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Parathyroid: primary hyperparathyroidism [53m] [27] - Coggle Diagram
Parathyroid: primary hyperparathyroidism [53m] [27]
presentation
often incidental finding of hypercalcaemia
PTH
from the four parathyroid glands
function
increase calcium resorption from the kidneys
stimulate vitamin D to active vitamin D conversion
promotes calcium uptake from the bowel
stimulate osteoclasts
release calcium from bone
under negative FB control
raised calcium = lowered PTH
lowered calcium = increased PTH
TYPES
Primary
adenoma of the parathyroid gland
commonly asymptomatic
often incidental finding
symptoms/signs when present
kidney stones
reduced bone density
neuropsychiatric symptoms
LAB FINDINGS
PTH high or normal
Calcium high
SECONDARY
Two causes
Low serum calcium because of:
renal disease
bowel disease
liver disease
very low vitamin D
PTH elevated
liberates calcium from bone
LAB FINDINGS
PTH high
Calcium low or normal
TERTIARY
usually in presence of chronic renal disease
usually following secondary hypoparathyroidism
parathyroid glands autonomously produce PTH
LAB FINDINGS
PTH high
Calcium high
from:
https://gpcpd.com/handbook/GP%20Update/Endocrinology/Parathyroid:%20primary%20hyperparathyroidism
Hypercalcaemia (in adults)
when to check calcium
Thirst
Urinary frequency
Constipation
Nausea
Vomiting
(Drowsiness is a late sign)
Bone pathology
osteoporosis
fragility fractures
Renal pathology
EG renal stone
cancers known or suspected and associated with hypercalcaemia
Lung cancer
Myeloma
Chronic non-specific presentations (consider calcium check):
pain
Bone
Muscle
Joint
mental health
anxiety
depression or low mood
irritable
apathy
lethargy
digestive problems
mild confusion
CALCIUM FINDINGS and what to do
NORMAL serum corrected calcium
recheck serum corrected calcium on TWO separate occasions
serum corrected calcium second report:
2.6 mmol/L
Check PTH
repeat calcium
consider TFTs and myeloma screen
PTH Normal
cancer
hyperthyroidism
vitamin D toxicity
sarcoid
thiazides
acromegaly
Phaeochromocytoma
PTH below midpoint of reference range
cannot rule out primary hyperparathyroidism
1 more item...
PTH raised or above mid point and primary hyperparathyroidism suspected
likely primary hyperparathyroidism
1 more item...
2.5-2.59 mmol/L
Check PTH
repeat calcium
consider TFTs and myeloma screen
PTH Normal
cancer
hyperthyroidism
vitamin D toxicity
sarcoid
thiazides
1 more item...
acromegaly
Phaeochromocytoma
PTH below midpoint of reference range
Primary hyperparathyroidism unlikely
corrected serum calcium UP TO 2.9 mmol/L
any symptoms of hypercalcaemia?
NO
Serum corrected calcium MORE THAN 3 mmol/L
DISCUSS WITH SECONDARY CARE THAT DAY
may required admission
rehydration
treatment
MANAGEMENT IN PRIMARY CARE
avoid
dehydration
look for suspect medications
thiazide diuretics
stop if possible
Lithium
DON'T restrict dietary calcium
Aim for serum vitamin D concentration ABOVE 50nmol/L
MONITORING people with PRIMARY hyperparathyroidism
when to measure serum corrected calcium
yearly if successful parathyroid surgery
yearly if not had surgery or successful surgery
check GFR
OSTEOPOROSIS RISK
known osteoporosis
refer endocrine
surgery improves BMD but skeletal recovery is slow
if not had surgery or successful surgery
DEXA at diagnosis
repeat every 2-3 years
consider surgery if osteoporosis present
Known renal stone
refer urology
if not had surgery or successful surgery
USS renal tract