It was clearly pancreatitis, how did it become parathyroid adenoma?

85-year-old Grandma Xie was hospitalized for pancreatitis some time ago. At that time, the blood calcium was slightly high. After treatment, the pancreatitis improved. Five days later, she had chest tightness and palpitations and went to the hospital again. After examination, it was found that the blood calcium was 3.04mmol/L, the blood phosphorus was low by 0.48 mmol/L, and the parathyroid hormone (PTH) was high at 364.5pg/ml. Ultrasound examination showed no abnormalities in the parathyroid area. MIBI examination indicated the right thyroid inferior dorsal nodule, considering the possibility of parathyroid hyperplasia or adenoma. The final diagnosis was "primary hyperparathyroidism" and was treated in the thyroid surgery department of our hospital. Postoperative pathology confirmed that it was a right parathyroid adenoma. After the operation, the patient's parathyroid hormone (PTH) and blood calcium were normal, and he was discharged smoothly. During this period, the family members could not understand how pancreatitis was related to the parathyroid gland? Today, let's get to know the parathyroid glands in our body, which are inconspicuous but have a big role.

1. Small body with great energy

1. Where is the parathyroid gland?

With the diversity of physical examination items nowadays, many people have included the thyroid gland as a routine item in physical examinations, so people are not unfamiliar with the thyroid gland, but they may not know the parathyroid gland. It is not difficult to see from the literal meaning that it is the gland next to the thyroid gland. It is naturally very small, 3~6mm, light yellow, like soybeans. The parathyroid gland is always attached to the thyroid gland. Most people have 4 parathyroid glands, 2 on each side, divided into upper parathyroid glands and lower parathyroid glands (as shown in the picture-source Baidu Gallery). Occasionally, there are 1~2 "disobedient" parathyroid glands around the thyroid gland (inside the thymus). Because the parathyroid glands are located deep, it is difficult to feel them on the surface of the body during physical examination. The identification of parathyroid glands during thyroid surgery is also a problem for many surgeons.

2. What use can such a small thing have?

Don't underestimate it, it will secrete a parathyroid hormone (PTH) to regulate the body's calcium and phosphorus metabolism, and regulate and maintain calcium and phosphorus balance through the three organs of the kidneys, bones, and intestines. When there is a problem with the parathyroid glands, these three organs may show corresponding clinical symptoms, and when these organs have problems, they may also reversely affect the parathyroid glands and cause abnormalities. High blood calcium and low blood phosphorus caused by excessive secretion of PTH is called hyperparathyroidism, referred to as "hyperparathyroidism", and low blood calcium and high blood phosphorus caused by insufficient secretion of PTH is called hypoparathyroidism, referred to as "hypoparathyroidism".

2. The matter of "hyperparathyroidism" and "hypoparathyroidism"

1. Hyperparathyroidism: They are both hyperparathyroidism, so why are they different?

1) Primary hyperparathyroidism: You are ill.

This is due to the parathyroid gland's own pathological changes, which causes excessive secretion of parathyroid hormone (PTH). It is usually seen in parathyroid adenoma (86%), rarely in parathyroid hyperplasia (7%), and parathyroid adenocarcinoma (1%). Because adenoma secretes excessive PTH autonomously and is not affected by the feedback of blood calcium, high calcium will not reduce PTH, but will only soar together. What symptoms do the three organs mentioned above have at this time?

① Kidney: PTH in the kidney promotes the conversion of 25-hydroxyvitamin D into the more active 1,25-dihydroxyvitamin D, which promotes the absorption of calcium in the intestine and aggravates hypercalcemia. When blood calcium is high, the kidneys have to excrete more, and there is more calcium in the urine. The patient may develop urinary stones or renal calcitonin deposition. At the same time, the kidneys reduce phosphorus reabsorption and the blood phosphorus is low. At this time, we see high PTH, high blood calcium and low blood phosphorus on the test report.

② Bones: PTH can promote the decalcification of osteoclasts, causing calcium to be removed from bones, resulting in osteoporosis. In the early stages, there may be bone pain, and in the later stages, there may be bone deformities, pathological bones, and shortening of stature. Some patients may develop bone cysts, which manifest as local bone protrusions.

③ Intestine: High concentrations of calcium can stimulate gastrin, causing increased gastric acid secretion by gastric parietal cells, which can easily lead to the formation of high-acid multiple gastric and duodenal ulcers, activate trypsinogen in the pancreatic duct, cause autodigestion and oxidative stress response of the pancreas, and cause pancreatitis.

Seeing this, I should be able to explain Grandma Jie’s doubts to her family.

2) Secondary hyperparathyroidism: Others are sick, so I have to bear the consequences.

It is mostly caused by kidney disease, intestinal malabsorption and other diseases that cause calcium and phosphorus metabolism disorders, leading to hypocalcemia, which in turn stimulates the parathyroid glands to secrete PTH. Long-term stimulation causes the parathyroid glands to proliferate and swell, secreting more PTH. At this time, we see high PTH, low blood calcium and high blood phosphorus on the test report.

3) Tertiary hyperparathyroidism: When a fire breaks out in the city gate, everyone is affected

On the basis of secondary hyperparathyroidism, the parathyroid glands continue to proliferate and swell to form adenomas, and the passive secretion of PTH changes to active secretion of PTH. At this time, we see high PTH, high blood calcium, and high blood phosphorus on the test report.

2. Hypoparathyroidism: Whether it is true or false, it must be treated.

1) Secondary hypoparathyroidism: It is caused by a series of changes caused by the lack or reduction of PTH secretion after thyroid surgery, which is mainly manifested by decreased PTH, hypocalcemia, and hyperphosphatemia. Numbness and twitching of the hands and feet, spasms of the hands, feet, and facial muscles, and eagle claws may occur.

2) Pseudohypoparathyroidism: It is a hereditary disease with defective PTH receptors, no response of peripheral organs to PTH, and increased PTH secretion, which is mainly manifested by normal or increased PTH, hypocalcemia, and hyperphosphatemia. Typical patients may have slow development, mental retardation, short stature, and shortened metacarpal bones, especially symmetrical shortening of the 4th and 5th metacarpal bones.

Hypocalcemia can also cause cataracts, and metastatic calcification may cause epilepsy. Chronic hypocalcemia patients often feel weak, tight, have difficulty walking, stutter, and have unclear pronunciation. For hypercalcemia and hypocalcemia, finding out the cause is the key, early detection, early diagnosis, and early treatment.

3. What are the inspection methods?

1. Test blood calcium and blood phosphorus. If blood calcium is high, further examination is needed to clarify the cause of high calcium.

2. Blood PTH test, combined with calcium and phosphorus analysis.

3. Ultrasound examination: convenient, fast, safe and radiation-free, but the parathyroid glands are located deep and the glands are small. Sometimes it is difficult to detect parathyroid lesions by ultrasound, especially ectopic parathyroid glands.

4. MIBI examination (parathyroid isotope imaging): helps locate one or more parathyroid lesions, especially those that cannot be identified by ultrasound.

5. X-ray and bone density to understand the bone condition, especially for patients with bone pain, bone deformity and fracture.

4. Who should be cautious?

1. Kidney disease, recurrent urinary stones, uremia and hemodialysis patients, because 25-hydroxyvitamin D is converted into the more active 1,25-dihydroxyvitamin D in the kidneys, which can play a role. If kidney disease leads to calcium and phosphorus metabolism disorders, it will stimulate the parathyroid glands to secrete more PTH, and parathyroid hyperplasia or adenoma may occur over time.

2. When we experience bone pain without obvious reasons, fractures without major trauma, or become shorter, we should check the condition of the parathyroid glands to see if we have parathyroid disease. PTH will act on osteoblasts and osteoclasts, mobilize calcium from the bones, release bone calcium into the blood, and cause the loss of calcium in our bones, leading to bone pain, osteoporosis, and even a decrease in height.

3. Loss of appetite, indigestion, and about 5% of patients have pancreatitis attacks: Long-term poor appetite and indigestion caused by digestive tract diseases will reduce calcium absorption, which will in turn stimulate the increase of PTH secretion. Hypocalcemia is common in pancreatitis. If pancreatitis is accompanied by high calcium, be alert to the possibility of parathyroid disease.

4. Limb numbness and occasional convulsions. If these symptoms occur after thyroid surgery, parathyroid gland damage may be considered.

5. Those with a family history are mostly diagnosed with multiple endocrine neoplasia

5. Treatment

1. Hyperparathyroidism, such as parathyroid adenoma or parathyroid hyperplasia, can be treated by surgery

2. For patients with hypoparathyroidism, hypocalcemia caused by hypoparathyroidism can be corrected through oral or intravenous calcium supplementation.

Author: Xu Wenjuan, General Surgery, Pudong New Area Punan Hospital, Shanghai