Primary Hyperparathyroidism

Presentation:
- most present asymptomatically and come to attention after screening bloodwork reveals hypercalcemia.
- otherwise look for signs of hypercalcemia - stones, bones, psychiatric overtones, abdominal moans

Investigations:
- PTH, calcium, phosphate
- 24h urine calcium to differentiate for FHH
- 99Tc sestamibi and high resolution ultrasound.
- together these imaging tests will usually localize the lesion and allow for unilateral neck exploration.
- if not localized by above studies consider CT, MRI or PET scan

Indications to operate hyperpara:
- symptomatic - some would argue this includes vague symtpoms such as dysphoria and failure to thrive in the elderly
- serum calcium > 3 mmol/l
- 24h urine calcium > 400 mg/l
- age <50
- bone density < 2 sd
- unable yo follow up with medical observation

Unilateral exploration:
- should be accompanied ideally with intraop PTH assay.
- if not available then ?frozen section
- if PTH assay not available ?warn pt about possible need to return to explore other side

Perioperative Complications:
- hungry bone syndrome: if preop calcium was very high > 3, then there may be rapid bone reabsorption of calcium postoperative. May need yo give patient supplemental calcium postoperatively.
- severe hypercalcemia: may need to give IV palmidrobate infusion over 4 hours to decrease calcium. Effects can last days to weeks. If not sufficient the give IV bisphosphonates (inhibits osteoclastic bone reabsorption)