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Primary and secondary hyperparathyroidism: symptoms and treatment

What it is?

Hyperparathyroidism is an endocrine disease that increases the production of parathyroid hormone (the main parathyroid hormone).

The latter (PTH) regulates the amount of calcium in the blood, ensuring its normal values. When calcium decreases, parathyroid hormone production in the parathyroid glands increases, with an excess of calcium, respectively, the formation of this hormone is inhibited.

Normally, parathyroid hormone is an important regulator of bone tissue renewal. Under his influence, calcium from the bone passes into the bloodstream, which leads to the stimulation of normal bone formation. He also delays the excretion of calcium through the kidneys, and excretion of phosphorus, on the contrary, increases.

Indirectly, parathyroid hormone affects the increase in calcium intake, through the formation of a special form of vitamin D, which facilitates the absorption of trace elements in the intestine.

Hyperparathyroidism

With a short impulse effect on the bone, the parathyroid hormone will stimulate bone formation, and during long-term and continuous bone destruction. In the main, a violation of the parathyroid glands is observed in adults.

  • Hyperparathyroidism in children is formed quite rarely, it can occur in a child, if the family had cases of this disease. In newborns, it is possible to detect temporary hyperparathyroidism, if during pregnancy the mother had a decrease in the production of parathyroid hormone. The manifestations and causes of hyperparathyroidism are identical to those in adults.

Content

Primary hyperparathyroidism

In the primary hyperparathyroidism of the parathyroid glands, the formation of parathyroid hormone does not depend on the amount of calcium in the blood. Often, from the moment of occurrence of this disease to diagnosis, a lot of time passes, although hyperparathyroidism is the third most common endocrine disease (diabetes is in the first place, the second is an increase in thyroid function).

The reason for late diagnosis may be insufficient attention to the change in the amount of calcium in the blood, the range of which is very narrow and amounts to 2-2.8 mmol / l.

Often, the increase in normal numbers is ignored, although double registration of hypercalcemia is the basis for the diagnostic search for hyperparathyroidism. The peak of the development of the disease falls on 40-50 years, more often women suffer in the period after the onset of menopause .

The causes of primary hyperparathyroidism are conditions that lead to increased production of parathyroid hormone by altered parathyroid cells:

  • Parathyroid adenoma, or parathyroma, is a tumor that consists of active cells that produce a hormone. In 80% of cases, this tumor is single, that is solitary. Multiple adenomas are detected in 5% of patients;
  • Hyperplasia, i.e. an increase in the size of the glands due to the proliferation of normal glandular tissue (15%);
  • Syndromes of multiple endocrine neoplasias: MEN-1 and MEN-2A. When signs of hyperparathyroidism are detected, the patient should be checked for the presence of other components of these syndromes: medullary thyroid cancer, pancreatic islet tumor , pheochromocytoma.

Secondary hyperparathyroidism

This form develops as a reaction of the body to a reduced amount of calcium in the blood. In response to low calcium, an increase in parathyroid hormone occurs. The causes of secondary hyperparathyroidism are the following conditions that reduce the level of calcium in the blood:

  • Renal failure, in which, due to a number of biochemical disorders, a decrease in calcium in the blood occurs, and the formation of the desired form of vitamin D is impaired;
  • Digestive diseases: malabsorption syndrome, which leads to impaired absorption of calcium and vitamin D; cirrhosis of the liver, in which there is a violation of the conversion of vitamin D, resulting in a decrease in calcium intake from the intestine into the blood;
  • Conditions after digestive tract surgery, such as total gastrectomy and Billroth-2 surgery;
  • Permanent and prolonged lack of sun, leading to a decrease in the synthesis of vitamin D in the body.

The renal form of secondary hyperparathyroidism is observed in connection with the frequent use of hemodialysis and the improvement of life expectancy in patients with chronic kidney failure. The causes of tertiary hyperparathyroidism are hyperplasia or parathyroid adenoma, due to prolonged secondary hyperparathyroidism.

Symptoms of primary hyperparathyroidism

Symptoms of primary hyperparathyroidism Symptoms of the disease depends on the form of the disease, let's start with the symptoms of primary hyperparathyroidism.

In the initial period of manifestation of the primary form, the symptoms are non-specific, which makes diagnosis difficult. Patients complain of muscle and general weakness, rapid fatigue, lethargy. Further development of the disease has a variety of manifestations.

There are several forms in which the leading is a single sign, or a combination of them:

  1. Bone form;
  2. Visceropathic form;
  3. Neuropsychic form;
  4. Mixed form.

Bone changes. At a constantly elevated level of PTH, bone destruction prevails over its recovery. The destruction of bone tissue is observed in half of patients with hyperparathyroidism. Osteodystrophy manifestations are:

  • Bone pain, especially along the spine;
  • Deformities of the bones, the development of cavities in them, cysts detected on x-ray images;
  • "Duck" gait, as a result of deformation and pain;
  • Pathological fractures, i.e. fractures occurring with less impact on the bones than with a normal injury;
  • The loss of teeth, as a result of jaw osteoporosis;
  • Chondrocalcinosis of the joints - the deposition of calcium in the cartilage tissue of the joint, which leads to the restriction of its mobility, the appearance of thorns, pain when moving. Develops often.

Renal symptoms of hyperparathyroidism are expressed in 50% of patients; these are:

  • The earliest symptoms are thirst and a large amount of urine excreted, which, when tested in laboratory, has a low density. This can be mistakenly regarded as a manifestation of diabetes insipidus ;
  • Kidney stones are found in 25% of patients, often this condition is accompanied by pyelonephritis. The presence of kidney stones may not be felt in any way, but may be manifested by renal colic. Pyelonephritis is characterized by signs of inflammation in the form of the appearance of leukocytes in the urine, back pain and a rise in body temperature. In 2% of all patients with urolithiasis, primary hyperparathyroidism is detected;
  • Nephrocalcinosis - the deposition of calcium salts in the kidney tissue, is rarely observed, it is difficult, leading to renal failure .

Changes in the psyche for a long time are the only symptoms of hyperparathyroidism:

  • Depression, depression;
  • Drowsiness;
  • Decrease in intellectual abilities;
  • Memory impairment

Neuromuscular signs of hyperparathyroidism are caused by irritation of the nerve endings in the destruction of the bone structures of the spine, as well as the disruption of normal muscle contractions. Manifestations of this form:

  • Muscle weakness, most pronounced in the limbs;
  • Pain in the spine;
  • Amyotrophy;
  • Symptoms of tension;
  • Paralysis of the muscles of the pelvis, lower limbs;
  • The appearance of parasthesia - discomfort on the skin in the form of tingling, burning, crawling.

Organs of the gastrointestinal tract - the manifestation of violations can be observed in half of the patients:

  • Lack of appetite, weight loss, nausea, bloating, constipation. These manifestations are observed even at the onset of the disease;
  • Acute pain in the stomach, can be interpreted as manifestations of the "acute abdomen" - an emergency surgical pathology;
  • Peptic ulcers of the stomach, duodenum develop in 10% of patients with an increase in parathyroid hormone. Such ulcers are prone to frequent recurrences;
  • Changes in the pancreas: chronic inflammation (pancreatitis), calcium deposition in the tissue of the gland is rarely observed - pancreatocalcinosis and the formation of stones in the ducts - pancreatocalcosis.

Other organs and body systems

Changes in the cardiovascular system are expressed in increased blood pressure and a violation of the normal heart rhythm. An ECG may reveal an increase in the size of the left ventricle, which is a risk factor for death in this pathology.

Severe, albeit rare, complication of primary hyperparathyroidism is a hypercalcemic crisis. Develops if the level of calcium in the blood rises to 4 mmol / l. It can be triggered by the administration of diuretic preparations of the thiazide series, prolonged bed rest, as well as the erroneous prescription of calcium and vitamin D preparations in order to treat osteoporosis without finding out its true causes.

The following symptoms that add to the symptoms of hyperparathyroidism correspond to a sharp increase in blood calcium levels:

  • Excitement, psychosis, which quickly turns into a stupor and to whom. A coma is difficult to distinguish from a coma caused by another cause;
  • Gastrointestinal symptoms are increasing;
  • Dehydration and weakness develop rapidly;
  • Urination stops - anuria develops;
  • Muscular disorders develop in the upper half of the body, up to and including the cessation of the work of the diaphragm and intercostal muscles, which requires the start of artificial respiration;
  • Characteristic increase in temperature to 39 ° C.

Symptoms of secondary hyperparathyroidism

Manifestations of secondary hyperparathyroidism are caused by the symptoms of the disease that led to its development. Most often, these are manifestations of chronic renal failure.

Specific manifestations of the secondary form: pain in bones and joints, muscle weakness, fractures and bone deformities. The deposition of calcium salts in the joints of the arms and legs leads to the appearance of hard nodules around the joints.

Red eye syndrome refers to a combination of inflammation and calcification of the conjunctiva and cornea.

Treatment of hyperparathyroidism - drugs and techniques

When laboratory confirmation of hypercalcemia and increased levels of PTH, identifying symptoms characteristic of primary hyperparathyroidism, the treatment is surgical removal of the adenoma. After the elimination of hyperparathyroidism, medical treatment of bone tissue destruction is carried out.

Absolute indications for removal of adenoma:

  1. Life saving;
  2. Young patients without other health problems;
  3. In patients older than 50 years with asymptomatic, if hyperparathyroidism is detected by chance. The operation is carried out with the progression of osteoporosis , the level of calcium is more than 3 mmol / l, the presence of calcined kidneys, the decrease in creatinine clearance below 30%.

If for some reason, surgical treatment of hyperparathyroidism is not carried out, then patients need to drink plenty of fluids, move more actively, prevent the development of dehydration, control pressure, and post-menopausal women are recommended to take estrogens.

Prohibited from taking thiazide diuretics (eg, hypothiazide), as well as cardiac glycosides.

Every 6 months you need to check the level of calcium and creatinine in the blood, the level of excretion of calcium in the urine. Annual studies are abdominal ultrasound and bone density measurement (densitometry).

  • If hyperplasia of a parathyroid gland is detected, then all 4 glands are removed, which are then transplanted to the patient in the fiber on the arm.

Treatment of hypercalcemic crisis:

  • Intravenous drip of saline to eliminate dehydration;
  • In / in the introduction of bisphosphonates (to combat osteoporosis): pamidronate, ethyldronate from 4 to 24 hours;
  • V / m injection of calcitonin –hormone, whose action is opposite to parathyroid hormone;
  • Furosemide is injected only after dehydration is eliminated, 30 minutes after the start of the infusion of saline;
  • With a decrease in the level of phosphorus in the blood, preparations of phosphorus salts are used;
  • If the crisis is provoked by the use of vitamin D - apply glucocorticoids;
  • A crisis against kidney failure requires dialysis with a non-calcium buffer.

About the treatment of secondary hyperparathyroidism

Secondary hyperparathyroidism requires treatment of the underlying disease. To prevent the increase in the production of parathyroid hormone in renal failure, it is necessary to administer drugs that bind phosphorus: calcium gluconate, citrate, lactate, in order to maintain the blood phosphorus level not more than 1.5 mmol / l.

Assign preparations of the active form of vitamin D: rocaltrol and control the excretion of calcium in the urine (no more than 300 mg per day).

Tertiary hyperparathyroidism with the formation of adenoma requires only surgical treatment.

Forecast

If early detection of impaired parathyroid hormone results in adequate treatment of hyperparathyroidism, the prognosis is favorable.

Without treatment, all manifestations of the disease are aggravated, especially the destruction of bones, the increase in fractures, the formation of severe complications caused by the deposition of calcium in organs, such as nephrocalcinosis, pancreacinosis, etc., the development of urolithiasis, arrhythmias, often recurrent gastric ulcers and duodenal ulcer guts.

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