HYPERPARATHYROIDISM

Shariati Thursday Conference • 86 12 16 HYPERPARATHYROIDISM

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

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

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

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

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 metastasis or 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: • CNS Personal disturbance, coma, fatigue • Skin Dry skin, itching • Cardiovascular Hypertension, CHF

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

Lab exam, • Ca • Primary Up-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 quality macroradiography/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

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

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

HYPERPARATHYROIDISM