Insufficiency of the anterior pituitary gland : Diagnosis and differential diagnosis
Endocrinology / / May 20, 2016
The diagnosis is not difficult in the presence of a deployed pattern of simultaneous failure of the thyroid gland, adrenal cortex and gonads and such characteristic features as the loss of pubic hair and armpits, a special pallor, especially if these symptoms appeared shortly after the pathologicalchildbirth complications massive bleeding, shock or post-partum sepsis.
significantly greater diagnostic difficulties arise with the gradual development of the disease in patients with postpartum necrosis of the anterior pituitary, hypopituitarism who clinically detected after a long "latency" period.In these patients early in the disease to the forefront of the clinical picture often appears disturbance or reduction in the function of any one of glands under the regulatory influence of the anterior pituitary gland, while the changes in the function of other glands may be hidden or absent.As already mentioned, it is often the first manifestation of the disease is a violation of gonadotropic pituitary functi
Systematic monitoring of women after childbirth in massive bleeding and shock bolevshih or puerperal sepsis may help early detection and proper diagnosis of postpartum hypopituitarism.
When deficiency symptoms of anterior pituitary in climacteric women age period requires careful study anemneze with particular attention to the presence in the past, childbirth or abortion, complicated by massive bleeding, collapse or sepsis.
Purposeful examination of these groups of patients with the use of modern methods of hormonal studies - definition of urinary 17-keto steroids and 17 glucocorticoids, level 17 oksikortiko steroids in the blood sample with the SU-4885 and samples from pyrogens, the definition of basal metabolism, protein-bound iodinecapture of radioactive iodine by the thyroid gland - usually reveals insufficient function of the adrenal cortex and thyroid, associated with a decrease in the function of the anterior pituitary, low re-release of gonadotropins gives an indication of the decrease in gonadotropic pituitary function.
Differential diagnosis with primary chronic insufficiency of the adrenal cortex in patients with adrenal insufficiency appears in the clinical picture to the fore, based on the absence of pigmentation, hair loss and a characteristic pale in patients with hypopituitarism, and they have the explicit or implicit signs of insufficiency of sexand thyroid glands.Primary chronic adrenal insufficiency can be eliminated by using the ACTH stimulation tests in those patients with a decrease in the function of the anterior pituitary, who retain the ability to respond to stimulation of the adrenal adrenocorticotropic hormone.However, the negative results of the samples - no increase in urinary excretion of 17-ketosteroids and 17-hydroxycorticosteroids and raising 17 glucocorticoids in the blood after administration of ACTH - are not reliable sign primary adrenal damage, since the long-term course of disease adrenal cortex, some patients postpartum hypopituitarismIt loses its ability to respond to ACTH stimulation.
Those patients whose predominant symptoms of thyroid insufficiency, it may be necessary the differential diagnosis with primary hypothyroidism.In patients with hypopituitarism, in contrast to patients with primary myxedema usually no pronounced Mick-sedematoznye skin changes and significant hypercholesterolemia can be detected signs of insufficiency of sexual glands and the adrenal cortex;they increasingly tend to hair loss of pubic and axillary areas.With the introduction of thyroid stimulating hormone in patients with deficiency of the anterior pituitary increases the capture of radioactive iodine by the thyroid gland and the level of iodine, bound to proteins in the blood, which is not the case in patients with primary myxedema.In patients with hypopituitarism, as a rule, no circulating antibodies in the blood to tireoglobinu often detected in patients with primary myxedema.Diagnostic significance and results of treatment with thyroid hormones.The effect of therapy in patients with hypopituitarism significantly worse than in patients with primary hypothyroidism, and may even come a deterioration of general condition due to lack of identification of the symptoms of adrenal cortex as the elimination of hypothyroidism.
Due to the fact that the leading symptom of some forms of pathology deficient dientsefalogipofizarnoy anterior pituitary cachexia is, the idea of this pathology oo often occurs when there is common in patients with debilitating diseases such as malignant tumors, tuberculosis, sprue, chronic colitis.Diagnostic difficulties are compounded by the fact that the duration of the current debilitating diseases patients is often compromised function of gonads - female menstrual cycle is disrupted, in men - impotence develops, and there are signs of decreasing function of the adrenal cortex - hypotonia, poor allocation of 17-keto steroids in urine.In the differential diagnosis of primary importance is a thorough comprehensive examination of all organs and systems of patients with progressive emaciation.Loss of hair on the body, characteristic of patients with hypopituitarism, usually absent in patients with cachexia caused by malignant tumors and chronic infection.
A number of patients is necessary differential diagnosis between dientsefalogipofizarnoy pathology with decreasing function of the anterior pituitary and psychogenic anorexia (anorexia nervosa).In this disease, the main pathogenetic link is to limit food intake - Fasting - in connection with the neuro-psychiatric disorders.The disease is almost exclusively in young girls and women, and the impetus for its development are usually sexual conflict or the desire to lose weight.Patients initially consciously restrict food intake further their appetite is reduced dramatically, there is an aversion to food.Often pronounced anorexia, and an aversion to eating there at the very beginning of the disease.In advanced stages of psychogenic anorexia patients are often unable to keep the food accepted, they appear vomiting after eating.Some patients dissimuliruyut their disease, arguing that they eat enough, artificially cause vomiting after meals.In connection with starvation in these patients typically develop secondary failure of endocrine glands, just as occurs in patients alimentary dystrophy.Patients stop menstruation, there is chilliness, constipation, dry skin, bradycardia, hypotension.Hormonal study can not always help in the differential diagnosis.As in patients with deficiency of the anterior pituitary, with psychogenic anorexia with severe depletion reduced the basal metabolic rate and other indicators of thyroid functional activity.Isolation of 17-ketosteroids urine is at the lower limit of normal or below, though not reach such low numbers, which may be hypopituitarism patients.There are indications that in some patients with psychogenic anorexia in which excretion of 17-keto steroids significantly reduced the level of 17 glucocorticoids in the blood is often normal.
- Pathological Anatomy at the failure of the anterior pituitary
- deficiency of the anterior pituitary.The clinical picture
- deficiency of the anterior pituitary.These hormonal studies
- deficiency of the anterior pituitary.The disease
- deficiency of the anterior pituitary.Diagnosis and differential diagnosis
- Treatment failure of the anterior pituitary
Despite the similarity of symptoms of deficiency of the anterior pituitary and psychogenic anorexia, the differential diagnosis of these two diseases can usually be done at thebased on clinical data.Often, though not always, it is possible to identify the psychological conflict that led to the psychogenic anorexia, while in patients with hypopituitarism usually unable to communicate the disease to childbirth or abortion, complicated by bleeding, shock or sepsis, or to identify tumor symptoms or inflammation in dientsefalogipofizarnoyregion.Noteworthy is the difference of mentality sick and hypopituitarism of psychogenic anorexia.If the first is usually a comparatively early appears and progresses lethargy, apathy, indifference to the environment, and sometimes do not match the severity of somatic condition, the patients with psychogenic anorexia striking discrepancy between the degree of exhaustion and mental activity stored.Often, these patients continue their normal activities with such severe cachexia, where one would expect a complete loss of functionality.In contrast, patients with hypopituitarism in patients with psychogenic anorexia there is no loss of pubic hair and axillary regions, sometimes gain vellus hair growth is observed.Patients with psychogenic anorexia usually no atrophy of the mammary glands, even when pronounced cachexia, whereas patients with hypopituitarism mammary gland usually atrophic.