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Section II General Surgery P203Surgical Recall Sixth > Parathyroid C59 P452-458 > Flashcards

Parathyroid C59 P452-458 Flashcards

1
Q

ANATOMY
How many parathyroids are
there?
P452

A 
Usually four (two superior and two
inferior)
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2
Q

ANATOMY
What percentage of patients
have five parathyroid glands?
P452

A

≈5% (Think: 5 = 5)

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3
Q 
ANATOMY
What percentage of patients
have three parathyroid
glands?
P452
A

≈10%

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4
Q 
ANATOMY
What is the usual position of
the inferior parathyroid
glands?
P452
A

Posterior and lateral behind the thyroid

and below the inferior thyroid artery

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5
Q

ANATOMY
What is the most common
site of an “extra” gland?
P452

A

Thymus gland

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6
Q 
ANATOMY
What percentage of patients
have a parathyroid gland in
the mediastinum?
P452
A

≈1%

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7
Q 
ANATOMY
If only three parathyroid
glands are found at surgery,
where can the fourth one
be hiding?
P452
A 
Thyroid gland
Thymus/mediastinum
Carotid sheath
Tracheoesophageal groove
Behind the esophagus
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8
Q 
ANATOMY
What is the embryologic
origin of the following structures:
Superior parathyroid glands?
P453
A

Fourth pharyngeal pouch

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9
Q 
ANATOMY
What is the embryologic
origin of the following structures:
Inferior parathyroid glands?
P453
A

Third pharyngeal pouch

counterintuitive

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10
Q

ANATOMY
What supplies blood to the
parathyroid glands?
P453

A

Inferior thyroid artery

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11
Q 
ANATOMY
What percentage of patients
have all four parathyroid
glands supplied by the
inferior thyroid arteries
exclusively?
P453
A

≈80%

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12
Q

ANATOMY
What is DiGeorge’s
syndrome?
P453

A

Congenital absence of the parathyroid

glands and the thymus

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13
Q 
ANATOMY
What is the most common
cause of hypercalcemia in
hospitalized patients?
P453
A

Cancer

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14
Q 
ANATOMY
What is the most common
cause of hypercalcemia in
outpatients?
P453
A

Hyperparathyroidism

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15
Q

PHYSIOLOGY
What cell type produces
PTH?
P453

A

Chief cells produce ParaThyroid

Hormone (PTH)

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16
Q

PHYSIOLOGY
What are the major actions
of PTH?
P453

A 
Increases blood calcium levels (takes
from bone breakdown, GI absorption,
increased resorption from kidney,
excretion of phosphate by kidney),
decreases serum phosphate
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17
Q

PHYSIOLOGY
How does vitamin D work?
P453

A

Increases intestinal absorption of calcium

and phosphate

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18
Q

PHYSIOLOGY
Where is calcium absorbed?
P453

A

Duodenum and proximal jejunum

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19
Q

HYPERPARATHYROIDISM (HPTH)
Define primary HPTH.
P454

A

Increased secretion of PTH by parathyroid
gland(s); marked by elevated calcium,
low phosphorus

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20
Q

HYPERPARATHYROIDISM (HPTH)
Define secondary HPTH.
P454

A 
Increased serum PTH resulting from
calcium wasting caused by renal failure
or decreased GI calcium absorption,
rickets or osteomalacia; calcium levels
are usually low
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21
Q

HYPERPARATHYROIDISM (HPTH)
Define tertiary HPTH.
P454

A 
Persistent HPTH after correction of
secondary hyperparathyroidism; results
from autonomous PTH secretion not
responsive to the normal negative
feedback due to elevated Ca⁺ ⁺ levels
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22
Q

HYPERPARATHYROIDISM (HPTH)
What are the methods of
imaging the parathyroids?
P454

A 
Surgical operation
Ultrasound
Sestamibi scan
201TI (technetium)–thallium subtraction
    scan
CT/MRI
A-gram (rare)
Venous sampling for PTH (rare)
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23
Q 
HYPERPARATHYROIDISM (HPTH)
What are the indications for
a localizing preoperative
study?
P454
A

Reoperation for recurrent

hyperparathyroidism

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24
Q

HYPERPARATHYROIDISM (HPTH)
What is the most common
cause of primary HPTH?
P454

A

Adenoma ( >85%)

25
Q 
HYPERPARATHYROIDISM (HPTH)
What are the etiologies
of primary HPTH and
percentages?
P454
A

Adenoma ( ≈85%)
Hyperplasia ( ≈10%)
Carcinoma ( ≈1%)

26
Q 
HYPERPARATHYROIDISM (HPTH)
What is the incidence of
primary HPTH in the
United States?
P454
A

≈1/1000–4000

27
Q

HYPERPARATHYROIDISM (HPTH)
What are the risk factors for
primary HPTH?
P454

A

Family history, MEN-I and MEN-IIa,

irradiation

28
Q 
HYPERPARATHYROIDISM (HPTH)
What are the signs/
symptoms of primary HPTH
hypercalcemia?
P455
A 
“Stones, bones, groans, and
psychiatric overtones”:
    Stones: Kidney stones
    Bones: Bone pain, pathologic
       fractures, subperiosteal resorption
    Groans: Muscle pain and weakness,
       pancreatitis, gout, constipation
    Psychiatric overtones: Depression,
       anorexia, anxiety
    Other symptoms: Polydipsia, weight
       loss, HTN (10%), polyuria, lethargy
29
Q

HYPERPARATHYROIDISM (HPTH)
What is the “33 to 1” rule?
P455

A

Most patients with primary HPTH have a

ratio of serum (Cl⁻) to phosphate ≥33

30
Q

HYPERPARATHYROIDISM (HPTH)
What plain x-ray findings are
classic for HPTH?
P455

A

Subperiosteal bone resorption (usually in
hand digits; said to be “pathognomonic”
for HPTH!)

31
Q

HYPERPARATHYROIDISM (HPTH)
How is primary HPTH
diagnosed?
P455

A

Labs—elevated PTH (hypercalcemia,
↓ phosphorus, ↑ chloride); urine calcium
should be checked for familial
hypocalciuric hypercalcemia

32
Q

HYPERPARATHYROIDISM (HPTH)
What is familial hypocalciuric
hypercalcemia?
P455

A 
Familial (autosomal-dominant)
    inheritance of a condition of
    asymptomatic hypercalcemia
    and low urine calcium, with or
    without elevated PTH; in contrast,
    hypercalcemia from HPTH results in
    high levels of urine calcium
Note: Surgery to remove parathyroid
    glands is not indicated for this diagnosis
33
Q 
HYPERPARATHYROIDISM (HPTH)
How many of the glands are USUALLY affected by the
following conditions:
Hyperplasia?
P455
A

4

34
Q 
HYPERPARATHYROIDISM (HPTH)
How many of the glands are USUALLY affected by the
following conditions:
Adenoma?
P455
A

1

35
Q 
HYPERPARATHYROIDISM (HPTH)
How many of the glands are USUALLY affected by the
following conditions:
Carcinoma?
P455
A

1

36
Q 
HYPERPARATHYROIDISM (HPTH)
What percentage of adenomas
are not single but found in
more than one gland?
P455
A

≈5%

37
Q

HYPERPARATHYROIDISM (HPTH)
What is the differential
diagnosis of hypercalcemia?
P456

A 
“CHIMPANZEES”:
    Calcium overdose
    Hyperparathyroidism (1/2/3),
    Hyperthyroidism, Hypocalciuric
       Hypercalcemia (familial)
    Immobility/Iatrogenic (thiazide
       diuretics)
    Metastasis/Milk alkali syndrome (rare)
    Paget’s disease (bone)
    Addison’s disease/acromegaly
    Neoplasm (colon, lung, breast,
       prostate, multiple myeloma)
    Zollinger-Ellison syndrome
    Excessive vitamin D
    Excessive vitamin A
    Sarcoid
38
Q 
HYPERPARATHYROIDISM (HPTH)
What is the initial medical
treatment of hypercalcemia
(1 HPTH)?
P456
A

Medical—IV fluids, furosemide—NOT

thiazide diuretics

39
Q 
HYPERPARATHYROIDISM (HPTH)
What is the definitive treatment of HPTH in the
following cases:
Primary HPTH resulting
from HYPERPLASIA?
P456
A 
Neck exploration removing all
parathyroid glands and leaving at least
30 mg of parathyroid tissue placed in the
forearm muscles (nondominant arm, of
course!)
40
Q 
HYPERPARATHYROIDISM (HPTH)
What is the definitive treatment of HPTH in the
following cases:
Primary HPTH resulting
from parathyroid
ADENOMA?
P456
A

Surgically remove adenoma (send for
frozen section) and biopsy all abnormally
enlarged parathyroid glands (some
experts biopsy all glands)

41
Q 
HYPERPARATHYROIDISM (HPTH)
What is the definitive treatment of HPTH in the
following cases:
Primary HPTH resulting
from parathyroid
CARCINOMA?
P456
A

Remove carcinoma, ipsilateral thyroid
lobe, and all enlarged lymph nodes
(modified radical neck dissection for LN
metastases)

42
Q 
HYPERPARATHYROIDISM (HPTH)
What is the definitive treatment of HPTH in the
following cases:
Secondary HPTH?
P456
A

Correct calcium and phosphate; perform
renal transplantation (no role for
parathyroid surgery)

43
Q

HYPERPARATHYROIDISM (HPTH)
Tertiary HPTH?
P457

A 
Correct calcium and phosphate; perform
surgical operation to remove all parathyroid
glands and reimplant 30 to 40 mg in the
forearm if REFRACTORY to medical
management
44
Q 
HYPERPARATHYROIDISM (HPTH)
Why place 30 to 40 mg of
sliced parathyroid gland in
the forearm?
P457
A

To retain parathyroid function; if HPTH
recurs, remove some of the parathyroid
gland from the easily accessible forearm

45
Q 
HYPERPARATHYROIDISM (HPTH)
What must be ruled out in
the patient with HPTH from
hyperplasia?
P457
A

MEN type I and MEN type IIa

46
Q 
HYPERPARATHYROIDISM (HPTH)
What carcinomas are
commonly associated with
hypercalcemia?
P457
A

Breast cancer metastases, prostate
cancer, kidney cancer, lung cancer,
pancreatic cancer, multiple myeloma

47
Q 
HYPERPARATHYROIDISM (HPTH)
What is the most likely
diagnosis if a patient has a
PALPABLE neck mass,
hypercalcemia, and elevated
PTH?
P457
A

Parathyroid carcinoma (vast majority
of other causes of primary HPTH have
nonpalpable parathyroids)

48
Q

PARATHYROID CARCINOMA
What is it?
P457

A

Primary carcinoma of the parathyroid

gland

49
Q

PARATHYROID CARCINOMA
What is the number of
glands usually affected?
P457

A

1

50
Q

PARATHYROID CARCINOMA
What are the signs/
symptoms?
P457

A 
Hypercalcemia, elevated PTH,
PALPABLE parathyroid gland (50%),
pain in neck, recurrent laryngeal nerve
paralysis (change in voice), hypercalcemic
crisis (usually associated with calcium
levels > 14)
51
Q

PARATHYROID CARCINOMA
What is the common tumor
marker?
P457

A

Human Chorionic Gonadotropin

HCG

52
Q

PARATHYROID CARCINOMA
What is the treatment?
P457

A

Surgical resection of parathyroid mass
with ipsilateral thyroid lobectomy,
ipsilateral lymph node resection

53
Q 
PARATHYROID CARCINOMA
What percentage of all
cases of primary HPTH
are caused by parathyroid
carcinoma?
P458
A

1%

54
Q 
PARATHYROID CARCINOMA
POSTOPERATIVE COMPLICATIONS OF PARATHYROIDECTOMY
What are the possible
postoperative complications
after a parathyroidectomy?
P458
A 
Recurrent nerve injury (unilateral: voice
change; bilateral: airway obstruction),
neck hematoma (open at bedside if
breathing is compromised), hypocalcemia,
superior laryngeal nerve injury
55
Q 
PARATHYROID CARCINOMA
POSTOPERATIVE COMPLICATIONS OF PARATHYROIDECTOMY
What is “hungry bone
syndrome”?
P458
A

Severe hypocalcemia seen after surgical
correction of HPTH as chronically
calcium-deprived bone aggressively
absorbs calcium

56
Q 
PARATHYROID CARCINOMA
POSTOPERATIVE COMPLICATIONS OF PARATHYROIDECTOMY
What are the signs/
symptoms of postoperative
hypocalcemia?
P458
A

Perioral tingling, paresthesia,
+ Chvostek’s sign, + Trousseau’s sign,
+ tetany

57
Q 
PARATHYROID CARCINOMA
POSTOPERATIVE COMPLICATIONS OF PARATHYROIDECTOMY
What is the treatment of
hypoparathyroidism?
P458
A

Acute: IV calcium
Chronic: PO calcium, and vitamin D

58
Q

PARATHYROID CARCINOMA
POSTOPERATIVE COMPLICATIONS OF PARATHYROIDECTOMY
What is parathyromatosis?
P458

A 
Multiple small hyperfunctioning
parathyroid tissue masses found over the
neck and mediastinum—thought to be
from congenital rests or spillage during
surgery—remove surgically (RARE)

Section II General Surgery P203Surgical Recall Sixth (33 decks)

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