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Q1: Definition and recognition (2 min)
Examiner: Define acromegaly. How would you recognise it clinically?
Expected answer:
- Acromegaly = chronic growth hormone (GH) excess in adults, almost always from a pituitary somatotroph adenoma; IGF-1 mediates the tissue effects.
- The same excess before epiphyseal fusion causes pituitary gigantism.
- Recognition is insidious over years: compare old photographs; enlarging hands (rings tight) and feet (shoe size up); coarse features, prognathism, frontal bossing, macroglossia, widened teeth gaps.
- Systemic features: hypertension, diabetes, sweating, sleep apnoea; a macroadenoma causes headache and bitemporal hemianopia.
Q2: Investigations (3 min)
Examiner: How do you confirm acromegaly?
Expected answer:
- Screening: serum IGF-1 matched for age and sex — the single best screen, reflecting integrated GH secretion.
- Confirmation: 75 g OGTT — GH fails to suppress under 1 ng/mL (under 0.4 with sensitive assays).
- Localise: pituitary MRI for the somatotroph micro- or macroadenoma.
- Check the other pituitary axes (cortisol, free T4, gonadal, prolactin) and visual fields; screen comorbidities — echocardiogram, sleep study, colonoscopy, glucose and lipids.
- A random GH is unhelpful because secretion is pulsatile.
Q3: Management (3 min)
Examiner: Walk me through the treatment.
Expected answer:
- First-line: transsphenoidal surgery, curative when the adenoma is fully resected (especially microadenomas).
- Medical therapy for residual or inoperable disease: somatostatin analogues (octreotide LAR, lanreotide) suppress GH; pasireotide is more potent; pegvisomant (a GH receptor antagonist) normalises IGF-1; cabergoline in selected patients.
- Stereotactic radiotherapy is reserved for refractory disease; onset is slow.
- Lifelong IGF-1 monitoring with aggressive management of cardiovascular, metabolic and respiratory comorbidity.
Q4: Complications and prognosis (2 min)
Examiner: What kills these patients?
Expected answer:
- Leading cause of death: cardiovascular disease — acromegalic cardiomyopathy, arrhythmia, hypertension, heart failure.
- Other complications: diabetes, sleep apnoea, arthropathy, colonic polyps or colorectal cancer, hypopituitarism.
- Untreated: a 2 to 3 fold excess mortality; biochemical control (normal IGF-1) returns mortality toward the general population.
- Emergency: pituitary apoplexy (sudden headache, visual loss, ophthalmoplegia) — IV hydrocortisone and urgent surgery.