Acromegaly

 

Pituitary hormones:

Anterior

·     ACTH

·     TSH

·     GH

·     FSH and LH

·     PRL

Posterior

·     ADH

·     Oxytocin

 

Presentation:

Hx

Hypersecretion:

·     GH: acromegaly

·     PRL: similar effects to hypogonadism (?)

Insufficiency:

·     ↓FSH/LH: menstrual dysfunction in woman, impotence in men

·     ACTH and TSH deficiency rare

Mass effects:

·     Headache

·     Visual field defect (bitemporal hemianopia)

Ex

·     General: coarse features

·     Peripheries: enlarged hands, thick skin, sensory disturbance

·     Airway: macrognathia, macroglossia, deep voice

·     CVS: displaced apex, murmurs

Ix

·     ↑Serum IGF: diagnostic if clinical features present

·     OGTT: GH not suppressed

 

Issues:

Airway

·     Enlarged and distorted soft tissues

·     Narrowed subglottis

->Need plan ABCD

->±Need second anaesthetist

->±Need difficult airway trolley

->Difficult BMV: size 6 mask and guedel

->Difficult ETT: AFOI vs awake look vs VL; large blades + small ETT

Breathing

·     OSA in 50%

->Remifentanil infusion

->Awake extubation

Cardiovascular

·     HTN

·     LVH / diastolic dysfunction

·     Arrhythmias (AF?)

·     Ischaemic heart disease

·     Valvular heart disease (AR, MR)

·     Cardiomyopathy

->Need pre-op TTE

->Need arterial line

Endocrine

·     Hypersecretion:

-> Somatostatin

·     Insufficiency:

-> Replacement (esp. if glucocorticoid or thyroid)

·     T2DM

-> Regular ABG

-> Avoid dexamethasone for anti-emetic

·     Central diabetes insipidus

-> Monitor urine output

-> Monitor biochemistry (Na+ and osmo, urine and plasma)

-> ±Desmopressin (need endocrinology plan)

Musculoskeletal

·     Enlarged and distorted skeleton (e.g. kyphosis)

->Care with patient positioning; pad the joints

·     Neurovascular compression syndromes (e.g. ulnar artery in 50%)

->Avoid radial arterial line

 

 

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