hyperparathyroidism shariati thursday conference 86 12 16
DESCRIPTION
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 catalysisTRANSCRIPT
HYPERPARATHYROIDISMHYPERPARATHYROIDISM
Shariati Thursday Conference86 12 16
ParaThyroid Hormone (PTH) Biochemistry Physiology pathophysiology
Hyperparathyroidism Clinical manifestation Diagnosis
◦Lab finding◦ imaging
treatment
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
Physiology
GI intake
Urinary out put
Bone
PTHVit DCalcitonin
GISweat
GI intake
Urinary out put
Bone
GISweat
Physiology
400-1000mg
10-70%
100-300mg>4mg/kg abn.
7g98%
Vit D
GI intake
Urinary out put
Bone Ca
GISweat
Physiology
.
99%=1-2kg
Intra cellular Ca 0.1%
1%Pr.Bound Ca 40%Non-ionized Ca 10%Ionized Ca 40%
Bone Ca
Kidney Ca
GI Ca
In minutes Osteocyt&blast
In days Osteoclast
Pathophysiology◦Primary hyperpara◦Secondary hyperpara◦Tertiary hyperpara
◦pseudohyperpara
Pathophysiology◦Primary hyperpara
◦Diffiuse hyperplasia 10-40%◦Single adenoma 50-80%◦Multiple adenoma 10%◦Carcinoma 1%
◦Secondary hyperpara◦Tertiary hyperpara
◦pseudohyperpara
Pathophysiology◦Primary hyperpara◦Secondary hyperpara
◦Secondary to hypocalcemia Renal dysfunction P Malabsorption P
◦Tertiary hyperpara
◦pseudohyperpara
Pathophysiology◦Primary hyperpara◦Secondary hyperpara◦Tertiary hyperpara
◦Autonomus hyperactivity after secondary hyperpara
◦pseudohyperpara
Pathophysiology◦Primary hyperpara◦Secondary hyperpara◦Tertiary hyperpara
◦pseudohyperpara ◦Hypercalcemia of malignancy
without metastasisor primary hyperpara
Pathophysiology◦Primary hyperpara Ca / N ◦Secondary hyperpara Ca / N◦Tertiary hyperpara
◦pseudohyperpara
Pathophysiology
◦Osteoclast/Osteoblast
◦Osteoclast activity◦Osteoblast activity
◦Remodeling activity
Clinic
100,000 new case / year in USA 1/1000
4th and 6th decade F/M = 2/1
Clinical findings:
◦Renal◦Gastrointestinal◦Skeletal manifestation
◦CNS◦Skin◦Cardiovascular
◦hypercalcaemia
common
rare
nowadays
Renal Urinary tract calculi Nephrolithiasis
Gastrointestinal Peptic ulcer Pancreatitis
Skeletal 10-25% Tenderness Aching pain (peripheral joints & vertebrae) Sever pain, swelling, deformity
Rare manifestations:
CNSPersonal disturbance, coma, fatigue
SkinDry skin, itching
CardiovascularHypertension, CHF
Lab exam,
◦Ca◦P◦Alk Ph.◦Urin Ca
Lab exam,
◦Ca PrimaryUp-N Secondary N-Low
Total Ca 50% ionic calcium (acidosis, hypoproteinemia)◦P◦Alk Ph.◦Urin Ca
◦PTH
Lab exam,
◦Ca◦P
◦Primary Low◦Secondary Up/Low
◦Alk Ph.◦Urin Ca
◦PTH
Lab exam,
◦Ca◦P◦Alk Ph.
◦Hyperphosphatesia
◦Urin Ca
◦PTH
Lab exam,
◦Ca◦P◦Alk Ph.◦Urin Ca.
◦Hypercalciurea
◦PTH
Lab exam,
◦Ca◦P◦Alk Ph.◦Urin Ca.
◦PTH ◦Up ◦Rarely N
Radiologic findings,
◦Bone resorption
◦Bone survey Bone resorption of hand is highly sensitive If
high qualitymacroradiography/digitalized radiograhy
◦Bone densitometry
Radiologic findings,
◦Bone resorption
◦Bone survey Bone resorption of hand is highly sensitive If
high qualitymacroradiography/digitalized radiograhy
◦Bone densitometry
Bone resorption Subperiosteal Juxtaarticular Intraarticular, (high turn over, hyperthyroidism) Subchondral Endosteal, (MM, Osteoporosis) Subphysial Trabecular Sublig. And sub tendinous Brown tumor
Bone resorptionSubperiosteal Juxtaarticular Intraarticular, (high turn over, hyperthyroidism) Subchondral Endosteal, (MM, Osteoporosis) SubphysialTrabecular Sublig. And sub tendinousBrown tumor
Subperiosteal resorption
Diagnostic (prominent) DD: chronic renal disease Radial aspect of the hand phalanx
Middle phalanx Index & middle finger
Subperioseal resorption
Progressive
lace like appearance
Subperioseal resorption
Progressive
lace like appearance
speculated contour
Subperioseal resorption
Progressive
lace like appearance
speculated contour
complete resorption of cortex
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
Subperiosteal resorption
Phalanx tuft, acro-osteolysis
Subperiosteal resorption
Phalanx tuft, acro-osteolysis
Subperiosteal resorption
Phalanx tuft, acro-osteolysis
Trabecular resorption
Medullary bone In advance stages Granular appearance
In cranium is caractristic osteopenia+speckled appear=Salt and Pepper
Trabecular resorption
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
Brown tumor
Usually after other signs Occasionally as presenting finding
Diagnosis
◦Lab exam Ca PTH
◦Preoperative study Tc labeled Sestamibi
Treatment
◦Surgery
◦Adenoma resection◦Resection of 3.5 gland
◦Post operative care
Thank you for your attention