Parathyroid Disease & HypercalcemiaAt UCLA Endocrine Center, we specialize in the treatment of parathyroid diseases. We take care of patients who have been newly diagnosed with elevated blood calcium as well as patients who have persistent disease despite previous surgery. If you are seeking help for persistent disease after previous surgery, learn about reoperations for primary hyperparathyroidism. Show
What is Hypercalcemia (High Blood Calcium)?When your doctor orders routine blood tests, it is common to check a blood calcium level. The finding of a high
blood calcium level is very common, occurring in millions of Americans each year. Sometimes, this will just be a single event related to a laboratory error or being dehydrated on the day the lab was drawn. The first thing to do is to recheck the value with another blood test. When you have two or more blood tests showing high levels of calcium in your blood, we consider that hypercalcemia, and
encourage Causes of High CalciumUCLA endocrine surgeons Masha Livhits, MD & Michael Yeh, MD, presented a live-streaming webinar to discuss what causes hypercalcimia, or high levels of calcium in your blood which can weaken your bones, create kidney stones and interfere with how your heart and brain work. What Causes Hypercalcemia?Primary hyperparathyroidism is the most common cause of high blood calcium level in the general population. Primary hyperparathyroidism is when your parathyroid glands make excessive amounts of parathyroid hormone (PTH). Parathyroid hormone tells your bones, intestines, and kidneys to raise the level of calcium in your blood. The disease is most common in people over 60 but can also be seen in younger adults. Women are more likely to be affected than men. Other causes of high blood calcium include:
How is Primary Hyperparathyroidism Diagnosed?Initial evaluation of hypercalcemia begins with:
The diagnosis of primary hyperparathyroidism can be made on laboratory tests alone and does not require any imaging studies. The most classic pattern is to have an elevated blood calcium levels as well as a high level of parathyroid hormone. However, a significant proportion of patients with primary hyperparathyroidism can have parathyroid hormone levels in the “normal” range. In those cases, we often will also perform additional blood tests and even urine tests to help confirm the diagnosis. What if I have elevated parathyroid hormone (PTH) but normal calcium?Normal calcium levels despite high blood levels of parathyroid hormone could be a result of:
Normocalcemic hyperparathyroidism is a rare disease. Similar to primary hyperparathyroidism, the parathyroid glands are making too much hormone. However, in this disease, the calcium does not rise to an abnormal level. These are challenging diagnoses, and treatment plans should be tailored to each individual patient. Thus, we recommend consultation with our endocrinologists and endocrine surgeons. More about normocalcemic hyperparathyroidism. What are the Signs and Symptoms of Primary Hyperparathyroidism?The signs and symptoms of primary hyperparathyroidism come from a combination of the effect of excess parathyroid hormone and high levels of calcium on different organs: Osteopenia, osteoporosis, or fractures – caused by abnormal removal of calcium from bones, can also cause bony pain / muscle pain Kidney stones – the kidneys filter the calcium from the blood into the urine, but the high amount of calcium can crystallize into kidney stones, which can cause flank pain and bloody urine Impaired kidney function – the extra calcium can form deposits in the kidney, lowering kidney function slowly over time Increased urination and thirst – filtering the extra calcium also filters water, leading to frequent urination with dehydration and thirst Vague abdominal pain, constipation, nausea, loss of appetite – high levels of calcium also affects the GI tract, in rare cases patients can also develop pancreatitis Changes in mood or concentration, depression, fatigue – related to calcium’s affect on the nervous system, but this is less well understood How Is Primary Hyperparathyroidism Treated?The treatment options for primary hyperparathyroidism are:
Treatment depends on age and how severe your symptoms are. Surgery is typically recommended for:
If surgery is the best treatment option for you, the next step is to determine which of the four parathyroid glands may be enlarged and making the excess hormone. Most commonly, one of the four parathyroid glands have enlarged. However, it is possible to have two enlarged glands, or even mild growth of all 4 glands. Proper imaging tests help create a roadmap for a successful surgery. We routinely obtain multiple tests. Imaging of the parathyroid glands is challenging and sometimes the abnormal gland is not definitively seen by one or more imaging tests. That is because a normal parathyroid gland is the size of a grain of rice, and an abnormal gland may be the size of a green pea. Imaging is usually a combination of the following:
What is a parathyroid 4D CT scan?Parathyroid 4D-CT represents the latest technology in parathyroid imaging. The resolution of 4D-CT imaging is higher than that of any other type of parathyroid scan. Parathyroid 4D-CT is particularly useful when other imaging studies have been negative (failed to show the abnormal parathyroid gland) or when the anatomy of the neck has been distorted by prior surgery or co-existent thyroid disease. In our experience at UCLA of reading several hundred scans per year, we have been able to detect at least one abnormal parathyroid gland in 99% of cases. In other words, parathyroid 4D-CT is a highly sensitive scan. A parathyroid 4D-CT needs to be performed at an experienced, high-volume center. we have spent considerable effort optimizing 4D-CT for our patients with challenging parathyroid disease. This process of continuous quality improvement took several years: one year to optimize the scanning technique (2011), another year to validate the results in comparison to actual surgical findings in a standard patient population (2012), and a third year (2013) to validate the results in a more challenging patient population (principally patients who had had failed parathyroid surgery elsewhere who came to us for re-do surgery). More information on parathyroid 4D CT. What Are the Benefits of Parathyroid Surgery?Certain benefits are clearly established, and others less so. This is because
primary hyperparathyroidism can cause a wide constellation of symptoms, many of which can be vague or nonspecific. There are certain symptoms that reliably improve with surgery because we are certain they are caused by primary hyperparathyroidism. Here is what to
expect. Bone Health Will ImproveImprovements in bone mineral density following parathyroid surgery are very well established, and patients can routinely expect these benefits soon after surgery. Bone mineral density will significantly increase in the year following surgery, and continue to increase over the next 10 years. Bone Health and HyperparathyroidismUCLA endocrine surgeons Michael Yeh, MD, and Masha Livhits, MD, discuss hyperparathyroidism (overactive parathyroid glands), the role of parathyroid glands in regulating calcium levels, and treatments that can help maintain bone health. Updates for Hyperparathyroidism and OsteoporosisUCLA endocrine surgeons Masha Livhits, MD, and Michael Yeh, MD, discuss the latest research and treatment options for hyperparathyroidism and osteoporosis. Risk of Kidney Stones Will DecreasePatients who undergo surgery drastically reduce the chances of having a future kidney stone. However, it takes approximately one year after surgery for the risk to fall. Overall Quality of Life Will ImproveIt is now well known that patients with primary hyperparathyroidism report an overall improvement in their quality of life after surgery. This is related to an improvement in a number of areas: fatigue, exhaustion, pain in the muscles and bones, weakness, frequent urination, constipation, depression, and others. Sometimes these symptoms have come on so slowly that patients do not recognize they have been affected until after they improve. These following symptoms may also improve after parathyroid surgery in some patients, but not all, after parathyroid surgery.
How is Parathyroid Surgery Performed?Watch video of parathyroid surgery. This describes our main technique for minimally invasive parathyroidectomy with a 4 gland exploration through a central mini-incision, though variations exist. We begin with a 1-inch skin incision, hidden in a skin crease if possible. What surgical technique is used and why?We use either a focused lateral mini-incision technique or a central mini-incision technique. An incision length of approximately 2.0 cm (about ¾ inch) is used regardless of the approach and regardless of how many parathyroid glands are examined. Sometimes, in large or obese people, the incision is slightly longer. The operation is done under direct vision, without the use of a videoendoscope. In our opinion, this technique provides direct access to the parathyroid glands, minimizes tissue injury, and has superior cosmetic results. Indeed, every surgeon will have his or her own technique of performing parathyroid surgery. And that doesn’t matter. Experience does. So please do not let anyone convince you that their specific method is somehow superior. In most cases we believe it is beneficial to inspect more than 1 parathyroid gland, and often we inspect all 4. But of course this depends on the individual patient. How Long is Parathyroid Surgery?The average operating time is under 1 hour, with many operations being completed in less than 30 minutes. Though we value efficiency, we do not necessarily equate fast surgery with good surgery. Patient safety is our utmost priority. Ultimately, our operations take as long as necessary to complete in a safe and meticulous manner. We are here to take excellent care of each patient, one patient at a time. If one of us were to have surgery we would not want it to be rushed. So we are not going to rush your surgery. What is the Appearance of the Scar After Parathyroidectomy?All other things being equal, a small incision is nice to have. The reason we put incision size somewhat lower down on this priority list is that, at present, there is really not much difference in the incision sizes offered by expert parathyroid surgeons. They are all around 1 inch (2.5 cm). We do pay attention to incision length and cosmetic appearance because the neck is a difficult part of the body to cover up, and a significant number of our patients make a living on camera (see our Scar gallery). Intra-operative Parathyroid Hormone (IOPTH) MonitoringTo maximize success rates of parathyroid surgery and prevent disease from coming back, we monitor parathyroid hormone levels in real time during the operation. This is known as intra-operative parathyroid hormone monitoring (IOPTH). We utilize the very latest rapid IOPTH assay platform, which returns results within 8 minutes. An adequate decrease in parathyroid hormone level gives us confirmation that surgery has been successful. Frequently Asked Questions (FAQs)What is
Secondary Hyperparathyroidism? What is Osteoporosis? What Conditions Can Cause Osteoporosis?
Does Osteoporosis Cause Bone Pain or Achy Joints? I Eat a Diet That is High in Calcium. Why Did I Still Get Osteoporosis? How Does Hyperparathyroidism Cause Osteoporosis? How is Osteoporosis Detected? Are There any Blood Tests That Can Detect Osteoporosis? Should All Patients With Hyperparathyroidism Have a Bone Density Scan? How Can Patients With Hyperparathyroidism Minimize Bone Loss While Waiting for Parathyroidectomy? Some examples include:
Vitamin D supplementation can help in patients with Vitamin D deficiency. You should also avoid smoking and excessive alcohol use. What is the most common cause of hypoparathyroidism?The most common cause of hypoparathyroidism is removal of or accidental injury to the parathyroid glands during surgery to the neck.
What is the most common cause of tertiary hyperparathyroidism?The most common cause of tertiary hyperparathyroidism is chronic kidney disease. It can continue even after a kidney transplant.
What is the most common parathyroid disease?Hyperparathyroidism (HPT) is the most common type of parathyroid disease. In HPT, one or more glands are overactive. As a result, the glands make too much PTH. This may result in too much calcium in the blood—a condition called hypercalcemia.
What are the two most common causes of hypercalcemia?Hypercalcemia is caused by: Overactive parathyroid glands (hyperparathyroidism). This most common cause of hypercalcemia can stem from a small, noncancerous (benign) tumor or enlargement of one or more of the four parathyroid glands. Cancer.
|