Parathyroid
A practical approach to hypercalcaemia and suspected primary hyperparathyroidism.
1. Confirm the hypercalcaemia
If calcium is elevated, repeat and confirm with:
Once hypercalcaemia is confirmed, measure PTH.
2. Check PTH
PTH elevated or non-suppressed
Primary hyperparathyroidism is the likely diagnosis.
PTH suppressed
Consider a non-parathyroid cause of hypercalcaemia and investigate accordingly.
A high calcium with a PTH that is elevated or inappropriately normal is usually primary hyperparathyroidism.
3. Supporting investigations
Vitamin D
Check vitamin D as part of the biochemical assessment.
Renal function
Check creatinine and eGFR.
Phosphate
Phosphate can assist with interpretation of the biochemical picture.
In a patient with high calcium and a non-suppressed PTH, low vitamin D should not automatically be assumed to explain the elevated PTH.
4. Imaging comes after diagnosis
Parathyroid imaging is for localisation before surgery. It does not establish the diagnosis of primary hyperparathyroidism.
Localisation may include
Neck ultrasound • sestamibi SPECT/CT • 4D CT in selected cases
When to refer
Confirmed primary hyperparathyroidism
Patients with biochemically confirmed primary hyperparathyroidism who are medically fit for surgery should be considered for endocrine surgical assessment.
Referral is particularly important in patients with renal stones, reduced bone density or osteoporosis, significant hypercalcaemia, symptoms, or a preference for definitive treatment.
Refer a patient
Patients can be referred once the biochemical diagnosis is established. Localisation imaging does not need to be completed before referral.
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