eMedicine Specialties > Emergency Medicine > Endocrine & Metabolic

Hyperparathyroidism: Follow-up

Author: Philip N Salen, MD, Clinical Professor, Department of Emergency Medicine, PA Program, Desales University; Adjunct Clinical Associate Professor, Department of Emergency Medicine, Temple University Medical School; Research Director, Emergency Medicine Education, Saint Luke's Hospital
Contributor Information and Disclosures

Updated: May 6, 2008

Follow-up

Further Inpatient Care

  • Admit patients with significant symptoms due to hyperparathyroid-induced hypercalcemia and substantial elevations of calcium levels.
  • Patients who are markedly symptomatic or those with significant electrolyte disturbances should be evaluated by endocrinologists and surgeons experienced in parathyroid removal.

Further Outpatient Care

  • Calcium levels must be periodically monitored for several months postparathyroidectomy.
  • If calcium levels begin to rise postoperatively, the patient needs to be evaluated for possible accessory parathyroid glands.
  • Monitor asymptomatic patients for worsening hypercalcemia, deteriorating bone density or renal function, and other complications of hyperparathyroidism.
  • If the serum calcium concentration falls below 8 mg/dL postparathyroidectomy with a concomitant rise in serum phosphate level, consider the possibility of postsurgical hypoparathyroidism.

Deterrence/Prevention

  • Although patients should refrain from the ingestion of more calcium than is recommended for adults (1200-1500 mg/d), the calcium intake should not be excessively restricted (to <750 mg/d) because calcium-poor diets may promote processes associated with excessive secretion of parathyroid hormone (PTH).
  • Because many patients with asymptomatic primary hyperparathyroidism have levels of 25-hydroxyvitamin D that are at the lower end of the reference range or frankly low, the addition of a low level of supplementation achievable with a multivitamin (400 IU of vitamin D daily) is advisable.

Complications

  • Maternal hyperparathyroidism can lead to profound hypocalcemia and tetany, coma, and death in newborns in a syndrome known as neonatal severe hyperparathyroidism.
  • Nocturia and polyuria may result from the effects of elevated calcium levels on the renal tubule.
  • Approximately 20% of patients with hyperparathyroidism have nephrolithiasis.
  • CNS disturbances, coma, and death may result from markedly elevated serum calcium levels when left untreated.
  • Skeletal sequelae (eg, pathologic fracture) may occur.
  • Heart failure may occur.
  • Surgical complications include the following:
    • Hypoparathyroidism
    • Recurrent laryngeal nerve damage
    • Hemorrhage
    • Infection
    • Unsuccessful surgery
      • Persistent or recurrent disease occurs in 5-10% of individuals who undergo surgery for primary hyperparathyroidism.12  
      • Persistent primary hyperparathyroidism is defined as the presence of elevated serum calcium levels and PTH levels documented within 6 months of the initial operation. The most common cause of persistent primary hyperparathyroidism is the presence of a missed parathyroid adenoma, which is usually in an ectopic location in this setting. Less commonly, persistent disease may be secondary to inadequate resection of unappreciated multigland disease.12

Prognosis

  • The prognosis is excellent for patients after successful parathyroidectomy.
  • Asymptomatic patients who do not have indications for surgery have an excellent prognosis. Significant bone loss and other symptoms may be absent for years in subsequent follow-up visits.
  • Secondary hyperparathyroidism is associated with a poor prognosis likely due to underlying advanced chronic renal failure and resultant chronic hypocalcemia.

Patient Education

  • Educate patients about prescribed medications.
  • Educate patients regarding the importance of periodic laboratory and radiologic testing.

Miscellaneous

Medicolegal Pitfalls

  • Failure to address or arrange follow-up for asymptomatic patients who have mild-to-moderate elevations of calcium levels
  • Failure to treat significantly elevated calcium levels, especially in symptomatic patients
 


More on Hyperparathyroidism

Overview: Hyperparathyroidism
Differential Diagnoses & Workup: Hyperparathyroidism
Treatment & Medication: Hyperparathyroidism
Follow-up: Hyperparathyroidism
References
[ CLOSE WINDOW ]

References

  1. Allerheiligen DA, Schoeber J, Houston RE, et al. Hyperparathyroidism. Am Fam Physician. Apr 15 1998;57(8):1795-802, 1807-8. [Medline].

  2. Jacobs DS, Kasten BL, DeMott WR, Wolfson WL. Laboratory Test Handbook. Williams & Wilkins;1990:284-7.

  3. Boonen S, Vanderschueren D, Pelemans W, Bouillon R. Primary hyperthyroidism: diagnosis and management in the older individual. Eur J Endocrinol. Sept 2004;151(3):297-304. [Medline].

  4. Ruda JM, Hollenbeak CS, Stack BC. A systematic review of the diagnosis and treatment of primary hyperparathyroidism from 1995 to 2003. Otolaryngology- Head and Neck Surgery. March 2005;132:359-372.

  5. Sorensen HA. Surgery for primary hyperparathyroidism. BMJ. Oct 12 2002;325(7368):785-6. [Medline].

  6. Beard CM, Heath H 3rd, O'Fallon WM, et al. Therapeutic radiation and hyperparathyroidism. A case-control study in Rochester, Minn. Arch Intern Med. Aug 1989;149(8):1887-90. [Medline].

  7. Tezelman S, Rodriguez JM, Shen W, et al. Primary hyperparathyroidism in patients who have received radiation therapy and in patients who have not received radiation therapy. J Am Coll Surg. Jan 1995;180(1):81-7. [Medline].

  8. Carter AB, Howanitz PJ. Intraoperative testing for parathyroid hormone: a comprehensive review of the use of the assay and the relevant literature. Arch Pathol Lab Med. Nov 2003;127(11):1424-42. [Medline].

  9. Boggs JE, Irvin GL 3rd, Carneiro DM, Molinari AS. The evolution of parathyroidectomy failures. Surgery. Dec 1999;126(6):998-1002; discussion 1002-3. [Medline].

  10. Guarda LA. Rapid intraoperative parathyroid hormone testing with surgical pathology correlations: the "chemical frozen section". Am J Clin Pathol. Nov 2004;122(5):704-12. [Medline].

  11. Irvin GL, Carneiro DM. Management changes in primary hyperparathyroidism. JAMA. Aug 23-30 2000;284(8):934-6. [Medline].

  12. Alexander HR Jr, Chen CC, Shawker T, et al. Role of preoperative localization and intraoperative localization maneuvers including intraoperative PTH assay determination for patients with persistent or recurrent hyperparathyroidism. J Bone Miner Res. Nov 2002;17 Suppl 2:N133-40. [Medline].

  13. VanderWalde LH, Liu IL, O'Connell TX, Haigh PI. The effect of parathyroidectomy on bone fracture risk in patients with primary hyperparathyroidism. Arch Surg. Sep 2006;141(9):885-9; discussion 889-91. [Medline].

  14. Coker LH, Rorie K, Cantley L, et al. Primary hyperparathyroidism, cognition, and health-related quality of life. Ann Surg. Nov 2005;242(5):642-50. [Medline]. [Full Text].

  15. National Institutes of Health. Consensus conference. Diagnosis and management of asymptomatic primary hyperparathyroidism. Conn Med. Jun 1991;55(6):349-54. [Medline].

  16. al Zahrani A, Levine MA. Primary hyperparathyroidism. Lancet. Apr 26 1997;349(9060):1233-8. [Medline].

  17. Bilezikian JP. Management of acute hypercalcemia. N Engl J Med. Apr 30 1992;326(18):1196-203. [Medline].

  18. Bilezikian JP, Silverberg SJ. Clinical practice. Asymptomatic primary hyperparathyroidism. N Engl J Med. Apr 22 2004;350(17):1746-51. [Medline].

  19. Potts JT. Diseases of the parathyroid gland and other hyper- and hypocalcemic disorders. In: Harrison's Principles of Internal Medicine. 14th ed. 1998:2227-32.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

hyperparathyroidism, calcium levels, phosphorus levels, primary hyperparathyroidism, secondary hyperparathyroidism, tertiary hyperparathyroidism, hypercalcemia, parathyroid carcinoma, asymptomatic primary hyperthyroidism, hypophosphatemia, hyperchloremia, hypercalcemic parathyroid crisis, parathyroid insufficiency, parathyroid hormone, PTH, parathyroid glands, hypercalcemia of malignancy, urinary tract stones, adenoma, multiple endocrine neoplasia, MEN, familial hypocalciuric hypercalcemia, hyperparathyroidism–jaw tumor syndrome, chronic renal failure, nephrolithiasis, ureteral colic, renal stone disease, subperiosteal bone resorption, osteitis fibrosa cystica, chondrocalcinosis, pseudogout, dehydration, hypercalcemic parathyroid crisis, depression, hypercalciuria, hypertension, congestive heart failure, osteoporosis, osteopenia, cystic bone lesions, vertebral collapse, pancreatitis, pancreatic calcification, peptic ulcer disease, recurrent calcium nephrolithiasis, nephrocalcinosis, nodular goiter

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Philip N Salen, MD, Clinical Professor, Department of Emergency Medicine, PA Program, Desales University; Adjunct Clinical Associate Professor, Department of Emergency Medicine, Temple University Medical School; Research Director, Emergency Medicine Education, Saint Luke's Hospital
Philip N Salen, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey L Arnold, MD, FACEP, Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center
Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.