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anybody?

transphenoidal surgery........noresponse-------use dopamin agonists-----still no responce-------octrotide------no responce------lastly radiotherapy....guide me if incorrect..thanks.

its correct.

let us give some detail about it......hypothalam secrete GHRH, this stimulate pituit to secrete GH and GH stimulate liver to produce IGF-1 which promote growth of bone , cartilage, muscle and other organs. At the same time hypothala secrete somatostatin which inhibit secretion of GH as regulatory

Excess growth hormone and IGF-1 in the blood cause most of the physical problems in acromegaly.
•Too much IGF-1 causes the bone growth that leads to changes in physical appearance and function.
•It causes thickening of soft tissues such as skin, tongue, and muscles. Enlargement of the tongue can lead to breathing problems and sleep apnea. Overgrowth of muscles can entrap nerves, causing pain syndromes such as carpal tunnel syndrome.
•Excess IGF-1 causes enlargement of organs such as the heart, which can result in heart failure and rhythm disorders.
•Excess growth hormone changes the way the body processes sugar and fats. This can cause diabetes and high levels of fats such as triglycerides in the blood. This in turn can lead to atherosclerosis and heart disease.

In more than 95% of cases of acromegaly, the excess growth hormone is produced by a tumor of the pituitary gland called adenoma.

•Secretion of growth hormone by a pituitary tumor is not controlled by the feedback loop. The end result is an excess of IGF-1, which causes abnormal tissue growth.

•They can, however, grow to considerable size and cause problems by pressing on and invading surrounding tissues.


Pt ususally come to office bec of headache or visual issues ....usually in their 40's 50s

complete PE
then you order routine testing based on PE results

CBC, BMP, LFT, FINGER STICK GLU, EKG, CXR,PRL, LIPID PROFILE , TSH, CT of head
GH, GHRH,IGF-1 LEVEL,cortisol,testo,lh,fsh,acth, bhcg if pt is female
if symptoms of arthritis, then order esr, ana, rf


SEND HOME TO SCHEDULE IN FEW DAY, during this time, you get all lab results and imaging.
when patient arrives, do focus Exam, if patient selected for surgery.
then admit to ward.
If patient taking thyroxine or hydrocortison keep taking medication
if pt taking ocp, stop them
if pt taking aspirin or ibuprofen stop 10 days before surgery, reschedule surgery
if pt taking aceta...continue
order
Pulse oxi
IVA
nss
phenergan
npo
fobt
cbc
bmp
pt, ptt
type and cross
bed rest
pneumatic stocking
urine out
foley cath

consent for procedure
Consult Neurosurgery----pituitary adenoma
consult opth
ampicillin+sulba
order transphenoidal hypopyhsectomy
and move the clock surgery is done

monitor pt in icu
contine foley and urine output
complete bed rest
cbc
bmp
cortisol level
GH level
continue antibiotic
vitals
focus exam eye and head , neck
case should end if you do this much

follow up ct of head
colonoscopy later
schedule for appoint in weeks give antibiotic when u discharge
GH level
cortisol level
counseling for sex, alchol, medication compliance and side effect, counsel pt...etc

pls add your comment or something is missing.

pt is very happy that dr sami treat him/her...and goes home well....

First treatment choice Transphenoidal surgery depending on size of tumor and Gh level

Tumor less than 10 mm or Gh less than 45 ng

If more we will give medical treatment to lower the size of pituitary and Gh level. Once level/ size achieved schedule for surgery. watch for adh hormone abnormalities after surgery..


Medical treatment for tumor size more than 10 mm or gh more than 45

doc is Somatostatin analogs (SSAs) are the first medication group used to treat acromegaly
so one injection once a month

second is GH receptor antagonists (GHRAs) once daily.

third is dopamine agonists are sometimes effective in patients who have mild degrees of excess GH and have both acromegaly and hyperprolactinemia

For those patients in which surgery could not remove whole tumor, people are not suitable for surgery, medical and surgical treatment have not relieved Acromegaly we use Radiotherapy. Watch for gradual decline of all pituitary hormones overtime with radiotherapy and supplement all hormone if the need be.

thank you swani and king

great case discussion