrenergic symptoms
Convulsion (More common in young people and it can
take the form of either generalized tetany followed by prolonged
tonic spasms or the typical epileptiform seizures.Signs of latent tetany
Chvostek sign
Trousseau sign
Extrapyramidal signs (due to basal ganglia calcification)
Clinical Features:
Слайд 40Hypoparathyroidism
Other clinical manifestation
Posterio lenticular cataract
Cardiac manifestation:
Prolonged QT interval in the
ECG
Resistance to digitalis
Hypotension
Refractory heart failure with cardiomegally can occur.
Clinical Features:
Слайд 41Hypoparathyroidism
Other clinical manifestation
Dental Manifestation
Abnormal enamel formation with delayed or absent
dental eruption and defective dental root formation.
Malabsorption syndrome
Presumably secondary to
decreased calcium level and may lead to steatorrhoea with long standing untreated disease.Clinical Features:
Слайд 42Hypoparathyroidism
In the absence of renal failure the presence of hypocalcaemia
with hyperphosphataemia is virtually diagnostic of hypoparathyroidism. Undetectable serum iPTH
confirms the diagnosis or it can be detectable if the assay is very sensitive.Diagnosis:
Слайд 43Hypoparathyroidism
The mainstay of treatment is a combination of oral calcium
with pharmacological doses of vitamin D or its potent analogues.
Phosphate restriction in diet may also be useful with or without aluminum hydroxide gel to lower serum phosphate level.Treatment:
Слайд 44Emergency Treatment for Hypocalcaemic
Calcium should be given parenterally till adequate
serum calcium level is obtained and then vitamin D supplementation
with oral calcium should be initiated.Tetany:
Слайд 45Emergency Treatment for Hypocalcaemic
In patients with hyperparathyroidism and severe bone
disease who undergo successful parathyroidectomy hypocalcaemia may be severe and
parenteral calcium infusion with later supplementation with oral calcium and vitamin D.Hungry bone syndrome:
Слайд 46Pseudohypoparathysoidism and Pseudopseudohypoparathyroidism
A rare familial disorders with target tissue resistance
to PTH. There is hypocalcaemia, hyperphosphataemia, with increased parathyroid gland
function. There is also a variety of congenital defects in the growth and development of skeleton including:Short statue
Short metacarpal and metatarsal bones
Слайд 47Pseudohypoparathysoidism and Pseudopseudohypoparathyroidism
In pseudopseudohypoparathyroidism they have the developmental defects without
the biochemical abnormalities
The diagnosis is established when low serum calcium
level with hyperphosphataemia is associated with increased serum iPTH as well as diminished nephrogenous CAMP and phosphature response to PTH administration
