Académique Documents
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Yulius Tiranda
Departemen KMB
PSIK STIKes Muhammadiyah Palembang
Anatomy
The posterior section, also known as the
neurohypophysis,receives its signals through
axons that arise in neural bodies within the
hypothalamus and also traverse down the
stalk. Embryologically,the ante- rior pituitary
gland is derived from Rathkes pouch, an
evagination of the stomodeal ectoderm. In
contrast,the posterior pituitary arises in the
infundibulum, a part of the diencephalon.
HypothalamicPituitary
Pituitary Gland
Pituitary Gland
Master gland
Prolactin (PRL)
Secreted in a pulsatile manner
Elicits specific responses in peripheral target
tissues
Feedback control at the level of the
hypothalamus and pituitary to modulate
pituitary function exerted by the hormonal
products of the peripheral target glands
Tumors cause characteristic hormone
excess syndromes
Hormone deficiency
The six main pituitary hormones are Growth
Hormone (GH), Luteinising Hormone (LH), Follicle
Stimulating Hormone (FSH), thyrotropin (TSH),
Adrenocorticotropic Hormone (ACTH) and Prolactin
(PRL).
When one or more of these hormones is being
under-produced, the condition is called
hypopituitarism (also sometimes called multiple
pituitary hormone deficiency, or MPHD). When all
of these hormones are deficient, the condition is
called panhypopituitarism (pan means all).
Target
Organ
Hypopituitarism
An overview
Hypopituitarism, fi rst described clinically by
Simmonds in 1914,2 is the inability of the
pituitary gland to provide su cient hormones
adapted to the needs of the organism.
It might be caused by either an inability of the
gland itself to produce hormones or an insu
cient supply of hypothalamic-releasing
hormones.
Incidence and prevalence of hypopituitarism are
estimated to be 42 per 100 000 per year and 455 per
100 000, respectively. Although the clinical symptoms
of this disorder are usually unspecifi c, it can cause
life-threatening events and lead to increased mortality.
Current research has refi ned the diagnosis of
hypopituitarism.
Identification of growth hormone and corticotropin defi
ciency generally requires a stimulation test, whereas
other defi ciencies can be detected by basal hormones
in combination with clinical judgment.
Hypopituitarism
Etiology
Anterior pituitary diseases
Deficiency one or more or all anterior pituitary
hormones
Common causes:
Causes
Causes (2)
Causes (3)
Causes (4)
Causes of
hypopituitarism
Brain damage*
Traumatic brain injury
Subarachnoid
haemorrhage
Neurosurgery
Irradiation
Stroke
Pituitary tumours*
Adenomas
Others
Non-pituitary tumours
Craniopharyngiomas
Meningiomas
Gliomas
Chordomas
Ependymomas
Metastases
Infections
Abscess
Hypophysitis
Meningitis
Encephalitis
Symptoms and
Signs of Pituitary
Hormone
Deficience
Hyperpituitarism
Acromegaly
Hypopituitarism
Dwarfism
2. TSH deficiency causing thyroid hormone
deficiency:
Symptoms include fatigue, weakness, diculty
losing weight, generalized body puness, feeling
cold, constipation, diculty with memory and an
inability to concentrate. Skin may become dry and
the complexion pale.
In addition, anemia, high cholesterol levels and liver
problems may also occur. Patients with severe or
long-term deficiency can appear lethargic. Rarely,
severe thyroid hormone deficiency can cause coma,
low body temperature, and even death
3. LH and FSH deficiency in Women: LH and FSH
deficiency may cause loss of menstrual
cycles, infertility, decrease in sex drive and
vaginal dryness and osteoporosis, which can result
in a tendency to develop bone fractures.
LH and FSH deficiency in Men: LH and FSH
deficiency may cause loss of libido (interest in
sexual activity), diculty in achieving and
sustaining an erection and infertility due to a low
sperm count, and osteoporosis, which can result in
a tendency to develop bone fractures.
4. GH deficiency:
In children, GH deficiency causes slowing or
lack of growth and an increase in body fat.
In adults, GH deficiency may cause a
decrease in energy and physical activity,
change in body composition (increased fat,
decreased muscle mass), a tendency toward
increased cardiovascular risk factors/diseases
and decreased quality of life (including an
increased sense of social isolation).
5. PRL deficiency: In the case of PRL deficiency, the
mother might not be able to breast feed following
delivery.
6. Antidiuretic hormone deficiency: This hormone
deficiency results in diabetes insipidus (DI). DI is not the
same as diabetes mellitus, which is also known as type 1
or type 2 diabetes or sugar diabetes.
Symptoms of DI include increased thirst and frequent
urination, particularly at night. Pituitary adenomas
themselves rarely cause DI unless it occurs after surgery.
If DI occurs spontaneously, it usually indicates that some
other sort of tumor or inflammation is present in the area.
Gonadotropin Deficiency
Women
Oligomenorrhea or
amenorrhea
Loss of libido
Vaginal dryness or
dyspareunia
Loss of secondary
sex characteristics
(estrogen
deficiency)
Men
Loss of libido
Erectile dysfunction
Infertility
Loss of secondary sex
characteristics
(testosterone deficiency)
Atrophy of the testes
Gynecomastia
(testosterone deficiency)
ACTH Deficiency
Results in hypocortisolism
Malaise
Anorexia
Weight-loss
Gastrointestinal disturbances
Hyponatremia
Pale complexion
Unable to tan or maintain a tan
TSH Deficiency
Hypothyroidism
Atrophic thyroid gland
Prolactin Deficiency
Adults
Often asymptomatic
May complain of
Fatigue
Degrees exercise tolerance
Abdominal obesity
Loss of muscle mass
Children
GH Deficiency
Constitutional growth delay
Common
test
Infarction
Apoplexia
Sheehans syndrome
Autoimmune disorders
Lymphocytic hypophysitis
Hypopituitarism
Tumors
Pituitary surgery
Radiation treatment
Hypothalamic disease
Interruption of the
pituitary stalk
Extrasellar disorders
Craniopharyngioma
Rathke pouch
Hypopituitarism
Hypopituitarism
Developmental and
genetic causes
Dysplasia
Septo-Optic dysplasia
Developmental
hypothalamic
dysfunction
Kallman Syndrome
Laurence-Moon-BardetBiedl Syndrome
Frohlich Syndrome
(Adipose Genital
Dystrophy)
Acquired causes:
Infiltrative disorders
Cranial irradiation
Lymphocytic
hypophysitis
Pituitary Apoplexy
Empty Sella syndrome
Septo-Optic dysplasia
Kallman Syndrome
Laurence-Moon-Bardet-Biedl Syndrome
Frohlich Syndrome (Adipose Genital Dystrophy)
Hypopituitarism: Genetic
Septo-Optic dysplasia
Hypopituitarism: Developmental
Kallman Syndrome
characterized by
Hypopituitarism: Developmental
Kallman Syndrome
Males patients
Female patients
Diagnosis of exclusion
Repetitive GnRH administration restores normal pituitary
Fertility may also be restored by the administration of
gonadotropins or by using a portable infusion pump to deliver
subcutaneous, pulsatile GnRH
Hypopituitarism: Developmental
Laurence-Moon-Bardet-Biedl Syndrome
Hypopituitarism: Developmental
Hypopituitarism
Acquired causes:
Infiltrative disorders
Cranial irradiation
Lymphocytic hypophysitis
Pituitary Apoplexy
Empty Sella syndrome
Hypopituitarism: Acquired
Lymphocytic Hypophysitis
Etiology
Presumed to be autoimmune
Clinical Presentation
Diagnosis
Treatment
Hypopituitarism: Acquired
Pituitary Apoplexy
Hemorrhagic infarction of a pituitary adenoma/tumor
Considered a neurosurgical emergency
Presentation:
Hypopituitarism: Acquired
Pituitary Apoplexy
Risk factors:
Diabetes
Radiation treatment
Warfarin use
Corticosteroids
Pathophysiology
For pituitary adenomas, mechanical compression of portal
vessels and the pituitary stalk, and ischaemic necrosis of
portions of the anterior lobe, have been postulated to be the
pre dominant mechanism causing hypopituitarism.
Moreover, increases in intrasellar pressure have been
recorded in patients with pituitary macroadenomas, which
could be the cause of reduced blood fl ow through the portal
vessels and the pituitary stalk, resulting in diminished
delivery of hypothalamic hormones to the anterior pituitary.
Empty sella is caused by herniation of the subarachnoid
space and associated with fl attening of the pituitary gland.
This process is sometimes, but not necessarily, accompanied
by hypopituitarism.
Manifestasi Hipopituitarisme
Manifestasi Klinis
Insufisiensi adrenal. hal ini terjadi akibat defisiensi ACTH
sehingga pembentukan hormon-hormon korteks adrenal
terganggu, defisiensi kortisol, aldosteron, dan
adrenalandrogenberkurang.
Hipoglikemia, hal ini disebabkan karena defisiensi hormone
kortisol yang pengeluarannya dirangsang oleh ACTH yang
disekresi oleh hipofisis, salah satu fungsi kortisol
adalahmeningkatkan glukoneogenesis, dan menurunkan
glikolisis. Akibat dari defisiensi hormone inimaka terjadilah
penurunan glukoneogenesis, peningkatan glikolisis
akibatnya gula darahmenurun yang mengakibatkan
hipoglikemia. Hal ini diperparah dengan adanya defisiensi
GH,GH merupakan hormone yang bersifat hiperglikemia,
akibat defisiensi GH efek darihiperglikemiknya tidak ada.
Takikardia, hipoglikemia menyebabkan
epineprin bekerja yang selanjutnya akan
memengaruhidenyut nadi mengakibatkan
takikardi.
Kelemahan otot dan penurunan berat badan,
hal ini terjadi akibat dari hipoglikemia
yangmenyebabkan pengaktifan saraf simpatis
dan menghambat pelepasan insulin sehingga
jugamemengaruhi lipolisis dan pemecahan
protein.
Anemia, nerutropenia, eosinofilia, trombopenia,
llimfositosis. Salah satu fungsi glukokortikoidyang
sekresinya diatur oleh ACTH adalah meningkatkan
pembentukan eritrosit, trombosit, dangranulosit
basofil, limfosit dan monosit. Akibat dari kekurangan
efek dari glukokortikoid padasel pembentuk darah
menyebabkan anemia, neutropenia, eosinofilia,
limfositosis.
Rambut pubis yang jarang akibat dari defisiensi
androgen karena kadar ACTH menurun.
Tekanan darah menurun. Penurunan sensitivitas
katekolamin di jantung dan pembuluh
darahmenyebabkan hipotensi.
Amenore sekunder pada wanita dewasa. Akibat
defisiensi gonadotropin hormon,
menyebabkankorpus luteum tidak terbentuk dan
dinding endometrium tidak hiperplasi, yang
menyebabkantidak adanya peluruhan.
Atrofi payudara dan genitalia eksterna, pertumbuhan
payudara salah satunya diatur olehestrogen
hormone yang dihasilkan oleh oleh adanya peran
FSH dan LH, akibat dari kekuranganhormon ini
menyebabkan defisiensi pada estrogen akibatnya
terjadi atrofi payudara dangenitalia eksterna.
Pemeriksaan
Pemeriksaan Biokimia
1.Pasien dengan hipopituirarisme tidak akan merespon jika diberikan
pengujian hormon perangsangsekresi. Uji fungsi hipofisis kombinasi dapat
dilakukan pada pasien ini dengan menyuntikkan :1.
2.Insulin. Insulin akan menyebabkan hipoglikemia, pada saat hipoglikemia
dengan kadar serumglukosa yang kurang dari 40 mg/dl, normalnya
menyebabkan pelepasan GH, ACTH, kortisol.Namun pada penderita
hipopituitarisme mungkin tidak terjadi pelepasan tersebut atau hanyasedikit
hormon yang dilepaskan.2.
3.CRH. Pada orang normal CRH akan merangsang hipofisis untuk
mensekresikan ACTH, MSH.3.
4.TRH. Pada normalnya penyuntikan TRH akan merangsang hipofisis
mensekresikan TSH.4.
5.GnRH. Pada normalnya GnRH akan merangsang pelepasan hormon FSH dan
LH.
Pada penderita hipopituitarisme gagal untuk merespon empat rangsangan tersebut
Pemeriksaan Radiografi
Pada pasien hipopituitarisme yang diduga
akibat tumor hipofisis, perlu dilakukan
pemeriksaan radiografi untuk mencari
kebenaranya. Tumor-tumor pada hipofisis ini
sering menyebabkan hipopituitarisme.
Treatment
Sebagai contoh insufisiensi kelenjar adrenal
akibat dari defek ACTH diobati dengan
pemberian hidrokortisonoral. Pemberian
tiroksin oral pada defisiensi TSH. Pemberian
androgen dan estrogen oral juga
diberikansebagai pengganti dari FSH, LH yang
mengalami defisiensi akibat hipopituitarisme
Common nursing dx related to emotional needs
include:
Fear
Aniety
Anticipatory grieving
Ineffective denial
Ect...