hypothyoroidismfinal-220831074132-dcfd00dc (1).pptx

parathyroidsm

1. Parathyroid Dr. S K Gupta Professor, Department of General Surgery JIMSH

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

3. Inferior glands Develop from 3 rd pharyngeal pouch Infront of RLN Variable in position: Tracheo-oesophageal groove, Behind esophgus, Carotid sheath Blood supply- inferior thyroid artery (End artery)

4. Parathormone 84 aminoacids Secretion not dependent on pitutary gland Half life- 4 minutes Functions : Converts vitamin D into 1,25- dihydrocholecalciferol in kidney Absorption of calcium from gut Mobilises calcium from bone Reabsorption from renal tubules

5. Calcium metabolism 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 Functions Blood coagulation Neuromuscular activity Cellular activity Bone integrity.

6. Hyperparathyroidism (HPT)

7. Hyperparathyroidism Types Primary Secondary Tertiary

8. PRIMARY HPT 3 rd most common endocrine disease Causes hypercalcemia Etiology Parathyroid adenoma Familial/ genetic causes MEN 1 syndrome Therapeutic ionizing radiations Lithium: parathyroid hyperplasia and HPT with no bone or renal problems

9. Clinical features of HPT Clinical vignette: “Bones, stones, abdominal groans and psychic moans” Middle aged women( 3:1) Incidence: 1:1000 Asymptomatic > 50% cases

10. Clinical feature contd. BONES Raised PTH Increased osteoclastic activity Extensive decalcification of bone Bone pain, subosteal erosions Osteitis fibrosa cystica : single/ multiple cysts/ pseudotumours in the jaw, skull or phalanges Osteopenia, osteoporosis and pathological fracture

11. Clinical feature contd. STONES: Renal stone in 25% patients Recurrent stones Calcium phosphate and oxalate type Metaststic calcification, nephrocalcinosis, renal failure Calcification in renal vessels: renal hypertension.

12. Clinical feature contd. ABDOMINAL GROANS Stimulates gastrin release: peptic ulceration Precipitate acute pancreatitis Increases gall stone disease ( calcium bilirubinate) 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 Abdominal pain Vomiting Dehydration Oliguria Muscular weakness Death Serum calcium: >12mg%

15. Acute hyperparathyroidism (Crisis) Treatment Forced diuresis: 3-5 litres of saline with furosemide Rehydration: normal saline 300ml/hr Steroids: inhibit effects of vitamin D Dose: 400/ day iv for 5 days Bisphosphonate: Clodronate 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 Dcreased Increased Increased serum PTH level: specific and diagnostic, > 0.5 Bone density assessment Vitamin D estimation Increased urinary calcium level: >250 mg/24 hours Raised alkaline phosphate level

17. Investigations X-ray features: skull: salt and pepper appearance Phalanges: supperiosteal bone resorption Jaw: osteitis fibrosa cystica Spine: rugger jersy spine USG abdomen Thallium- technetium scan: hot spotes ( diagnostic of parathyroid adenoma)

18. Treatment Parthyroidectomy Indications Severe symptoms Young age group Markedly reduced bone density Serum calcium > 11mg% Urinary calculi Urinary calcium > 400 mg/24 hours

19. Parathyroidectomy Preoperative preperation: Vocal cords assesed Treatment of high calcium levels preoperatively Diuresis Steroids: prednisolone 20mg TDS for 5 days Phosphate infusion: 100mmol infusion in 6 hours Calcitonin subcutaneous injection: 200 units BD for 5 days Biphosphate- Etiodronate disodium: 7-5 mg/kg slow iv infusion for 3 days Mithramycin: 25 microgram/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 sternocleidomastoid with marker stitch Transplanted gland slice in 1mm pieces 18 pieces embedded

21. Parathyroidectomy Adenoma in gland with normal other glands: Removal of single gland Carcinoma: parathyroidectomy plus hemithyroidectomy with postoperative radiotherapy

22. Parathyroidectomy & its variants Surgical approaches; Classical approach Minimally invasive parathyroidectomy Median sternotomy extension Video- assisted parathyroidectomy Endosopic 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. Hypoparathyroidism with severe hypocalcaemia- when all glands are removed Hungry bone syndrome: In patients with preop hyperthyoidism , Thyroid hormone level drops acutely after surgery, stimulus to break down bone is removed, Bones remove calcium from plasma rapidly

24. Parathyroidectomy Presentation Hypocalcaemia Hypophosphatemia Hypomagnesemia Hyperkalaemia Vitamin D supplementation and elemental calcium: for 6 months Calcitriol with 2gm calcium supplement.

25. MEN Syndrome

26. MEN Syndrome Autosomal dominant. Types Type 1 (Werner’s syndrome)- 3P’s P arathyroid hyperplasia/ adenoma P itutary tumour- Prolactinoma P ancreatic tumour- Gastrinoma, Insulinoma,Glucoganoma,VIP’oma Chromosome 11

27. MEN syndrome Type II A ( Sipple syndrome): chromosome 10 Medullary carcinoma thyroid Pheochromocytoma Parathyroid hyperplaisa Type II B or Type III Medullary carcinoma thyroid Pheochromocytoma Mucosal Neuroma Marfanoid habitus

28. Hypoparathyroidism

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

30. Hypoparathyoidism 2. Permanent: Less common (0.4%) Continues beyond 6 months Decreased calcium Increase in phosphorous. 3. Hungry bone syndrome: Common (5-13%)

31. Hypoparathyoidism Causes-: Direct trauma to parathyroid glands Devascularization of glands Removal of gland during surgery

32. Hypoparathyoidism Clinical features: Circumoral tingling, numbness and paresthesia Carpopedal spasm, laryngeal stridor Respiratory musckle spasm, suffocation Cataract formation Convulsion.

33. Hypoparathyoidism Treatment : IV calcium gluconate: 10ml, 10% solution oveer 10 minutes Ssymptoms not resolve: Calcium infusion at 1-2 mg/kg/hr 1-2 gm oral calcium per day. (Calcium carbonate: 1250 mg= 500mg elemental calcium) - Vitamin D supplementation: 0.25- 1 microigram/day.

34. Thank you