02b: Adrenal HT Flashcards
Adrenal mechanisms for HT can be caused by excess:
- Glucocorticoids (ZF)
- Mineralocorticoids (ZG)
- Catecholamines (medulla)
90% of all congenital adrenal hyperplasia is due to (X) deficiency. Is HT a symptom?
X = 21-a hydroxylase
No (but other enzyme deficiencies causing CAH do have HT)
List the causes of primary aldosteronism. Star the most common. Double-star the severe causes.
- Bilateral hyperplasia*
- Adrenal adenoma/carcinoma**
- Glucocorticoid-remediable
Pt with treatment-resistant BP makes you suspicious for (X), especially if (Y) serum levels are (low/high).
X = hyperaldosteronism
Y = K
Low
Screening for hyperaldosteronism via which test/lab?
Plasma aldo:renin ratio (aka aldo:PRA ratio)
Aldo:PRA ratio cutoff greater than (X) as well as plasma (Y) greater than 10 suggests diagnosis of…
X = 30
Y = aldosterone
Hyperaldosteronism
List the guidelines for screening with aldo:PRA ratio
- BP over 150/100 despite 3 BP meds
- Low K
- Adrenal incidentaloma
Pt has high serum aldosterone and a high aldo:PRA ratio. What’s the next step?
Confirm diagnosis of hyperaldosteronism by V-loading maneuver (oral salt loading, saline infusion); normal response is to lower aldosterone
Hyperaldosteronism: (X) is the most reliable test to distinguish unilateral adenoma from bilateral hyperplasia
Venous aldosterone and cortisol samples from adrenal veins
Hyperaldosteronism from adenoma: what’s the Rx?
Surg (often curative) and maybe medical therapy (K-sparing diuretics)
Hyperaldosteronism from bilateral hyperplasia: what’s the Rx?
- K sparing diuretics
- Ca channel blockers
- ACEi
T/F: Pheochromocytomas make up only 1% of hypertensive cases
True
Patient has spike in BP during surgery. What should he/she be screened for?
Pheo
T/F: FHx of Pheo is reason to screen patient
True
Which familial syndromes put patient at risk for Pheo?
- Familial Pheo
- MEN-2
- Neurofibromatosis
- VHL syndrome
Diagnostic tests for Pheo. Star the one with the highest sensitivity and double-star the one with highest specificity.
- Plasma metanephrines*
- Urine metanephrine/normetanephrines
- Urine VMA**
T/F: Pheo screening is limited by certain requirements due to too many false positives.
True
T/F: Pheochromocytoma is limited to adrenal medulla.
False - 90% are located there, but can appear at other sites
The “Rule of 10’s” applies to which disease?
Pheo
10% are extra-adrenal
10% are familial
10% are bilateral
10% are malignant
Pheo Rx:
- Surg
2. Med (pre-op/palliative)
Medical Rx for Pheo includes:
- Alpha-blocker
- Ca channel blocker
- Beta-blocker (ONLY after alpha-blocker)
Patient has been diagnosed with unilateral adrenal pheochromocytoma. First step for Rx is:
Pre-op prep with alpha blockers (10-14 days before surg) to prevent severe BP changes during/after surg
Incidentalomas are seen in (X)% of CTs and MRIs. (Y)% make some hormone and (Z)% are malignant.
X = 2-4 Y = Z = 10
You discover an adrenal incidentaloma on patient’s abdominal CT. If this is a functioning mass, what is it most likely to be secreting?
Cortisol
less likely: pheo, aldosteronoma
T/F: About 52% of adrenal masses are metastases.
False - only 2%!
52% are cortical adenomas
T/F: Adrenal incidentaloma has low CT density, making you less concerned about malignancy.
True - low CT density = benign (lipid-rich)
T/F: About 25% of adrenal masses over 6 cm in diameter end up being cancer.
True
CT washout: measure (X) before and after (Y).
X = CT density (of mass) Y = i.v. contrast administered
Adrenal incidentaloma has CT density over 10 HU, so you do CT washout. What results would point toward an adenoma?
Fast washout (a more rapid rise then decline in CT density after contrast administration, compared to pheo/malignant mass)
