12 - Adrenal Disorders Flashcards
Describe the adrenal glands
- Tiny glands that sit on top of kidneys
- They make epi, norepi, aldosterone and cortisol
What do epi and norepi do?
- Epinephrine – flight or fight. Increases HR, BP, dilates pupils, redirects blood to muscles
- Norepinephrine – Increases BP
What does cortisol do?
Regulates BP, cardiac function, immune system, mood, insulin metabolism
What does aldosterone do?
- Increase blood pressure
- Controls water and sodium balance (water retention with low BP)
- Helps kidneys keep sodium or get rid of potassium
What is secreted from the medulla of the adrenal gland?
Epinephrine and norepinephrine
What problems can arise from problems form the medulla or epinephrine/norepinephrine?
- Pheocytocytoma
- Autonomic failure
What is secreted from the cortex of the adrenal gland?
Aldosterone and cortisol
What problems can arise from problems with the cortex/aldosterone?
Conn’s disease
Hypoaldosteronism
What problems can arise from problems with the cortex/cortisol?
Cushing’s disease
Addison’s disease
What is a pheochromocytoma?
Growth on the adrenal(s) leads to increased production of epi and NE
Why is a pheochromocytoma called a 10% tumor?
Called 10% tumor, because 10% are…
- Malignant
- 2 sided
- In kids
- Familial
- Recur
Signs and symptoms of pheochromocytoma
Rapid HR High BP Flushed Anxiety Pale
Need to surgically remove, radiation if malignant
What can cause autonomic failure?
A lack of epinephrine/norepinephrine
What is POTS?
Postural orthostatic tachycardic syndrome
- A combination of symptoms from a variety of causes (viral, cancer, adrenals, etc.)
- Patient will faint with SOB and fatigue
- Orthostatic hypotension
How will you treat hypotension?
Hypotension medication
What is Addison’s disease?
Failure of adrenals to make enough cortisol (sometimes aldosterone can be low too)
It is rare –> 1/100,000
What causes Addison’s disease?
- Lack of adrenal function/response to ACTH
- Lack of ACTH from the pituitary to act on the adrenals
Which cause of Addison’s disease is primary? Which is secondary?
Primary
- Lack of adrenal function/response
- Most common
- Mostly autoimmune
Secondary
- Pituitary dysfunction leading to a lack of ACTH
- Less common
What signs and symptoms of Addison’s do you NEED to know?
- Low glucose
- Low sodium
- High potassium
** NEED TO KNOW **
What other symptoms will you see in Addison’s?
- Weight loss
- Decreased appetite
- Fatigue
- Low BP
- Darkening of skin folds/membranes
- Electrolyte imbalances
What is an Addison’s crisis?
Not enough cortisol for the patient when they get sick or are in a stressful situation
- This can be fatal
- Abdominal, back, leg pain
- Dehydration and hypotension
- MAJOR low glucose, low sodium and high potassium
How do you treat an Addison’s crisis?
STEROIDS
You can also pretreat an Addison’s patient with steroids before stress, such as a surgical case
How do you test for Addison’s?
Give synthetic ACTH
- If the cortisol level goes up, there is a problem in the pituitary gland producing ACTH
- If the cortisol level does not go up, there is a problem with the adrenal gland
What are the signs and symptoms of Cushing’s disease?
- Trunk obesity
- Buffalo hump
- Hypertension
- Hyperglycemia, hypernatremia, hypokalemia
- Moon face
- Purple stretch marks
- Easy fractures
- Sex hormone dysregulation
What will long term Cushing’s lead to?
- Obesity
- Osteoporosis
- Diabetes
- Muscle weakness
- Skin issues
What causes Cushing’s?
Lots of things
- Iatrogenic (we give them steroids for chronic problems so they develop Cushings)
- Pituitary tumors
- Ectopic tumors (islet cell, small cell, thyroid)
- Adrenal problems
- Familial causes
What do we commonly use steroids for?
- Autoimmune
- Lung
- Tendonitis
- GI issues
Long term use can be an iatrogenic cause of Cushing’s disease
What causes an overproduction of ACTH?
- Over stimulation of adrenals, leading to too much cortisol
- Pituitary tumors (adenomas) – called Cushing’s Disease. If large enough, can over-secrete other hormones (prolactin)
- Ectopic ACTH from hormone secreting tumors (almost always lung cancers)
How do you diagnose Cushing’s?
- 24 hour urine – measure amount of cortisol made over 24 hours
- Once you determine that this is high, chase down the source
What do you do if cortisol is high?
Dexamethasone suppression test
When given steroids, body should adjust and decrease its own production – sees if the brain is responding and shutting down ACTH (remember control center is in the brain)
How do you treat Cushing’s?
- If they are on steroids, taper off the steroids
- If they have a pituitary adenoma. surgery and maybe radiation
- If they have ectopic production, remove tumor
- If there is an adrenal lesion, surgically remove
Possibly treat with a new medicaiton - Signifor, which reuces cortisol in Cushing’s disease
What do you give to a Cushing’s disease patient when they have a stressful event?
Like Addisons, Cushings may require stress dosing of steroids during illnesses, prior to surgery, etc…
Seems contradicting, but this is what works
What is Conn’s disease?
Hyperaldosteronism
Overproduction of aldosterone
- Benign tumor (usual)
Bilateral adrenal hyperplasia
Either caused by a benign tumor or bilateral adrenal hyperplasia (not sure why)
How common is Conn’s disease?
We used to think it was rare, but really it is not
What can Conn’s be responsible for?
Resistant hypertension
Now we think 5-15% of hypertensive patients have adrenal hyperplasia or an adrenal mass and that is causing the high BP
There are many problems associated with high BP
What is the treatment for Conn’s disease?
Treatment
- Take out adrenal (if there is a mass) or
- Spiranolactone (blocks aldosterone)
What are the signs and symptoms of Conn’s disease?
- Hypertension
- Low potassium***
Hypertensive patient with low potassium –> NEED to consider Conn’s
What glucose issue can be present in up to 20% of Conn’s disease patients?
Glucose intolerance – they have high glucose but it does not lead to diabetes
What acid base issues may patients with Conns have?
Metabolic alkalosis
Why will metabolic alkalosis develop?
Renal loss of hydrogen ions occurs when excess aldosterone (Conn’s syndrome) increases the activity of a sodium-hydrogen exchange protein in the kidney
Excess sodium increases extracellular volume and the loss of hydrogen ions creates a metabolic alkalosis. Later, the kidney responds through the aldosterone escape to excrete sodium and chloride in urine.
