Digestive manifestations of parathyroid disorders

Case report: Microwave ablation is a safe and effective method for primary hyperparathyroidism in pregnancy

Primary hyperparathyroidism (PHPT) is a rare disease in pregnancy and endangers the health of both pregnant women and fetuses. However, the treatments are very limited for PHPT and most of them are unsatisfactory because of the peculiar state in pregnancy. The only curable method is parathyroidectomy which can be safely performed in the second trimester of pregnancy. In this case, we reported a pregnant woman with primary parathyroid adenoma presenting hypercalcemia and severe vomit at the end of first trimester. Finally, she got cured by microwave ablation at the end of first trimester and gave birth to a healthy baby boy.

Classical and Nonclassical Manifestations of Primary Hyperparathyroidism

This narrative review summarizes data on classical and nonclassical manifestations of primary hyperparathyroidism (PHPT). It is based on a rigorous literature search, inclusive of a Medline search for systematic reviews from 1940 to December 2020, coupled with a targeted search for original publications, covering four databases, from January 2013-December 2020, and relevant articles from authors' libraries. We present the most recent information, identify knowledge gaps, and suggest a research agenda. The shift in the presentation of PHPT from a predominantly symptomatic to an asymptomatic disease, with its varied manifestations, has presented several challenges. Subclinical nephrolithiasis and vertebral fractures are common in patients with asymptomatic disease. The natural history of asymptomatic PHPT with no end organ damage at diagnosis is unclear. Some observational and cross-sectional studies continue to show associations between PHPT and cardiovascular and neuropsychological abnormalities, among the different disease phenotypes. Their causal relationship is uncertain. Limited new data are available on the natural history of skeletal, renal, cardiovascular, neuropsychological, and neuromuscular manifestations and quality of life. Normocalcemic PHPT (NPHPT) is often diagnosed without the fulfillment of rigorous criteria. Randomized clinical trials have not demonstrated a consistent long-term benefit of parathyroidectomy (PTX) versus observation on nonclassical manifestations. We propose further refining the definition of asymptomatic disease, into two phenotypes: one without and one with evidence of target organ involvement, upon the standard evaluation detailed in our recommendations. Each of these phenotypes can present with or without non-classical manifestations. We propose multiple albumin-adjusted serum calcium determinations (albumin-adjusted and ionized) and exclusion of all secondary causes of high parathyroid hormone (PTH) when establishing the diagnosis of NPHPT. Refining the definition of asymptomatic disease into the phenotypes proposed will afford insights into their natural history and response to interventions. This would also pave the way for the development of evidence-based guidance and recommendations. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

A Case of Gitelman Syndrome with Hypercalcemia Secondary to Primary Hyperparathyroidism

Gitelman syndrome is a rare autosomal recessive salt-losing tubulopathy characterized by hypokalemia, hypomagnesemia, hypocalciuria, and secondary hyperaldosteronism. However, hypercalcemia secondary to hypocalciuria is extremely rare during the disease. A 36-year-old normotensive man who suffered a motor vehicle accident was presented with hypokalemia, hypomagnesemia, and mild hypercalcemia. He had a past medical history significant for bipolar depression disorder and a history of chronic atrial fibrillation. He was diagnosed with Gitelman syndrome. However, he was noncompliant with his medications. A laboratory workup revealed hypokalemia, hypomagnesemia, hypercalcemia, and a high parathyroid hormone level. Thorough investigations identified primary hyperparathyroidism as the primary cause of hypercalcemia. To our knowledge, Gitelman syndrome and primary hyperparathyroidism are an extremely rare association that is present in our case.

Is there a correlation between the initial calcium level and Balthazar classification in patients with acute pancreatitis?

BACKGROUND

While a life-threatening course is observed in 2-3% of patients with acute pancreatitis (AP), mortality can be up to 50% in severe AP. In our study, we research relationship between calcium level and Modified Balthazar (MB) score.

METHODS

354 patients who were followed up with a diagnosis of AP between 2013 and 2019 were included in our study. Serum calcium level was measured within the first 24 h. Abdominal computed tomography (CT) was performed in all patients in the first 12 h and between 3 and 7 days. The severity of AP was determined according to the MB classification. The correlation between calcium level and MB classification was examined.

RESULTS

206 (58.2%) of the patients were women. Mean age was 54.8±17.9 years (range: 18-100). It was observed that the rate of severe AP was significantly higher in the low calcium group compared to the MB classification in which tomographies taken at ad-mission and 72 h after were evaluated (p<0.05). Furthermore, progression was higher in low calcium group (p<0.05). The cutoff value was 9.35 mg/dl for the ROC analysis performed to distinguish mild pancreatitis from moderate-severe pancreatitis according to the MB classification performed by CT obtained after 72 h based on the Ca values. For the cutoff value of 9.35 mg/dl (AUC: 0.581, p=0.018, 95% Cl: 0.514-0.649), the sensitivity was 57.4% and the specificity was 53.1%.

CONCLUSION

Since there is a correlation between the initial calcium level and the severity of the disease according to the CT-scan obtained later, the calcium level gives us an idea of the course of the disease.

Chronic vomiting: Rare causes not to be missed

Establishing the cause of vomiting can be challenging in 10% of patients. In such situations, the clinicians need to consider non-gastrointestinal causes including metabolic and endocrine disorders. Clinical and laboratory clues may prompt further relevant tests that will lead to the correct diagnosis. We discuss three such patients with chronic vomiting.

Hypoparathyroidism-retardation-dysmorphism syndrome-Clinical insights from a large longitudinal cohort in a single medical center

BACKGROUND

Hypoparathyroidism, retardation, and dysmorphism (HRD) Syndrome is a rare disease composed of hypoparathyroidism, retardation of both growth and development, and distinctive dysmorphic features. Here, we describe the long-term morbidity and mortality in a large cohort of HRD patients and suggest recommendations for follow up and treatment.

METHODS

Medical records of 63 HRD syndrome patients who were followed at Soroka Medical Center during 1989-2019 were reviewed retrospectively. Information regarding demographics, medical complications, laboratory findings, and imaging studies was collected.

RESULTS

The mortality rate was 52%. The main causes of death were infectious diseases including pneumonia, septic shock, and meningitis. Multiple comorbidities were found including brain anomalies in 90% of examined patients (basal ganglia calcifications, tightening of corpus callosum, Chiari malformation, hydrocephalous, and brain atrophy), seizures in 62%, nephrocalcinosis and/or nephrolithiasis in 47%, multiple eye anomalies were recorded in 40%, bowel obstructions in 9.5%, and variable expression of both conductive and senso-neural hearing loss was documented in 9.5%.

CONCLUSION

HRD is a severe multisystem disease. Active surveillance is indicated to prevent and treat complications associated with this rare syndrome.

Primary Hyperparathyroidism as a Rare Cause of Unexplained Recurrent Abdominal Pain: Case Presentation and Literature Review

Abdominal pain is a common symptom in surgical practice. Around 11%-45% of pediatric population present with abdominal pain. In 29%-87.5% of pediatric population diagnosed with primary hyperparathyroidism (PHPT), abdominal pain and other gastrointestinal (GI) symptoms were the presenting complaint. Hyperparathyroidism is a condition characterized by increased parathyroid hormone (PTH) secretion. It usually presents with nonspecific symptoms of fatigue, poor appetite, weight loss, abdominal pain, nausea, emesis, and bone pain.

We present a case of a 13-year-old girl who experienced a recurrent abdominal pain associated with nausea and vomiting, which was diagnosed eight months later when her laboratory investigation revealed high amylase, calcium, and PTH, which raised a suspicion of pancreatitis secondary to hyperparathyroidism. Imaging studies showed retrosternal lesion within the thymus gland, most likely a thymic parathyroid adenoma. The patient's symptoms resolved following thoracoscopic thymectomy, which was performed in another center.

To assess the relationship between GI symptoms and PHPT, we reviewed 13 articles published between 2007 and 2020 in the English literature which reported 331 cases of primary PHPT and found that GI symptoms are the fourth most common presentation in patients with PHPT. In those patients, the reported incidence of GI symptoms including abdominal pain was 18.67%. Out of the 331 cases included, only one case mimicked our case as abdominal pain was the main presenting symptom.

Unexplained recurrent abdominal pain should raise the suspicion for rare causes. Hyperparathyroidism should be included in the differential diagnosis of recurrent abdominal pain.

Sporadic Primary Hyperparathyroidism

Sporadic primary hyperparathyroidism is a common endocrinopathy, particularly afflicting postmenopausal women and both African American men and women. Although classic signs and symptoms of the disease are well appreciated and described, because of the ease and availability and low threshold for screening, the disorder often is diagnosed in patients who are minimally symptomatic or asymptomatic. Surgery conducted by experienced endocrine surgeons has a high cure rate, particularly if guided by concordant imaging. In patients who cannot safely undergo surgery or who fail to be cured, medical therapy with the oral calcimimetic cinacalcet is a validated option for controlling serum calcium levels.

[The clinical practice guidelines for primary hyperparathyroidism, short version]

Primary hyperparathyroidism (PHPT) is an endocrine disorder of parathyroid glands characterized by excessive secretion of parathyroid hormone (PTH) with an upper normal or elevated blood calcium level. Classical PHPT refers to a symptomatic, multi-system disorder, wich can lead to a significant decrease in the quality of life, disability of patients, and even an increased risk of premature death. Hypercalcemia and the catabolic effect of PTH on various cells are considered as the main pathogenetic mechanisms of the PHPT associated complications. In the last two decades, there has been an increase in the incidence of PHPT, mainly due to the mild forms of the disease, primarily due to the routine calcium screening in North America, Western Europe and, Asia. High prevalence of the disease, as well as the variety of clinical manifestations, cause the attention of different specialists - physicians, rheumatologists, urologists, nephrologists, cardiologists and other doctors. This review cover the main issues of Russian guidelines for the management of PHPT, approved in 2020, including laboratory and instrumental methods, differential diagnosis, surgical and conservative approach, short-term and long-term follow-up. This guidelines also include the recommendations for special groups of patients with hereditary forms of PHPT, parathyroid carcinoma, PHPT during pregnancy.

Systemic Disease Associations with Disorders of Gut-Brain Interaction and Gastrointestinal Transit: A Review

Functional gastrointestinal disorders (FGID) are now classified within the Rome IV framework as disorders of gut-brain interaction (DGBI). Disorders of gastrointestinal transit (as defined by abnormalities on contemporary gastrointestinal motility testing) frequently are associated with symptoms that are also characteristic of DGBIs. In this narrative review, we outline a non-inclusive set of systemic diseases or risk factors that have been classically associated with DGBIs and disorders of gastrointestinal transit; these include diabetes mellitus, paraneoplastic syndromes, surgery, Parkinson's disease, systemic sclerosis, endocrinopathies, polypharmacy, and post-infectious syndromes.

Primary Hyperparathyroidism: A Narrative Review of Diagnosis and Medical Management

Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcemia in the outpatient setting. Symptomatic presentation includes non-specific signs and symptoms of hypercalcemia, skeletal fragility, nephrolithiasis and nephrocalcinosis. The majority of individuals present at an asymptomatic stage following routine biochemical screening, without any signs or symptoms of calcium or parathyroid hormone (PTH) excess or target organ damage. Indications for surgery have recently been revised as published in recent guidelines and consensus statements. Parathyroidectomy is advised in patients younger than 50 years old and in the presence of either significant hypercalcemia, impaired renal function, renal stones or osteoporosis. Surgery is always appropriate in suitable surgical candidates, however, medical management may be considered in those with mild asymptomatic disease, contraindications to surgery or failed previous surgical intervention. We summarized the optimal medical interventions available in the care of PHPT patients not undergoing parathyroidectomy. Calcium and vitamin D intake should be optimized. Antiresorptive therapy may be used for skeletal protection in patients with an increased fracture risk. Cinacalcet, a calcimimetic agent, has been shown to effectively lower serum calcium and PTH levels. The effect of medical treatment on the reduction in fracture risk is unknown and should be the focus of future research.

Physical Activity-Dependent Regulation of Parathyroid Hormone and Calcium-Phosphorous Metabolism

Exercise perturbs homeostasis, alters the levels of circulating mediators and hormones, and increases the demand by skeletal muscles and other vital organs for energy substrates. Exercise also affects bone and mineral metabolism, particularly calcium and phosphate, both of which are essential for muscle contraction, neuromuscular signaling, biosynthesis of adenosine triphosphate (ATP), and other energy substrates. Parathyroid hormone (PTH) is involved in the regulation of calcium and phosphate homeostasis. Understanding the effects of exercise on PTH secretion is fundamental for appreciating how the body adapts to exercise. Altered PTH metabolism underlies hyperparathyroidism and hypoparathyroidism, the complications of which affect the organs involved in calcium and phosphorous metabolism (bone and kidney) and other body systems as well. Exercise affects PTH expression and secretion by altering the circulating levels of calcium and phosphate. In turn, PTH responds directly to exercise and exercise-induced myokines. Here, we review the main concepts of the regulation of PTH expression and secretion under physiological conditions, in acute and chronic exercise, and in relation to PTH-related disorders.

Quantification of Symptom Load by a Disease-Specific Questionnaire HPQ 28 and Analysis of Associated Biochemical Parameters in Patients With Postsurgical Hypoparathyroidism

In hypoparathyroidism (HypoPT), patients suffer severely from reduced quality of life. The complexity of HypoPT demands a disease‐specific control instrument to characterize symptom load. We employed a newly developed disease‐specific Hypoparathyroid Patient Questionnaire (the HPQ 40/28) to investigate and quantify HypoPT patients' complaints and contributing factors. In this cross‐sectional, two‐center study, patients with postsurgical HypoPT (n = 49) were matched for gender and age and compared with patients having undergone thyroid surgery without HypoPT (n = 39) and patients with primary hyperparathyroidism (n = 35). The HPQ 40/28 was completed when patients visited the respective center. Clinical background information, blood tests, and current medication were documented by the physician. Serum calcium lay within the reference range in 87% of HypoPT patients, serum phosphate in 95.7%, and calcium–phosphate product (CPP) in 100%. HPQ 40/28 scores for the scales “pain and cramps” (PaC), “neurovegetative symptoms” (NVS), “numbness or tingling,” and “heart palpitations” were significantly elevated in comparison with control groups. Correlations between complaints and laboratory parameters could be demonstrated in the HypoPT group, with serum calcium correlating with NVS (r = 0.309, p < 0.05) and serum phosphate with loss of vitality (r = 0.349, p < 0.05). CPP was the main contributor to symptom load with an influence on PaC (r = 0.295, p < 0.05), loss of vitality (r = 0.498, p < 0.001), numbness or tingling (r = 0.328, p < 0.05), and memory problems (r = 0.296, p < 0.05). In conclusion, the newly developed HPQ 40/28 successfully identified and quantified symptoms typical in HypoPT patients. Using the HPQ 40/28, the CPP was identified as the predominant factor in the severity of complaints in HypoPT. © 2020 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Do Symptoms and Serum Calcium Levels Affect the Results of Surgical Treatment of Primary Hyperparathyroidism?

Introduction

The purpose of this study was to investigate the difference in surgical outcomes between symptomatic and asymptomatic patients with primary hyperparathyroidism (PHPT) and between patients with high serum calcium and those with normal blood calcium, as well as to explore the epidemiological trend of PHPT in northern China.

Methods

Clinicopathologic data of 197 patients (50 men and 147 women) with PHPT who underwent surgery at the First Affiliated Hospital of Harbin Medical University from 2008 to 2017 were analyzed. Changes in clinicopathology were compared among different subgroups of patients. Patients were categorized into subgroups based on serum calcium levels, whether or not they presented with symptoms, and admission time.

Results

Of the total patients, 82.23% had hypercalcemic primary hyperparathyroidism (HCPHPT), 17.77% had normocalcemic primary hyperparathyroidism (NCPHPT), 45.18% had symptomatic primary hyperparathyroidism (SPHPT), and 54.82% had asymptomatic primary hyperparathyroidism (ASPHPT). Seventy-seven cases of PHPT involved thyroid nodules, with 22 confirmed as papillary thyroid carcinoma, and 29 confirmed as nodular goiter. There was no significant difference in the success rate of surgery, postoperative recurrence rate, and the symptoms of temporary hypocalcemia between the HCPHPT and NCPHPT groups, and between the SPHPT and ASPHPT groups. The incidence of PHPT has increased threefold since 2013.

Conclusions

Symptoms and serum calcium levels did not affect the results of surgical treatment for PHPT. The incidence of PHPT in northern China is increasing. Moreover, PHPT manifestation has shifted from the symptomatic to the asymptomatic form. Thyroid surgery should be performed in PHPT patients with thyroid nodules.

Should Symptoms Be Considered an Indication for Parathyroidectomy in Primary Hyperparathyroidism?

Asymptomatic primary hyperparathyroidism is a very common endocrine condition, yet management of this disease process remains controversial. Primary hyperparathyroidism can lead to a myriad of symptoms which not only decreases the quality of life of patients but also increases the risk of cardiovascular disease, osteoporosis, and kidney stones. Parathyroidectomy is the only known cure for the disease. This review explores the definition of asymptomatic primary hyperparathyroidism, the burden of disease, and the overwhelming benefits of parathyroidectomy.

Hyperparathyroidism

Primary hyperparathyroidism is a common endocrine disorder of calcium metabolism characterised by hypercalcaemia and elevated or inappropriately normal concentrations of parathyroid hormone. Almost always, primary hyperparathyroidism is due to a benign overgrowth of parathyroid tissue either as a single gland (80% of cases) or as a multiple gland disorder (15-20% of cases). Primary hyperparathyroidism is generally discovered when asymptomatic but the disease always has the potential to become symptomatic, resulting in bone loss and kidney stones. In countries where biochemical screening tests are not common, symptomatic primary hyperparathyroidism tends to predominate. Another variant of primary hyperparathyroidism has been described in which the serum calcium concentration is within normal range but parathyroid hormone is elevated in the absence of any obvious cause. Primary hyperparathyroidism can be cured by removal of the parathyroid gland or glands but identification of patients who are best advised to have surgery requires consideration of the guidelines that are regularly updated. Recommendations for patients who do not undergo parathyroid surgery include monitoring of serum calcium concentrations and bone density.

[Parathyroid disease: The full spectrum, from adenoma to carcinoma. Report of 3 cases]

BACKGROUND

Primary hyperparathyroidism is a disease characterised by the autonomous production of parathyroid hormone. The most common cause is an adenoma, followed by hyperplasia, and rarely carcinoma.

CLINICAL CASES

Three cases are presented. The first case is associated with a brown tumour that was diagnosed as hyperplasia after study and surgery. The second case was related to pathological fractures, and a lower right adenoma 236 times bigger than a normal parathyroid was excised. The last case presented with abdominal pain and heartburn. Histopathology reported a carcinoma, which was removed using surgery en bloc. All patients have improved.

CONCLUSION

Hyperparathyroidism symptoms are very difficult to identify and diagnose, thus a detailed and broad approach is needed when hyperparathyroidism is suspected.

High frequency of asymptomatic hyperparathyroidism in patients with fibromyalgia: random association or misdiagnosis?

Fibromyalgia (FM) and hyperparathyroidism may present similar symptoms (musculoskeletal pain, cognitive disorders, insomnia, depression and anxiety), causing diagnostic confusion.

OBJECTIVES

To determine the frequency of asymptomatic hyperparathyroidism in a sample of patients with FM and to evaluate the association of laboratory abnormalities to clinical symptoms.

METHODS

Cross-sectional study with 100 women with FM and 57 healthy women (comparison group). Parathyroid hormone (PTH), calcium and albumin levels were accessed, as well as symptoms in the FM group.

RESULTS

In FM group, mean serum calcium (9.6±0.98mg/dL) and PTH (57.06±68.98pg/mL) values were considered normal, although PTH levels had been significantly higher than in the comparison group (37.12±19.02pg/mL; p=0.001). Hypercalcemic hyperparathyroidism was diagnosed in 6% of patients with FM, and 17% of these women exhibited only high levels of PTH, featuring a normocalcemic hyperparathyroidism, with higher frequencies than those expected for their age. There was no significant association between hyperparathyroidism and FM symptoms, except for epigastric pain, which was more frequent in the group of patients concomitantly with both diseases (p=0.012).

CONCLUSIONS

A high frequency of hyperparathyroidism was noted in women with FM versus the general population. Normocalcemic hyperparathyroidism was also more frequent in patients with FM. Longitudinal studies with greater number of patients are needed to assess whether this is an association by chance only, if the increased serum levels of PTH are part of FM pathophysiology, or even if these would not be cases of FM, but of hyperparathyroidism.

The PNEI holistic approach in coloproctology

The psycho-neuroendocrine-immune approach relies on the concept of considering diseases from a holistic point of view: the various components (psyche, nervous system, endocrine system, and immune system) control the diseased organ/apparatus and in turn are influenced by a feedback mechanism. In this article, we will consider the psycho-neuroendocrine-immune approach to coloproctological disorders, by providing clinical cases and discussing them in light of this approach.

Digestive tract symptoms of primary hyperparathyroidism

Due to the wide use of screening tests for serum calcium, the prevalence rate of primary hyperparathyroidism (PHPT) has become higher and higher lately. PHPT has become the third largest endocrine system disease after diabetes and hyperthyroidism. Most of the patients diagnosed with PHPT in China had obvious clinical manifestations. Acute pancreatitis (AP), peptic ulcer and chronic constipation were its main digestive tract symptoms, which result in hypercalcemia and high parathyroid hormone (PTH). These digestive tract symptoms will disappear with the cure of PHPT. PHPT has an obvious correlation with AP, peptic ulcer and chronic constipation.In order to reduce the misdiagnosis rate and get better clinical effect, clinicians should fully recognize its clinical characters to get a better understanding of this disease. To reduce misdiagnosis, screening of high-risk patients is also necessary. In this paper, by searching the literature, we summarize the digestive tract symptoms of PHPT and make relevant analysis and discussion.

[Total serum calcium and corrected calcium as severity predictors in acute pancreatitis]

OBJECTIVES

To evaluate total serum calcium (TC) and albumin-corrected calcium (ACC) as prognostic severity factors in acute pancreatitis (AP).

METHODS

Ninety-six patients were included in the study. They were diagnosed with AP and admitted to the Hospital Regional de Veracruz within the time frame of January 2010 to December 2012. AP severity was determined through the updated Atlanta Classification (2013). TC and ACC values were measured in the first 24hours of admittance and the percentages of sensitivity (S), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) were calculated through ROC curves and contingency tables.

RESULTS

In accordance with the updated Atlanta Classification, 70 patients presented with mild AP, 17 with moderately severe AP, and 9 with severe AP. Of the patient total, 61.5% were women, and 69.8% presented with biliary etiology. The maximum TC cut-off point was 7.5mg/dL, with values of S, 67%; Sp, 82%; PPV, 27%, and NPV, 96%. The maximum ACC cut-off point was 7.5mg/dL, with values of S, 67%; Sp, 90%; PPV, 40%; NPV, 96%. Both had values similar to those of the Ranson and APACHE II prognostic scales.

CONCLUSIONS

TC and ACC, measured within the first 24hours, are useful severity predictors in acute pancreatitis, with sensitivity and predictive values comparable or superior to those of the conventional prognostic scales.

The effect of parathyroidectomy on chronic constipation in patients affected by primary hyperparathyroidism

Primary hyperparathyroidism (PHPT) is usually associated with chronic constipation; however, its prevalence is not defined by standardized criteria. The aim of the study was to evaluate both the prevalence of chronic constipation, defined by the standardized Rome diagnostic criteria III (Rome III) in PHPT, and the effect of parathyroidectomy (PTx). Fifty postmenopausal PHPT patients and 50 sex- and age-matched controls were studied. Each patient underwent mineral metabolism biochemical evaluation and completed a questionnaire and a 2-week diary card about bowel habits. PHPT patients were reevaluated after 6 months. According to Rome III, 40 % of PHPT patients had chronic constipation compared with 12 % of controls (p = 0.0002). The only difference between constipated PHPT patients (group A, n = 20) and those without constipation (group B, n = 30) was higher mean PTH values (79.9 ± 18.7 ng/l vs. 65.4 ± 26.0 ng/l; p = 0.03), which predicted the presence of constipation (p = 0.004, OR 1.059, CI 1.011-1.059). Forty percent of PHPT patients had undergone PTx. In group A, constipation was resolved in 80 % of patients after PTx compared to none of the same group who had not undergone PTx (p = 0.0007). In group B, 17.6 % of patients who had not undergone PTx became, after 6 months, constipated. According to Rome III, a higher prevalence of chronic constipation in PHPT patients was observed compared with controls. PTH levels predicted constipation. A significant reduction of chronic constipation was reported following successful surgery.

Gastrointestinal manifestations in APECED syndrome

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) (or autoimmune polyendocrine syndrome type 1) is a rare autosomal recessive disorder caused by mutations in the autoimmune regulator gene. It causes a loss in central immune tolerance, failure to eliminate autoreactive T cells in the thymus, and their escape to the periphery. APECED patients are susceptible to mucocutaneous candidiasis and multiple endocrine and nonendocrine autoimmune diseases. Although it depends on the series, approximately 25% of APECED patients are affected by gastrointestinal (GI) manifestations, mainly autoimmune-related disorders like autoimmune hepatitis, atrophic gastritis with or without pernicious anemia (Biermer disease), intestinal infections, and malabsorption. In contrast to the major organ-specific autoimmune symptoms of APECED, the GI symptoms and their underlying pathogenesis are poorly understood. Yet isolated case reports and small series depict severe intestinal involvement in children, leading to malabsorption, multiple deficiencies, growth impairment, and possible death. Moreover, very few systematic studies of GI function with intestinal biopsies have been performed. GI symptoms may be the first manifestation of APECED, yet they may have various causes; effective treatment will therefore vary. We provide here an updated review of GI manifestations in APECED, including principles of diagnosis and therapy.

Symptoms of gastroesophageal reflux disease improve after parathyroidectomy

BACKGROUND

Primary hyperparathyroidism can be associated with symptoms related to GERD, but it is unclear which symptoms of GERD improve after parathyroidectomy. Our goal was to assess prospectively for changes in specific GERD symptoms after parathyroidectomy using a validated questionnaire.

METHODS

Using the GERD health-related quality of life (GERD-HRQL) questionnaire, symptoms of heartburn were prospectively assessed before and 6 months after treatment of hyperparathyroidism with parathyroidectomy. This validated questionnaire includes 10 items, with a Likert scale of 0-5. Scores range from 0 to 45, a lesser score indicates fewer/less severe symptoms.

RESULTS

Pre- and postoperative surveys were available for 51 patients. Parathyroidectomy improved the overall questionnaire score (12.5 ± 1.3 vs 4.5 ± 0.9, P < .0001). Overall scores for each question improved after parathyroidectomy, including symptoms of dysphagia (P = .001) and overall satisfaction with symptoms (P < .0001). However, the number of patients taking antireflux medication before and after parathyroidectomy was not substantially different (34 vs 28 patients, P = .17).

CONCLUSION

All symptoms of GERD improved after parathyroidectomy for hyperparathyroidism. Despite the decrease in symptoms, there was not a change in the number of patients who remained on anti-reflux therapy. For patients with symptoms of GERD, a trial off antireflux medications after parathyroidectomy should be considered.

Hypoparathyroidism: from diagnosis to treatment

PURPOSE OF REVIEW

This review provides an update on hypoparathyroidism (HPT), focusing on the major aspects of diagnosis, clinical manifestations and management of patients with hypocalcaemia due to HPT.

RECENT FINDINGS

Recent advances in the understanding of the physiologic actions of parathormone (PTH) and vitamin D, and the application of molecular genetics, have clarified certain aspects of the pathogenesis, classification, diagnosis and management of HPT.

SUMMARY

PTH promotes bone resorption, decreases urinary calcium excretion, enhances the conversion of 25-hydroxyvitamin D to 1, 25-dihydroxyvitamin D and increases intestinal calcium absorption and phosphate renal excretion. Understanding the molecular cause of the disease in patients and their families has the potential for proper tailoring of genetic counselling, family screening and treatment. Signs and symptoms may be associated not only with the severity, chronicity and therapeutic endpoints in HPT but also with the different causes of the disease. Hypocalcaemia may be an asymptomatic laboratory finding or a life-threatening metabolic disturbance. Although the therapy of acute hypocalcaemia is usually readily accomplished, chronic hypocalcaemia remains a very difficult treatment problem. Replacement therapy with PTH could be a therapeutic option for refractory HPT.