Tumors of the body’s “master gland” cause various symptoms – headaches, depression, sexual dysfunction, vision loss – that doctors often attribute to other conditions. UCSF endocrinology and neurosurgery specialists discuss keys to identifying patients as well as the merits of telehealth referrals in the time of COVID.
me. We'd like to start the scientific program, and I'm gonna turn over Dr Auggie, who's going to start our presentation about pituitary tumors, And then I'll finish up with the hype, opportunity, tourism, and we may go back and forth amongst ourselves as well during the presentation. Thanks. I, uh Well, as Louis mentioned, we're gonna share the presenting duties. We don't wanna overwhelm you with slides, so we're going to just sort of talk in a very casual and deliberate manner and allow plenty of time for questions at the end. Um, this is the title I chose that ended up reflecting the content we're gonna be providing, which is really talking about our approach at UCSF, which is multidisciplinary, uh, surgery and partnership with endocrinology. Um, inclusion of other specialties as needed on a case by case basis on duh. We've sort of broken this down for parts. Um, we're gonna start with Lewis talking about his perspective in terms of the endocrine evaluation of pituitary patients, new pituitary. And then I will talk about the surgical evaluation of, ah, pituitary patient has sort of done in partnership with Lewis, and then I'll hand it back over to Louis because in the postoperative period in particular, we want to be attentive to patients who he had some hyper patriotism for their tumor on DWI way sort of finalized the medical management of that after surgery, as well as some of the podium abnormality that can arise with pituitary surgery and how we navigate that. And then the last item which was sort of planned for this was thoughts on telehealth, although we've certainly covered a fair bit of that. So we won't probably do too much of that at the end. But, um, without further ado, I'm going to turn it over to Louis. Three. Talk about the undercurrent evaluation, and he can just let me know about advancing slides. Okay, so as you know, pituitary gland is a master gland in the body. It interacts with the brain on, has and get signals from the brain, and also measures blood borne hormone levels to sort of regulate the production of hormones by the target glands, their cells in the pituitary that make prolactin that are important during lactation cells that make growth hormone that lead deliver to make I G F one. And together these two lead to growth, but also ah, lot of other important things in adults we could talk about later. If you're interested, uh, LH and FSH drive the gonads and men and women. A CH drives the adrenal glands, and TSH drives the thyroid. These the patootie in its target lands, work in concert. It's almost like a thermostat or a regulator. If the thyroid hormone level is low, for example, the particular will send out a larger signal to try to increase started hormone. And that's why you'll find the high TSH in patients with Hashimoto started itis. For example, um, once started hormone comes up to normal. If it's able to, the pituitary slows back down its signal. Thio produce that. So think of it as the supervisor that's managing the workload. Andi, uh, these different cell types that make these different hormones in the pituitary gland. Any one of them, including some non functioning cell types and some interesting all cells and other types of cells stem cells, for example. They can form a pituitary adenoma, and basically it's ah, the a plastic disorder where one cell divides and becomes multiple daughter cells, if you will, that forms a tumor as distinct from hyperplasia, where a lot of different cells in the pituitary gland or enlarge so pituitary adenoma does occur in about 10.6 toe 27% of autopsies. If you look at different studies of people who died in car accidents and from whatever reasons, so they're fairly common. Uh, if you look at Emory findings, you can see lesions and of three millimeter or greater in a fairly significant proportion of subjects. There was a study from the NH many years ago where if they sort of baited the radiologist saying Suspect pituitary tumor, 34% of the films were thought to have a particular adenoma if they had to. Radiologist evaluating there was concordance in about 10% of those cases, and when three radiologists were reviewing the films, that was concordance in about 20%. So we find them. We find pituitary adenomas. Incidentally, all the time, patients knocked their head or fall, or what have you, and they get a scan and they found to have a pituitary adenoma we often have to determine. Is this a clinically significant or an insignificant lesion next slide. So when we talk about clinically apparent tumors. If you think that you know 1 1/5 for example, or 1/4 of patients will have a pituitary adenoma by autopsy and about 40% of those produce proactive, by the way, they're Onley clinically apparent in 18 per 100,000 persons. If you look at Emory detection of macro adenomas, it's roughly 164 100,000 persons. Um, so there's there a couple of big gaps here. There's a gap between the number of people who have tumors microscopically, who aren't detected during life. To have that, and then the number of people who are found to have it on memory seems to be greater than the clinical, uh, incidents of clinically apparent pituitary adenomas. And I think a lot of this comes from the fact that physicians, other allied health care providers, positions assistance or expectation, er's whatever aren't really sort of in tune with the notion of a pituitary adenoma and the myriad symptoms and signs that it might develop. And many patients are diagnosed late because of that. Many are not even diagnosed it all during life. That's why there's, um, seen it autopsy that were suspected during life. Ah, woman might have regular menses for years, and she's told that all of my patients have irregular menses. Don't worry about it, but the fact you may have had a collect in Omagh men might have erectile dysfunction. Patients may have chronic headaches thought to be migraines, for example. So I think this in part explains the big gap between those observations. Next slide. What? We can classify pituitary adenomas in different ways. First is by size. We consider micro adenoma is to be a centimeter less macro had no means to be greater than a centimeter. Giant tumor is greater than four centimeter. We can characterize tumors, according Toa hormone status. UH, some are non functioning and those air either no cell adenomas or silent hormone producing but not secrete ing adenomas. And then there are functioning tumors as well. Next slide, pituitary and number of patients usually present if they have symptoms and signs again, a fair proportion of people are detected. Incidentally, if they have symptoms and signs, they may have mass effects or hormonal abnormalities. We'll talk about each of these in a moment. Some patients present with hypo pituitary ism on that could be even in conjunction with evidence of one hormone secreted in excess, for example, efficient with acromegaly in a macro, adenoma may have growth hormone access and I Jeff one elevation but hypogonadism and maybe hypothyroidism because the tumor is destroying the pituitary gland. Next slide. The mass effect since there's the panel on the on the Left is a painting by Picasso, and it was meant to sort of illustrate a patient with a headache. And I think that it was a cluster headache that he was painting. That sort of reminds us that many, many patients of duty had numbers. Do have headaches for very since Sunday, reasons many. She has done a tremendous podcast on this topic. Video, actually on our website. Pituitary World News. You can look it up if you're interested. The visual field studies show classic by Temple him Ian autopsy. And this, because the tumor goes from below impresses up on the under surface of the visual pathways and through either arterial compression or Exxon. Oil flow problems can lead to loss of the temporal visual fields in a patient with a tumor that's going directly upwards from underneath the visual pathways in the optic eye as um, we can see variations on the theme here. Some people have a superior temporal quadrant anoxia people tumors above the chasm, having inferior quadrant anoxia. But the classic thing you hear about is by temporal Hemi anoxia, and patients don't often notice this. Some some of them are surprised when they found to have this degree of visual constriction. But when you talk to them, you'll find out that they may be sideswiped the mailbox or hit a curb or didn't see a car, almost caused an accident or bumped their head on the kitchen cabinet or bump into a doorway, for example, because they've lost their peripheral visual field, and the field loss usually occurs so slowly that they don't often recognize that they have lost vision. Some patients with pituitary apoplexy, which is a pituitary stroke or hemorrhage, and have sudden visual compromise. However, the bottom panel on the right there shows the tumor that's invading the left. Cavernous scientists on their cranial nerves in this part of the cavernous Sinus, mostly the the ocular motor tro, clear and of distance nerves, and in the upper branch of the fifth cranial nerve and any one of these can be affected by tumor going into the cavernous Sinus so you can see an art film apply. GIA have actually seen a couple of people who have had facial pain as a result of, uh, and super Ordell Pain as a result of involvement of the tumor in their cavernous Sinus is so These are the things that we call mass effects that are related to the mass of the timber headache. Visual complaints authentically, just some patients have stuffy nose. We've had a couple of people have hippest axis, a couple of people of CSF gonorrhea as well when they presented with pituitary adenomas. But those air more rare complications of pituitary tumors. Next slide. Yeah, some of the common symptoms we see in our patients if you just look at what the number, the presenting symptoms and signs and the more common symptoms and signs are decreased libido and erectile dysfunction. Amen Arria, blackberry or restaurant production. Mundane symptoms of hypogonadism such as depression, hot flashes, hot flashes, night sweats, a Teague wait game and headaches. And I would venture a guess that every one of you saw a patient with one or more of these symptoms or signs in your clinics today, and you may see it again tomorrow. That doesn't mean that all these patients gonna have benefited pituitary disorders. But these were some of the more common things that people have that lead them on the pathway to a diagnosis. So you need to keep in mind and sort of allow pituitary disease to enter your differential diagnosis of patients who have any of these particular symptoms and signs and especially the first four next slide. Yeah, when we talk about hormone overproduction, the most common tumor is a prolactin oma drive from the prolactin producing sales, it can cause black diarrhea. Amen Area, irregular menses and infertility. Prolactin interferes with gonadotropin releasing hormone secretion by the hypothalamus, which this regulates LH and FSH production, which then leads to this regulation of ovarian function on you can actually see marked a memory A and, uh, early menopause, if you will do the hyper product Neemia in such patients, next slide Cushing syndrome was due to a C T H overproduction by an A C. T. H producing pituitary adenoma. And these are the patients who are walk into the clinic and look like they've been on prednisone for chronic lung disease or skin disease or room and logic conditions. Those air the more common causes of pushing syndrome. Exogenous steroids. Any time you see someone who looks like they're taking explosion, the steroids who's not on steroids, don't dismiss it. Think about the fact that they may have been a CTX producing tumor over driving in the adrenal gland. To produce Cushing is resulting in the central obesity, the muscle atrophy and the thinning of the extremities. Austria or stretch marks on the skin, the cervical dorsal fat pad thickening in the hyper tricked Acis, The Echo, Moses and Plethora, or the red and face Children with Cushing's syndrome often will stop growing tall and will start gaining weight on Sometimes your school performance suffers, and those are the symptoms that you might see in a child Next slide. Acromegaly, of course, is due to grow from an overproduction. Ah, lot of movie stars and basketball players have had it, if you know Andre the Giant or Jaws from the James Bond series of movies, plus, many others have had acromegaly due to growth hormone secreting pituitary tumor, some of the classic features are the hands and feet enlarge, the mandible grows. Radio Lee and longitudinal is to patients get pragmatism. The teeth separate from the only things I know that will cause new teeth separation and patients they get frontal bossing and large nose and ears, spade like hands that look like a shovel and a whole host of other conditions like hypertension, glucose, intolerance, arthritis, spinal stenosis, sleep apnea, uh, colon polyps, and so on. Next slide and then the rare tumor. But we see occasional patients that UCSF is, ah, hyperthyroidism due to TSH producing adenoma. And this is the patient that had a greater and accept Thomas, uh, due to the sympathetic hyperactivity due to a TSH producing tumor of the pituitary gland that showed up on this, uh och tria tied scan, the thyroid also showed up a swell. They're rare, but we do see occasional hyper thyroid patients, and the clue is that if you see a patient who has elevated teeth or in T three levels in an inappropriately normal or a high TSH level inappropriately normal, meaning that if the n graves disease patients that their T four and T three high. They suppress their TSH so it be inappropriately normal. TSH was even normal in the setting of high T four and T three levels. One of the conditions do that called thyroid hormone resistance. But the first thing you do if you see hyperthyroidism with a high TSH or normal TSH is referred the patient endocrinologist for evaluation next slide. So I have a number of peeves things that I've seen in practice that sort of bother me and encourage people to work at it and try not toe sort of succumb thio some of these things because you're busy. But try to really uncover disease. And these are decreased libido erectile dysfunction in men who were treated with medications. They're giving, uh, them fast food s traits inhibitors to improve their erectile function, or they're giving him even testosterone. And nobody is really trying to figure out what's the underlying problem. Amen. Area or irregular menses and women, they're ignored. I can't tell you how many women have told me that, the doctor said All my patients have irregular menses. Don't worry about it. Gallach diarrhea. That's attributed to prior breastfeeding and other things that I will not mention because of a lack of time vision disturbances that are not fully fully evaluated. We see a few people a year who had chronic progressive visual loss, and they're seeing doctors, and no one thinks about a pituitary adenoma. It's often attributed to age and some of the older patients. It really what we have is an intelligence so called intelligent positions. They're not practicing satisfactory medicine medicine. They're not developing a differential diagnosis, which is essential, and they're not trying to sort of figure out what the cause of the symptoms and signs are. They're just treating the end result and then, you know, 15 years later and the patients found to have a big pituitary tumor that minutes can't cure because it's so invasive already. So we're big advocates of early diagnosis and treatment, and the only way to have that is a if those of your own frontlines practicing frontline medicine, if you will. I'm a protected sub sub specialist, so I'm not on the front line. But we really do need people in the front line to do their best to try to identify these patients to lead to early diagnosis and treatment. It's not unusual, for example, for people with acromegaly to have 7 to 25 or 30 years delay in diagnosis Cushing syndrome 2 to 10 years delay in diagnosis prolactin normal patients. Women usually are very sensitive if they're men, Cesaire disrupted that. Sometimes it still takes 2 to 5 years to get a diagnosis. Men with prolactin gnome is even longer. Uh, eso, uh, being being aware of the symptoms and signs and and doing some special study on this will help you diagnose your patient sooner rather than later. Next slide the finish. Yeah. So I'm gonna talk about surgery and what with a political pituitary patient. Um and, ah, lot of what I do is sort of overlaps with probably echoes some of the same themes. Um, I think as a surgeon, you know, it's so important for us to know anatomy and and I do think that, um, you know, I find it very educational to share sort of pearls of anatomy with in talks like these. So you know, the pituitary gland. If you look at it sort of in a what we call a sagittal plane, the anterior front, the posterior back, and then top on bottom. Um, the important thing from a patient's perspective is that the diaphragm Acela separates the brain contents from the pituitary. And because pituitary surgery is invariably done through a transfer Neuville quarter, we come through the nose from the low, so we access the pituitary gland without touching any cranial tissue. We stay out of the brain, and we essentially stay out of spinal fluid on DSO as a result of tell patients that although this is, you know, I am a brain surgeon, the pituitary surgery we we don't touch your brain, and that's what makes it so safe that other than the tissue in the nose, the only tissue we touches the pituitary. And we have a lot of ways of protecting the normal gland to make the surgery, say fas well. And then, within the gland, there's the anterior lobe, where most of the adenoma sit. The posterior lobe that houses the um, it's the depo for the A, T, H and C, the president etcetera. And then the intermediate lobe, which is sort of a collapse space but will house Rockies cleft cysts in an expanse all manner when patients have Iraqis, cleft cysts um, the Stella. The pituitary is covered by bone in Dura. Ah, patient with a tumor. The bone may erode, but the dura will always maintain its integrity. The dura is innovated so that if a patient has a headache from a pituitary tumor, the theory is that it's due to stretching of the dura on Ben above. The pituitary is where the optic eye is, Um sits, and I'll talk about that in a moment. But that's why a tumor that grows upward can call vision loss. When we look at this on an Emory, the important things to keep in mind the optic eye as um is gonna usually be gray the pituitary gland. We'll have a slightly brighter color. Um, the pituitary stalk will sit in the midline and be between the gland and the autism. Here you see a bony cept ation in this fine oId Sinus. As a surgeon, I'm always aware of those because those are important landmarks. During surgery, when there's a tumor, though, typically an adenoma will form on one side or the other. This is very important because whatever side doesn't have the adenoma. That's where the normal gland is. So This is a patient within the adenoma on the left, the left, his hair, the right of hair. And it's causing the stock to deviate towards the right. So wherever that stock is, that's where the normal gland is. So the normal gland here is on the right. So I routinely look at these memories for these types of questions because that equips me to better performed the surgery safely and efficiently by knowing all these things. And here you see why the patients lose vision. Large tumor displaces the optic nerve superior early. Um, I like to think about symptoms and three categories. If it goes upwards, it will cause pressure on the optic Aya's and with vision loss. If the tumor grows towards the surrounding grand, it'll cause hyper to terrorism. And if the tumor stretches the dura, it might cause some headaches. Um, this isn't a slide I like to show because Louis mentioned the classic visual deficit for a patient with two tree adenoma is a bi temporal hemming and hope see where you lose perfect vision. But it's very important to keep in mind that, um, that not every patient follows the textbook, and in part. That's because our anatomies vary. So if you do cattle Eric studies and autopsies, it turns out that only 80% of us have our chi as, um directly over the very and. And that's the only way you could really get it by temporal heavy. Nope. CIA. But in 10% of us, the chi as um is what's called prefixed. It sits in front of the pituitary, so if a tumor grows upwards, it effects post chi asthmatic tracks. And if you remember your anatomy, that's going to cause Contra lateral vision laws. Um, in some patients, 10%. The chi is, um, is post fixed and it's behind the gland and a tumor will grow upwards. In effect, just one optic nerve and the patient may lose vision in one eye. We went back and looked at over 1000 patients at UCSF, and in fact, Onley. 50% of them had a bi temporal hemi. Nope. CIA. The rest were these various deficits that I show here. So it's important to not limit your focus for a bi temporal Hemi. Nope. CIA, really. Anyone with vision loss that can't be explained by some other finding such as glaucoma or cataract warrants a memory to figure out if a pituitary tumor is the cause, or just a memory in general, because an emery will show you the optic nerves and explain the source of vision loss in most patients. Um, Araki's cleft cyst is one of the two common pathologies that we treat in, uh, surgically, the two most common. And as I mentioned, they tend to form between the front in the back of the gland. Most patients with rats case cleft cysts won't need surgery. But if assist is large enough for clearly symptomatic, we would take these patients to surgery. And we don't just want to drain the cyst. We want to try to remove as much of the wall as we can. Um, the data show, however, that if you remove the entire wall, you don't really get any added benefit, and you do get increased risk of diabetes and separatists. We do what's called an a aggressive but safe removal of the wall, and patients typically do respond to that basically, get better. Um, there is a recurrence rate of about 10 to 20% but if assist is going to come back. It's usually in the first two years and are institutional recurrence rate. When we looked at it recently was 9%. Most of the system they come back won't need surgery necessarily because they'll be small. Um, the other thing to keep in mind is that some Rockies closest will sit outside the gland. So here's an example. In greatly cysts sitting above the pituitary, it's what's called a super seller. Wrath keys, cleft cyst. And just to show you what this looks like during surgery, we opened the Dura get CSF because CSF is above the gland and the gland is actually see the cyst. It's that yellow tissue. The gland is is lower over here, and this is all cyst, and there's the optic nerve and the patient was having a visual deficit. And so we get that cyst out of the super seller cistern and leave behind a clean and healthy optic nerve that's free of pressure as well as the normal arteries that are behind the cyst. And then, after surgery, we get why, now you can see just gone in the optic nerve Looks good. Um, pituitary adenomas, as I mentioned the most important thing for us to look at it. Where is the gland? Where's the tumor? And you know, if the patient has symptoms were, ah, large enough tumor, then will typically recommend surgery through a trance in oil corridor. Here's a patient who had a history of a tumor surgery at a pituitary tumor, surgery an outside hospital and returned with recurrence of the tumor and three days of vision loss, Onda hemorrhage and the tumor Almost an apoplexy type situation. Um, and this is what that looked like. Importantly, I recognize that the patient had normal gland. Ah, thin rim of normal gland up against the CSF space and the upper right, and we have a big hemorrhagic tumor. So we're going to release the blood we're going to dig, dissect out the tumor and apply some gentle traction to tease it out of the away from the normal gland. But this is all tumor that's released, and you see the Iraq noid membrane that and that little bit of gland floating on the Iraq annoyed that is carefully preserved. This is all normal gland on bond tumor that is completely eliminated, and after surgery, you see that normal gland, the optic nerves, some mucosa in the solenoid Sinus with a complete resection. So I thought those would be helpful to illustrate some of the important point around surgery on Do with that, I'm gonna turn it back over to Louis to talk about, um, hyper particular tourism. Um, and just some of his thoughts on that. So Hi, Papa. Tourism. I put this at the end, even though some patients present with it because of a small number of patients will have high papa tourism after surgery. Aziz. Well, as the blood supply to the gland might be disrupted by getting a tumor out, let's go ahead to the next slide. Um, no, I don't think you got the slides that I sent you next. Slide. Um okay, so let me define hi, Papa to tourism. So high Papa to tourism is a complete or a partial deficiency of one or mawr interior pituitary hormones. And those a racy th that that causes adrenals, cruise cortisol, tea estates. It causes authority Bruce t four and t three. Uh, LH and FSH that caused the gonads to do their thing on then growth hormone, which causes the liver to produce I. D F. One Um, you can have complete or partial deficiency of one or more hormones, and you can see that pattern in any patient with any pituitary disease where they've had radiotherapy or surgery or a tumor that's not been treated. We often see these things in head trauma patients a swell the way we proceed with the work up in any patient's pituitary disease or suspicion of pituitary tumor is to simply look at the hormones that I mentioned. So a lot of people will see the refers patients, and they've checked the LH and FSH but not looked at the estrogen and women or the testosterone and men. You have to look at the pituitary hormones and the target gland hormones. 8 a.m. Cortisol and the A C T H I. G F one and the growth hormone T 43 the TSH. So those are the things that we like to check in our patients when it comes to looking at numbers. Um, the the important thing to remember is that the patient's pituitary is not working. So the pituitary target gland hormone maybe low. It might be normal, but not able to respond and being adequately produced hormone to drive a target gland. So we may say T foreign T three levels were in the low part of the normal range, but the TSH could be normal or low, normal or even undetectable. This is where, if you suspect hypothyroidism and a patient, you should be checking a T 43 TSH. If it's Hashimoto's of post surgery or authority itis, the TSH will be high. T 43 will be low. If it's pituitary disease, you may see a low normal, normal or even a slightly high TSH in in the setting of frankly, low hormone levels. And all the glands in the target systems work that way. The syndrome of hypothyroidism is the same as in patients of Hashimoto's. It's just that seems to not be a severe adrenal. Insufficiency is cortisol deficiency, not cortisol. In mineral cortical deficiency, the patients might lose weight, uh, have fatigue, etcetera, loss of appetite, for example. Sometimes they present with depression and other psychiatric abnormalities. High focus on autism can be infertility, sexual dysfunction, a Maria, the whole spectrum for men and women and then growth hormone deficiency. Often, patients have poor exercise capacity, exercise, intolerance, weight gain, loss of muscle mass, loss of strength, brain fog, higher risk for heart disease and stroke and osteoporosis. So it's a very complex set of symptoms and signs. If you took a look at all the symptoms and signs of all the different pituitary tumors with the different overproduction and under production syndromes, it's a laundry list of things that patients can have wrong with them. And not everybody has everything wrong with them when they have hormone deficiencies, even complete hormone deficiency states. So it requires a lot of work in a lot of thought toe arrive with the diagnosis of high papa to tourism, and then when it comes to treatment, we treat these hormone deficiencies in the same way you would if it was a target gland that had failed with a few caveats. For example, on this one is very important to remember if you have a patient with hypo pituitary ism and hypothyroidism. As a result, you can't use TSH to monitor treatment in Hashimoto's story. Dinosaur Post surgical hypothyroidism. You measure the TSH to decide if your T four doses correct, but in pituitary patients, the TSH is the problem because of the pituitary disease. So what? We aim for our mid range normal T four and T three levels, sometimes in the upper half the normal range. But we'll move it around, depending on whether a patient's symptoms and signs have been resolved with treatment. But that's the general concept of treatment of a pituitary patient who has cycle. Patriotism is you replace the target gland hormone, but you don't look at the pituitary hormone to make sure the doses appropriate. You look at the target gland hormone. You look at the thyroid hormone that you're giving or the extra general the testosterone, and you forget about the LH and FSH and the TSH and things like that. Now what we've been talking about the anterior pituitary gland, the post your pituitary gland, if I could have the next slide stores Basa Preston, which is produced in the in the hypothalamus in several couple separate different nuclear super optics. Their particular nuclei, this hormones produced by the brain, passes through the Exxon's down the pituitary stalk and is stored in the post your pituitary and secretary Granules and the terminals of these Exxon's where they have been on Capitol Aries and the hormone vasopressin is released when our Osma clarity increases. If you don't drink water all day because you're busy rounding or what have your same patients in the clinic, you're going to start firing your asthma receptors as you get dehydrated to the insensible water losses across your skin and through the losses of water in the urine. To sort of get rid of your salutes and things like that, you're going to get a little dehydrated. You're a similarity is going to go up that's gonna fire the Osma receptors that's gonna lead to raise a press and release from the post your pituitary gland, which is gonna have you hold on the more of the water that kidney is filtering. And in that way we defend against hyper in a tree. Me a hyper on similarity and you defend up until point and then your thirst mechanism kicks in so you could take in more water to prevent volume depletion and dehydration. So patients who have pituitary disorders uh, it could be postoperative, but there's some inflammatory disorders that you can have like a limb. Pacific hypothesis itis, sarcoidosis, Langerhans, cell history of psychosis, sometimes people, German oma tumors and a whole host of other conditions as well that I won't mention. You can have a disorder that affects the post your pituitary in leads to deficiency of vasopressin. And if they suppression is there to conserve water, you can imagine that a deficiency is going to lead to increased urinary water losses. So the classic features are patients past large quantities of dilute urine. Andi. As a result of that, they get a little bit volume depleted. So they have, uh, the increased, ah, similarity that goes along with that that leads to thirst, and the thirst prompts them to drink. So the classic thing is Polly Area Polly dipsy A and thirst. Um, this. Some patients don't have any thirst whatsoever, and this disorder can be temporary or permanent. Um, it could be due to Neurogen. It causes ready the pituitary or the kidney can be insensitive to vase oppressing. And the treatment in most cases, especially those of pituitary, is giving vase oppressing back to the patient. And we use this fairly regularly in our practice because we see patients was all sorts of inflammatory pituitary conditions. The next slide mhm. Okay, E in east. You want to add anything about the high Papa to tourism and the pituitary function? No. I mean, I think we've found, uh, around surgery that patients who have preoperative hyper tourism have a slightly greater risk of hypo Nutri Mia. So those are among the patients we watch more closely after surgery on that could include, you know, preemptively giving them a slip to get a sodium check at home around. Uh, you know, the week after surgery Thio catch any drops while we can manage them or gently as an outpatient. I thought it was to not talk about hyponatremia tonight, but we had a very interesting case today. I want to talk about just because I think it will serve as a teaching point, regardless of whether you're seeing pituitary patients or not. And this was a patient that one of the other surgeons had operated on last week and then probably about six days after surgery, the patient started developing headaches, and we tell all of our patients that if you get a headache within a week or two of pituitary surgery, you want to check your serum sodium because that's often a sign that your sodium has fallen after surgery because basic Preston has been released in an erratic, unregulated fashion from the pituitary gland causes. You retain water, get waterlogged, your sodium level falls, and one of the symptoms of cerebral oedema is the headache. So when you get high pony treatment, you get straight Galadima until the brain auto regulates and gets rid of Oz moles and can regulate its volume. So our patient developed headaches was sick for about a day, day and a half with headaches finally called the office yesterday spoke to one of the nurse practitioners, who said, very astutely understanding that it might be postoperative pipe MoneyTree Mia and street, Galadima said, You need to go serum sodium checked right away. And of course, I find out about this this morning looking through the chart records and the messages that were sent to me through the electronic medical record and I went into the chart and saw that the patient didn't have a sodium check yesterday, So I had the nurse practitioner called the patient. But the patient says, Oh, I've started feeling fine, so I didn't go get the sodium level check and I, uh, was very alarmed, because if a patient has postoperative hyponatremia in a few days of headache and now it's feeling fine, it doesn't mean they're sodium is back to normal. It means they have probably volume regulated the brain, and they're no longer symptomatic. So we sent this patient to the lab anyways, and I think they went reluctantly in the sodium was 108. And then by time they got to our emergency room permission. It was 105 which is getting fairly close to where a normal person will sort of become comatose or ton did maybe even have a seizure if the patient has other intracranial disease or more likely to have problems at a higher level of sodium. But 105 is probably the lowest sodium I have seen at UCSF, and while on here, the patient was relatively except a Matic and doing better because their brain had auto regulated the volume. And I think that way see hyponatremia in and a lot of different medical conditions. And that's a very illustrative point that just because the headaches gone or the patient seems asymptomatic doesn't mean they can't have life threatening hyponatremia, and in the proper clinical context, you need to suspect the problem and then proceed with treatment. So our patient was admitted because the study was so low. We started with emergency resuscitation with 3% saline. That was started about two hours ago, according what the residents said when they called me and after the sodium is up safe level around 1 20 will probably stop that fluid, restrict, see what happens and then maybe use a drug called Talbot. Then that actually blocks the vasopressin receptor and will help the patient developed a medically induced diabetes. Insipid this, if you will, to get rid of the extra water that they have retained. So it's very instructive patient that had postoperative hyponatremia. But many of the things that can be learned from this patient apply the hyponatremia have any cause, especially the shh for A s I. A. D H varieties that you're all probably singing your practices. Mhm