Parathyroid disorders

Parathyroid glands are four pea-sized glands located just behind the thyroidgland in the front of the neck. The function of parathyroid glands is to produce a hormone called parathyroid hormone (parathormone), which helps regulatecalcium and phosphorous in the body. Hyperparathyroidism is the overproduction of this hormone. Hypoparathyroidism is the result of a decrease in production of parathyroid hormones; the result is a low level of calcium in the blood.

Thyroid glands and parathyroid glands, despite their similar name and proximity, are entirely separate, and each produces hormones with different functions. Hyperparathyroidism may be primary or secondary. It most often occurs in those over age 30, and most commonly in patients 50 to 60 years old. It rarelyoccurs in children or the elderly. Women are affected by the disease up to three times more often than men. It is estimated that 28 of every 100,000 people in the United States will develop hyperparathyroidism each year. Hypoparathyroidism affects both males and females of all ages.

Normally, parathyroid glands produce the parathormone as calcium levels dropand lower to meet the demands of a growing skeleton, pregnancy, or lactation.However, when one or more parathyroid glands malfunctions, it can lead to overproduction of the hormone and elevated calcium level in the blood. Therefore, a common result of hyperparathyroidism is hypercalcemia, or an abnormallyhigh level of calcium in the blood. Primary hyperparathyroidism occurs as a malfunction of one of the glands, usually as a result of a benign tumor, called adenoma. Secondary hyperparathyroidism occurs as the result of a metabolicabnormality outside the parathyroid glands, which causes a resistance to thefunction of the parathyroid hormones. Primary hyperparathyroidism is one of the most common endocrine disorders, led only by diabetes and hyperthyroidism.

Often, there are no obvious symptoms or suspicion of hyperparathyroidism, andit is first diagnosed when a patient is discovered to be hypercalcemic during a routine blood chemistry profile. Patients may believe they have felt fine, but realize improvements in sleep, irritability, and memory following treatment. When symptoms are present, they may include development of gastric ulcers or pancreatitis because high calcium levels can cause inflammation and pain in the linings of the stomach and pancreas.

Most of the symptoms of hyperparathyroidism are those present as a result ofhypercalcemia, such as kidney stones, osteoporosis, or bone degradation resulting from the bones giving up calcium. Muscle weakness, central nervous system disturbances such as depression, psychomotor and personality disturbances,and rarely, even coma can occur. Patients may also experience heartburn, nausea, constipation, or abdominal pain. In secondary hyperparathyroidism, patients may show signs of calcium imbalance such as deformities of the long bones.Symptoms of the underlying disease may also be present.

Most commonly, hyperparathyroidism occurs as the result of a single adenoma,or benign tumor, in one of the parathyroid glands. About 90% of all cases ofhyperparathyroidism are caused by an adenoma. The tumors are seldom cancerous. They will grow to a much larger size than the parathyroid glands, often tothe size of a walnut. Genetic disorders or multiple endocrine tumors can alsocause a parathyroid gland to enlarge and oversecrete hormone. In 10% or fewer of patients with primary hyperparathyroidism, there is enlargement of all four parathyroid glands. This condition is called parathyroid hyperplasia.

The accidental removal of the parathyroid glands during neck surgery is the most frequent cause of hypoparathyroidism. Complications of surgery on the parathyroid glands is another common cause of this disorder. There is the possibility of autoimmune genetic disorders causing hypoparathyroidism such as Hashimoto's thyroiditis, pernicious anemia, and Addison's disease. The destruction of the gland by radiation is a rare cause of hypoparathyroidism. Occasionally, the parathyroids are absent at birth causing low calcium levels and possible convulsions in the newborn. Symptoms in the advanced and continuous stages of hypoparathyroidism include splitting of the nails, inadequate tooth development and mental retardation in children, and seizures.

Abnormal low levels of calcium result in irritability of nerves, causing numbness and tingling of the hands and feet, with painful-cramp like muscle spasms known as tetany. Laryngeal spasms may also occur causing respiratory obstruction.

Diagnosis of hyperparathyroidism is most often made when a blood test (radioimmunoassay) reveals high levels of parathyroid hormone and calcium. A blood test that specifically measures the amount of parathyroid hormone has made diagnosis simpler. X-ray examinations may be performed to look for areas of diffuse bone demineralization, bone cysts, outer bone absorption and erosion of the long bones of the fingers and toes. Hypercalcemia is mild or intermittentin some patients, but is an excellent indicator of primary hyperparathyroidism. Dual energy x-ray absorptiometry (DEXA or DXA), a tool used to diagnose and measure osteoporosis, is used to show reduction in bone mass for primary hyperparathryroidism patients. Once a diagnosis of hyperparathyroidism is reached, the physician will probably order further tests to evaluate complications. For example, abdominal radiographs might reveal kidney stones.

For secondary hyperparathyroidism, normal or slightly decreased calcium levels in the blood and variable phosphorous levels may be visible. Patient history of familial kidney disease or convulsive disorders may suggest a diagnosisof secondary hyperparathyroidism. Other tests may reveal a disease or disorder, which is causing the secondary hyperparathyroidism.

Hyperparathyroidism cases will usually be referred to an endocrinologist, a physician specializing in hormonal problems, or a nephrologist, who specializes in kidney and mineral disorders.

Patients with mild cases of hyperparathyroidism may not need immediate treatment if they have only slight elevations in blood calcium level and normal kidneys and bones. These patients should be regularly checked, probably as oftenas every six months, by physical examination and measurement of kidney function and calcium levels. A bone densitometry measurement should be performed every one or two years. After several years with no worsened symptoms, the length of time between exams may be increased.

Patients with more advanced hyperparathyroidism will usually have all or halfof the affected parathyroid gland or glands surgically removed. This surgeryis relatively safe and effective. The primary risks are those associated with general anesthesia. There are some instances when the surgery can be performed with the patient under regional, or cervical block, anesthesia. Often studies such as ultrasonography prior to surgery help pinpoint the affected areas.

Removal of the enlarged parathyroid gland or glands cures the disease 95% ofthe time and relief of bone pain may occur in as few as three days. In up to5% of patients undergoing surgery, chronically low calcium levels may result,and these patients will require calcium supplement or vitamin D treatment. Damage to the kidneys as a result of hyperparathyroidism is often irreversible. Prognosis is generally good, however complications of hyperparathyroidism such as osteoporosis, bone fractures, kidney stones, peptic ulcers, pancreatitis, and nervous system difficulties may worsen prognosis.

Presently hypoparathyroidism is considered incurable. The disorder requires lifelong replacement therapy to control symptoms. Medical research however, continues to search for a cure.

Secondary hyperparathyroidism may be prevented by early treatment of the disease causing it. Early recognition and treatment of hyperparathyroidism may prevent hypercalcemia. Since the cause of primary hyperparathyroidism, or the adenoma which causes parathyroid enlargement, is largely unknown, there are not prescribed prevention methods.

There are no specific preventive measures for hypoparathyroidism. However, careful surgical techniques are critical to reduce the risk of damage to the gland during surgery.

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