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DISEASES OF THE PARATHYROID GLANDS

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Title: DISEASES OF THE PARATHYROID GLANDS


1
DISEASES OF THE PARATHYROID GLANDS
  • HYPERPARATHYROIDISM
  • HYPOPARATHYROIDISM

2
Thyroid/Parathyroid glands
1normal thyroid gland 2 and 3parathyroid
gland 4enlarged thyroid gland
3
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4
Parathyroid gland
  • Secretion Parathyroid hormone (PTH,
    Parathormone)
  • Function ? plasma Ca2 concentration
  • 1. ? osteoclast activity
  • 2. ? Ca absorption from GI tract
  • 3. ? Ca reabsorption from kidney tubules
  • Hyperparathyroidism ?hypercalcemia
  • Hypoparathyroidism ?hypocalcemia

5
Hyperparathyroidism
  • Causes
  • 1º hyperparathyroidismadenoma or carcinoma
  • 2º hyperparathyroidismpoor diet low Ca intake
    renal disease
  • Clinical signs
  • Many animals show no clinical signs
  • signs occur as organ dysfunction occurs
  • urinary/renal calculi (high plasma Ca)
  • cardiac arrhythmias, tremors (Ca necessary for
    normal muscle contraction
  • Anorexia, vomiting, constipation
  • weakness

6
Hyperparathyroidism
  • Dx
  • Routine chemistry panel
  • ? blood Calcium (normal 8-10 mg/dl))
  • /- ? blood Phosphorus (normal 2-6 mg/dl)
  • PTH assay
  • normal PTH dogs 20 pg/ml, cats 17 pg/ml
  • In a normal animal if blood Ca is high, PTH is
    low (neg feedback)
  • 1º Hyperparathyroidism Ca high, PTH elevated
  • Ultrasound of neck enlarged glands, abdomen -
    uroliths

7
Hyperparathyroidism
  • Tx
  • 1. Surgical removal of diseased parathyroid
    (generally 4 lobes are imbedded in thyroid gland)
  • Other options
  • 2. Ultrasound-guided chemical (ethanol)
    ablation
  • 3. Ultrasound-guided heat (laser) ablation
  • Post-Op Care
  • 1. Hospitalize for 1 wk ?PTH may predispose
    animal to hypocalcemia
  • 2. Calcium therapy (oral tabs, liquid)
  • 3. Vit D supplements (promotes Ca intestinal
    absorption)

8
Hyperparathyroidism
  • Client Info
  • Most hyperparathyroid animals show no signs when
    first diagnosed
  • Run yearly chem panels on all normal, older
    animals

9
  • Hyperparathyroidism clinical case

10
Hypercalcemia Other causes
  • Causes
  • Neoplasia (lymphoma, perianal gland tumors)
  • Renal failure
  • Hypoadenocorticism
  • Vitamin D rodenticide
  • Drugs or artifacts (ex lipemia)
  • Clinical signs vary with cause
  • PU/PD, anorexia, lethargy, vomiting, weakness,
    stupor/coma (severe), uroliths

11
Hypercalcemia
  • Tests
  • Elevated serum calcium levels
  • Low to low-normal phosphorus concentrations

12
Hypercalcemia
  • Treatment
  • Fluids 0.9 NaCl
  • No Ca2 containing fluids
  • Diuretics (furosemide)
  • Steroids
  • Complications
  • Irreversible renal failure
  • Soft tissue calcifications

13
Hypocalcemia
  • Causes
  • Parathyroid disease
  • Inadvertent removal of parathyroid during
    thyroidectomy (most common cause
  • 1º Hypoparathyroidism (uncommon in animals)
  • Chronic renal failure
  • may cause ? serum P, which can result in ? serum
    Ca (CaP inverse relation)
  • Vit D normally activated in kidney
  • Protein-losing nephropathy results in loss of
    albumin-bound Ca
  • Puerperal Tetany (Eclampsia)late gestation thru
    post-partum period
  • Improper prenatal nutrition
  • Heavy lactation
  • Inappropriate Ca supplementation

http//www.thepetcenter.com/gen/eclampsia.htmlThe
_video
14
Hypocalcemia
  • Clinical Signs
  • Restlessness, muscle tremors, tonic-clonic
    contractions, seizures
  • Tachycardia with excitement bradycardia in
    severe cases (Ca is necessary for proper muscle
    contractions)
  • Hyperthermia
  • Stiffness, ataxic

15
Hypocalcemia
  • Dx
  • Total serum lt6.5 mg/dl
  • Tx
  • IV infusion of 10 Ca gluconate solution (monitor
    HR and rhythm during infusion)
  • Diazepam (IV) to control seizures
  • Oral supplements of Ca (tabs, caps, syrup)
  • Improve nutrition

16
Hypocalcemia
  • Client info
  • Well-balanced diet increase volume as pregnancy
    progresses
  • Signs in pregnant animal is emergency call vet
    immediately
  • May recur with subsequent pregnancies
  • Early weaning is recommended

17
DISEASES OF THE PANCREAS
  • DIABETES MELLITUS
  • INSULINOMA
  • EXOCRINE PANCREATIC INSUFFICIENCY

18
Review of pancreas functions
  • Long flat organ near duodenum and stomach
  • Exocrine function (the majority of the pancreas)
  • Digestive enzymes
  • Endocrine function islets of Langerhans
  • Alpha cells gt glucagon
  • Beta cells gt insulin
  • Delta cells gt somatostatin

19
Pancreas
20
Pancreas beta cells
21
Review
  • Insulin
  • Moves glucose into cells to be used for energy
  • Decreases blood glucose
  • Glucagon
  • Raises blood glucose
  • Stimulates liver to release glucose
  • Stimulates gluconeogenesis
  • Other hormones from other glands perform similar
    functions (hyperglycemic effect)
  • Growth hormone
  • Glucocorticoids

22
Insulin/Glucagon Balance
23
Endocrine Pancreas
  • Hyperglycemia
  • Definition Excessively high blood glucose levels
  • Normal in dogs 60-120 mg/dl
  • Normal in cats 70 -150 mg/dl

24
Diabetes Mellitus
  • Definition Disorder of carbohydrate, fat and
    protein metabolism caused by an absolute or
    relative insulin deficiency
  • Type I Insulin Dependent DM very low or
    absent insulin secretory ability
  • Type II Non insulin dependent DM (insulin
    insensitivity) inadequate or delayed insulin
    secretion relative to the needs of the patient

25
Diabetes mellitus
Incidence Dogs 100 Type I (Insulin
dependent) Cats 50 Type I and 50 Type
II -non-insulin dependent cats can sometimes
be managed with diet and drug therapy Causes
Chronic pancreatitis Immune-mediated disease
-beta cell destruction Predisposing/risk
factors Cushings Disease Acromegaly Obesity
Genetic predisposition Drugs (steroids)
26
Diabetes mellitus
  • Age/sex
  • Dogs 4-14 yrs, females 2x more likely to be
    affected
  • Cats all ages, but 75 are 8-13yrs, neutered
    males most affected
  • Breeds Poodles, Schnauzers, Keeshonds, Cairn
    Terriers, Dachshunds, Cockers, Beagles

27
DIABETES MELLITUS
  • Pathophysiology
  • Insulin deficiency gt impaired ability to use
    glucose from carbohydrates, fats and proteins
  • Impaired glucose utilization gluconeogenesis gt
    hyperglycemia
  • Clinical signs develop when
  • Exceeds capacity of renal tubular cells to
    reabsorb
  • Dogs BG gt 180-220 mg/dl
  • Cats - BG gt 200-280 mg/dl
  • Glycosuria develops
  • Osmotic diuresis
  • Polyuria/polydipsia
  • UTI
  • Suppress immune system

28
DIABETES MELLITUS
  • SYSTEMS AFFECTED
  • Endocrine/metabolic electrolyte depletion and
    metabolic acidosis
  • Hepatic liver failure 2 to hepatic lipidosis
    (mobilization of free fatty acids to liver leads
    to hepatic lipidosis and ketogenesis)
  • Ophthalmic cataracts (dogs) from glaucoma
  • Renal/urologic UTI, osmotic diuresis
  • Nervous peripheral neuropathy in cats
  • Musculoskeletal Compensatory weight loss

29
Diabetes Mellitus
  • Clinical Signs
  • Polyuria
  • Polydipsia
  • Polyphagia
  • Weight loss
  • Dehydration
  • Cataract formation-dogs
  • Plantigrade stance-cats

30
Diabetes in CatsPlantigrade posture
Plantigrade posture Diabetic neuropathy
31
Diabetes Cataracts
Increase in sugar (sorbitol) in lens causes an
influx of water, which breaks down the lens fibers
32
Diabetic Ketoacidosis
2 metabolic crises ? lipolysis in adipose
tissue ? fatty acids ?ketone bodies ?ketoacidosis
?coma (insulin normally inhibits lipolysis) ?
hepatic gluconeogenesis (in spite of high plasma
glucose levels) (insulin normally inhibits
gluconeogenesis)
33
Diabetic Ketoacidosis
  • Definition True medical emergency secondary to
    absolute or relative insulin deficiency causing
    hyperglycemia, ketonemia, metabolic acidosis,
    dehydration and electrolyte depletion
  • DM causes increased lipolysis gt ketone
    production and acidosis

34
Diabetic Ketoacidosis
  • Diagnosed with ketones in urine or ketones in
    blood
  • Can use urine dip stick with serum.
  • Clinical Signs
  • All of the DM signs
  • Depression
  • Weakness
  • Tachypnea
  • Vomiting
  • Odor of acetone on breath

35
Diabetic Ketoacidosis
  • IV fluids to rehydrate 0.9 NaCl
  • K (potassium) supplement
  • Regular insulin to slowly decrease BG
  • Monitor BG q 2-3 hrs
  • When BG close to normal and patient stable switch
    to longer acting insulin

36
DIABETES MELLITUS
  • DIAGNOSIS
  • CBC normal
  • Biochemistry panel
  • Glucose gt 200 mg/dl (dogs), gt250 (cats)
  • UA
  • Glycosuria!!!! (causes UTI)
  • Ketonuria
  • USG low
  • Electrolytes may be low due to osmotic diuresis
  • Blood gases (if ketoacidotic)
  • Fructosamine levels mean glucose level for last
    2-3 weeks (dogs)
  • Ideal to test for regulation checks

37
DM Rx INSULIN AND DIET!!!
Table 1. Traditional insulin outline.
Duration/onset category Insulin types Concentration
Rapid acting Regular (Humulin R) U-100 (100 units/ml)
Intermediate acting NPH (Humulin N) U-100
Intermediate acting Lente (Vetsulin by Intervet) NO LONGER AVAILABLE U-40 (40 units/ml)
Long acting PZI (Idexx) U-40
Long acting Ultralente NO LONGER AVAILABLE U-100
Long acting Glargine insulin analog U-100
38
Diabetes Insulin therapy
39
DM Insulin therapy
  • Beef-origin insulin is biologically
  • similar to cat insulin NOT RECOMMENDED because
    of production methods
  • Porcine-origin insulin (porcine lente) is
    biologically similar to dog insulin
  • Dogs and cats have responded well to human
    insulin products
  • Cats longer-acting protamine zinc insulin
    (human recombinant PZI)
  • Insulin Glargine not approved for use in cats
    and PZI have same duration of action

40
DM Insulin therapy
  • INSULIN ADMINISTRATION
  • ALWAYS USE THE APPROPRIATE INSULIN SYRINGE! (U-40
    vs. U-100)
  • Insulin is given in units (insulin syringes are
    labeled in units, not mL)
  • 30 units, 50 units, 100 units

41
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42
DM dietary management
  • DIET
  • DOGS high fiber, complex carbohydrate diets
  • Slows digestion, reduces the post-prandial
    glucose spike, promotes weight loss, reduces risk
    of pancreatitis
  • Hills R/D or W/D
  • CATS high protein, low carbohydrate diets
  • Cats use protein as their primary source of
    energy blood glucose is maintained primarily
    through liver metabolism of fats and proteins
  • Purina DM, Hills M/D
  • Often a diet change in cats can dramatically
    reduce or eliminate the need for insulin
  • This is particularly true for type II

43
Diabetes Mellitus
  • Oral hypoglycemics
  • Sulfonylureas Glipizide cats
  • Direct stimulation of insulin secretion from the
    pancreas
  • Adverse side effects, although uncommon, include
    vomiting, loss of appetite, and liver damage
  • Alpha-Glucosidase Inhibitors Acarbose
  • Delays digestion of complex carbohydrates and
    delays absorption of glucose from the intestinal
    tract.
  • Insulin is more effective than oral hypoglycemics

44
Diabetes Mellitus Monitoring
Find an ear vein Prick the ear to get Place
drop of blood blood sample on green tip
readout in a few seconds
45
Diabetes Rx Urine glucose
46
Diabetes monitoring Urine glucose
47
DM monitoring
48
DM
  • Client Education
  • Lifelong insulin replacement therapy
  • Insulin administered by injection
  • Refrigerate insulin, mix gently (no bubbles),
    single use syringes
  • Cataracts common, permanent
  • Consistent diet and exercise
  • Recheck BG or curve regularly or fructosamine
    levels
  • Progressive
  • If animal does not eat- NO INSULIN

49
  • Diabetes Mellitus clinical case

50
Endocrine Pancreas
  • Hypoglycemia
  • Definition Low blood glucose levels
  • Causes
  • Neonatal and juvenile
  • Septicemia
  • Neoplasia
  • Starvation
  • Iatrogenic insulin overdose
  • Portosystemic shunt
  • Many others

51
Insulin Shock
  • Causes
  • Insulin overdose (misread syringe)
  • Too much exercise
  • Anorexia
  • Signs
  • Weakness, incoordination, seizures, coma

52
Insulin Shock
  • Prevention
  • Consistent diet (type and amount)/consistent
    exercise (less insulin with exercise)
  • Monitor urine/blood glucose at same time each day
  • Feed 1/3 with insulin the rest 8-10 h later (at
    insulin peak)
  • Have sugar supply handy

53
Insulinoma
  • CAUSE tumor of beta cells, secreting an excess
    of insulin
  • SIGNS prolonged hypoglycemia?weakness, ataxia,
    muscle fasciculations, posterior paresis, brain
    damage, seizures, coma, death,

54
Insulinoma Dx
  • Chem Panel
  • ?blood glucose
  • Simultaneous glucose and insulin tests
  • Low glucose, High insulin gt insulinoma
  • Observations
  • Symptoms occur after fasting or exercise
  • when symptomatic, blood glucoselt50 mg/dl
  • symptoms corrected with sugar administration

55
Insulinoma Rx
  • Surgical Rx removal of tumor
  • Medical Rx
  • Acute, at home
  • administer glucose (Karo) keep animal quiet,
    seek vet care
  • Acute, in Hosp
  • adm. glucose (50 Dextrose)
  • Chronic care
  • feed 3-6 small meals/day (high protein, low
    fat)
  • limited exercise
  • glucocorticooid therapy (antagonizes insulin
    effect at cellular level)
  • Diazoxide (?insulin secretion, tissue use of
    glucose, ?blood glucose)
  • Octreotide (Sandostatin) injectionsinhibits
    synthesis and release of insulin by both normal
    and neoplastic beta cells

56
Insulinoma Client info
  • 1. Usually, by the time insulinoma is diagnosed,
    metastasis has occurred so prognosis is poor
  • 2. With proper medical therapy, survival may be
    12-24 mo
  • 3. Always limit exercise and excitement
  • 4. Feed multiple, small meals throughout day
    keep sugar source close during exercise
  • 5. Karo syrup on mm provides for rapid
    absorption of glucose into blood stream
  • 6. Avoid placing hand into dogs mouth during
    seizure to avoid being bitten
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