Hyperparathyroidism

Primary hyperparathyroidism is defined by the presence of hypercalcaemia (>2.6 mmol/litre) in the presence of inappropriate (i.e. not inhibited) or high PTH levels. The cause remains unknown and most patients (>85%) have a single adenoma. In modern medical practice most patients are deemed asymptomatic at the time of diagnosis. The traditional mnemonic of ‘bones/groans/stones/moans’ is rarely seen. A combination of neck ultrasound and Sestamibi scanning demonstrates the position of adenomas in some two thirds of patients and they can benefit from a minimally invasive parathyroidectomy done under general anaesthesia or under sedation/local anaesthesia. Patients with negative scans need bilateral neck exploration. Medical treatment is reserved for patients with failed surgical treatment or those with limited life expectancy considered too unwell for surgical intervention.Secondary hyperparathyroidism is a physiological response to a metabolic drive (e.g. chronic renal failure) that leads to four-gland hyperplasia. Medical treatment of patients on dialysis aims to reduce the biochemical abnormalities that promote parathyroid glands hyperplasia. Despite such measures some patients develop hypercalcaemia and PTH levels several times higher than normal range and develop symptoms, hence surgical treatment becomes indicated. Four-gland excision is currently preferred in many centres though alternative treatments include total parathyroidectomy plus autotransplantation or subtotal parathyroidectomy.