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    Home > Active Ingredient News > Endocrine System > Practise a sharp eye and recognize "pituitary crisis"

    Practise a sharp eye and recognize "pituitary crisis"

    • Last Update: 2021-05-09
    • Source: Internet
    • Author: User
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    *Only for medical professionals to read for reference.
    The clinical manifestations of pituitary crisis are complex, the symptoms are changeable and critical, and the misdiagnosis rate is high.
    If timely diagnosis and treatment are not available, it is often life-threatening.

    Various lesions of the pituitary gland or hypothalamus can affect the endocrine function of the adenohypophysis.
    When all or most of the pituitary gland is destroyed, a series of endocrine gland dysfunction manifestations will occur.
    The main target glands involved are the gonads, thyroid, and thyroid gland.
    The adrenal cortex is clinically called hypophyseal hypofunction.

    Pituitary crisis is a medical emergency and severe disease that occurs based on the original hypophyseal function due to various factors that cause insufficient secretion of the pituitary gland or multiple hormones, leading to further failure of the target gland's function.
    It is also called "anterior pituitary function".
    Reduce the crisis".

    Although pituitary crises are rare, the clinical manifestations are complex, the symptoms are changeable and critical, and the misdiagnosis rate is high.
    If they are not diagnosed and treated in time, they are often life-threatening.

    For this reason, the author refers to the literature and summarizes the diagnosis of pituitary crisis for readers.

    1 Common causes of pituitary crises Pituitary crises are more common causes of Sheehan syndrome and pituitary stroke.

    1.
    Sheehan syndrome (Sheehan syndrome): It is due to pituitary embolism and avascular necrosis caused by postpartum hemorrhage, which in turn leads to hypophyseal hypofunction, which causes pituitary insufficiency, and can progress to a pituitary crisis in an emergency state.

    2.
    Pituitary apoplexy: Sudden intratumoral hemorrhage, infarction, necrosis of pituitary tumors, tumor swelling, and acute neuroendocrine disease.

    In addition, various stress factors, such as infection, diarrhea, vomiting, dehydration, hunger, cold, acute myocardial infarction, cerebrovascular accident, surgery, trauma, anesthesia and sedatives, improper use of hypoglycemic drugs can be used in pituitary function Pituitary crisis is induced on the basis of hypothyroidism.

    2 Clinical manifestations of pituitary crisis The clinical symptoms of pituitary crisis are diverse and lack specificity.
    The prominent manifestations are adrenal insufficiency or adrenal crisis and symptoms of hypothyroidism or mucinous edema coma, such as decreased resistance, fever, Prone to infection; fatigue, low blood pressure; anorexia, vomiting, abdominal pain and diarrhea; electrolyte disturbance; collapse, lack of energy, lethargy; increased sensitivity to analgesics and sedatives; slow metabolism, edema, etc.

    Critical manifestations such as confusion, coma, or shock are often caused.

    Common types of coma are as follows: ▎1.
    Hypoglycemic coma: the most common, mostly due to eating too little or not eating, occurs on an empty stomach (prone to infection); or insulin-induced (insulin tolerance test or insulin treatment patients and high glucose Cause endogenous insulin secretion).

    Clinical manifestations: dizziness, dizziness, sweating, palpitation, pale complexion, headache, vomiting, nausea, hypotension, restlessness or unresponsiveness, mental disorders and convulsions or epileptic seizures, and coma in severe cases.

    ▎2.
    Infectious coma: It is caused by a lack of multiple hormones, decreased resistance, infection and accompanying high fever.

    Clinical manifestations: loss of consciousness (progressive), high fever, relatively slow pulse, hypotensive shock, and severe circulatory failure.

    ▎3.
    ​​Drug-induced coma: mostly caused by the use of conventional doses of sedatives, anesthetics, and hypoglycemic drugs.

    Clinical manifestations: loss of consciousness, prolonged lethargy.

    ▎4.
    Natriuretic coma: It is mostly caused by gastrointestinal disorders, surgery, infection and sodium loss; when glucocorticoids are first used, sodium excretion increases, which can lead to negative sodium balance and cause coma; thyroid hormone alone is used without timely supplementation Adrenal cortex hormones increase the body's adrenal hormone deficiency, while thyroid hormones also promote solute excretion.

    Clinical manifestations: obvious peripheral failure, loss of consciousness, shock, and coma.

    ▎5.
    Aquatic toxicity coma: due to excessive water intake (such as water diuresis test or spontaneous).

    Clinical manifestations: weakness, lethargy, loss of appetite, vomiting, mental disorders, convulsions, and coma in severe cases.

    There are also edema and weight gain.

    ▎6.
    Hypothermic coma: mostly caused by exposure to low temperature environment.

    Clinical manifestations: slow onset, coma, hypothermia (the rectal temperature can be lower than 30℃), vomiting, decreased vision, blindness, etc.

    ▎7.
    Coma after hypophysectomy: Hypophysectomy for various reasons leads to hypofunction of the endocrine glands, and water and electrolyte disorders after the operation.

    Clinical manifestations: lethargy or coma after surgery.

    ▎8.
    Pituitary stroke coma: due to acute bleeding in the pituitary tumor.

    Clinical manifestations: sudden onset, headache, dizziness, vomiting and even shock and coma.

    3 Laboratory examinations and imaging examinations of pituitary crisis 1.
    Laboratory examinations ① Lower blood sugar, even lower than 2.
    5mmol/L, is generally seen in hypoglycemic coma; serum sodium and chloride levels are low, seen in natriotic coma .

    ②Blood cortisol and thyroid hormones are all lower than normal, and must be absolute low values, ACTH, TSH and other pituitary hormones are lower than normal or in the lower limit of the normal range (the pituitary gland may be partially damaged leading to insufficient compensatory function, so Although the target hormone is severely lacking, the pituitary hormones such as ACTH and TSH cannot be fully compensated or compensatory increase).

    2.
    Imaging examinations Patients with suspected pituitary tumors and pituitary strokes can be examined by CT scan or MRI.

    1.
    During CT plain scan, the tumor may appear low-density or high-density area, and the tumor may show peripheral enhancement after injection of contrast agent.

    CT scan can still clarify the spread of subarachnoid hemorrhage and whether it extends to the ventricle.
    It can diagnose the course and time of pituitary adenoma hemorrhage, and has certain reference value for surgical selection.

    2.
    MRI examination of pituitary apoplexy can show that there is a high signal area in the lesion.

    Note that cerebrovascular angiography is not suitable for the crisis period.

    4 Diagnosis of pituitary crisis (1) A history of pituitary insufficiency (such as postpartum hemorrhage).

    (2) Coma or shock after stress, or urgent examination of pituitary hormones and their target hormones suggest pituitary insufficiency, combined with the clinical manifestations of hypotension, hypoglycemia, and hyponatremia, the diagnosis can be confirmed.

    (3) After the supplementation of glucocorticoid and thyroid hormone, the patient's symptoms and signs improved significantly.

    5How to avoid misdiagnosis of pituitary crisis? ▎Pituitary crisis is easily misdiagnosed as the following diseases: ①The gradual emergence of coma—misdiagnosed as stroke; ②With neck stiffness—misdiagnosed as meningitis; ③With convulsions—misdiagnosed as epilepsy; ④With slow heart rate— —Misdiagnosed as Aspen syndrome; ⑤Diabetic patients with starvation ketosis—misdiagnosed as diabetic ketoacidosis coma; ⑥Have taken anesthetics—misdiagnosed as anesthetic poisoning.

    ▎To avoid misdiagnosis, pay attention to the following points: ①Pay attention to the relevant medical history that causes hypophyseal dysfunction, and make detailed inquiry about the past history, birth history, and menstrual history, so as to discover the history of pituitary tumor surgery, pituitary radiotherapy, nasopharyngeal radiotherapy, History of postpartum hemorrhage, postpartum amenorrhea, no breasts, etc.
    ; ②Pay attention to physical examination, especially the examination of external genitalia, so as to find signs of hypophyseal hypofunction such as pubic and axillary hair loss, breast atrophy, light areola, pale and dry skin , And signs of hypothyroidism such as hypothermia, mucinous edema, bradycardia, etc.
    ; ③For patients who are unconscious, unconscious, lethargic, and weak, especially under stress conditions such as infection, diarrhea, vomiting, dehydration, and hunger , Cold, heatstroke, surgery, trauma, anesthesia, alcohol abuse, overwork, or various sedatives, sleep and hypoglycemic drugs, the possibility of pituitary crisis should be considered in the differential diagnosis; ④patients with hypopituitary function due to weakened immune function It is easy to be infected, but patients with severe hypothyroidism may not rise in body temperature, so the infection and severity cannot be judged based on body temperature.
    At the same time, patients with hypotensive shock may also lack the phenomenon of compensatory heart rate increase.

    References: [1] Yang Lianyue.
    Clinical experience in the Department of Endocrinology [M].
    Beijing: Science Press, 2011:11-12.
    [2] Xu Shutao, Zhang Qiyi, Li Chunbei.
    Clinical analysis of 24 cases of pituitary crisis[J ].
    Sichuan Medicine,2005,(11):89-90.
    [3] Zhao Minsu.
    Analysis of 23 cases of pituitary crisis[J].
    Journal of Medical Theory and Practice,2012,(24):3045-3046.
    [4] Li Yubing 、.
    Summary and review of diagnosis and treatment of pituitary crisis[J].
    Journal of Emergency and Critical Care Medicine.
    2017.
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