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21 Adrenal Flashcards

1
Q

Blood supply to adrenal gland

A 
Superior adrenal (inferior phrenic artery)
Middle adrenal (aorta)
Inferior adrenal (renal artery)
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2
Q

Superior adrenal artery

A

Inferior phrenic artery

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3
Q

Middle adrenal artery

A

Aorta

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4
Q

Inferior adrenal artery

A

Renal artery

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5
Q

Left adrenal vein goes to:

A

Left renal vein

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6
Q

Right adrenal vein goes to:

A

Inferior vena cava

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7
Q

Adrenal cortex innervation?

A

Nothing

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8
Q

Medulla innervation?

A

Sympathetic nervous system

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9
Q

Adrenal lymphatics

A

Subdiaphragmatic and renal lymph nodes

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10
Q

Incidentaloma

A

Seen in 1-2% of abdominal CT

5% are mets

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11
Q

Work up for incidentaloma

A

Check for functioning tumor: urine metanephrines, VMA< catecholamines, hydroxycorticosteroids, serum K with plasma renin/aldosterone
CXR
Colonoscopy
Mamography

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12
Q

Ominous characteristics for an incidentaloma

A 
Non-homogenous
>4-6cm
Functioning 
Enlarging
--> surgery
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13
Q

Common mets to adrenals

A

Lung CA
Breast CA
Melanoma
Renal CA

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14
Q

Cancer history with asymptomatic adrenal mass?

A

Biopsy

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15
Q

Adrenal cortex

A

From mesoderm
Glomerulosa - aldosterone
Fasciuclata - glucocorticoids
Reticularis - androgens/estrogens

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16
Q

Production of adrenal cortex hormones

A

Cholesterol -> progesterone -> androgens/cortisol/aldosteronew
All zones have 21- and 11-beta hydroxylase

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17
Q

Cortisol

A 
Inotropic
Chronotorpic
Increases vascular resistance
Proteolysis and gluconeogensis
Decrease inflammation
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18
Q

Aldosterone

A

Stimulates renal sodium resoprtion and secretion of K+ and H+
Stimulated by angiotensin II an dhyperkalemia

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19
Q

Excess estrogen and androgen by adrenals?

A

Almost always cancer

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20
Q

21-hydroxylase deficiency

A

Precocious puberty in males, virilization in females
Salt wasting and hypotension
Tx: cortisol, genitoplasty

Excess 17-OH progesterone

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21
Q

11-hydroxylase deficiency

A

Precocious puberty in males, virilization in females
Salt saving - HTN
Tx: cortisol, genitoplasty

Excess deoxycortisone (acts as mineralcorticoid)

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22
Q

Hypertension without edema, hypokalemia, weakness, polydipsia, polyuria

A

Hyperaldosteronism (Conn’s syndrome)

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23
Q

Primary hyperaldosteronism

A

Low renin

Adenoma (85%), hyperplasia (15%), ovarian tumor (rare), cancer (rare)

24
Q

Secondary hyperaldosteronism

A

Renin is high - more common than primary
CHF, renal artery stenosis, liver failure, diuretics
Batter’s syndrome (renin-secreting tumor)

25
Diagnosis for primary hyperaldosteronism
Salt-load suppression test (urine aldosterone will stay high) Aldosterone:renin ration >20 Labs: decreased K+, increased Na, increased urine K, metabolic alkalosis Plasma renin activity will be low
26
Localizing studies for hyperaldosteronism
MRI NP-59 scintigraphy (hyperfunctional adrenal tissue - differentiates adenoma from hyperplasia - 90% accurate) Adrenal venous sampling
27
What do you need to fix preoperative for hyperaldosteronism?
Hypertension | Hypokalemia
28
Treatment for hyperaldosteronism secondary to an adenoma?
Adrenalectomy
29
Treatment for hyperaldosteronism secondary to hyperplasia
Medical therapy - spironolactone, CCB, potassium supplementation Bilateral resection only done for refractory hypokalemia (increased morbidity) - need fludrocortisone postop
30
Hypocortisolism
Adrenal insufficiency, Addison's disease MCC - withdrawal of exogenous steroids MCC primary disease - autoimmune destruction Other - pituitary disease, infection/hemorrhage/metastasis/resection Low cortisol, high ACTH, low adosterone Dx: Cosyntropin test (give ACTH, measure urine cortisol - positive if it stays low)
31
Acute adrenal insufficiency
Hypotension, fever, lethargy, abdominal pain, nausea, vomiting Decreased glucose, increased potassium Tx: Dexamethasone, fluids Confirmation: cosyntropin test (dexamethasone does not interfere)
32
Chronic adrenal insufficiency
Hyperpigmentation, weakness, weight loss, GI symptoms Increased potassium, decreased sodium Tx: Corticosteroids
33
Hypercortisolism
Cushing's syndrome MCC - iatrogenic - Measure 24-hr urine cortisol and ACTH If high cortisol, with low ACTH - cortisol secreting lesion (done) If high cortisol, with high ACTH - ACTH secreting lesion; Then do High-dose dexamethasone suppression test: - Urine cortisol suppressed - pituitary adenoma - Not suppressed - ectopic producer of ACTH
34
In hypercortisolism - how do you localize tumors and differentiate adrenal adenomas from hyperplasia?
NP-59 scintography
35
Pituitary adenoma
``` Cushing's disease Cortisol is NON-suppressable Microadenoma Localization - petrosal sampling, MRI Tx: transsphenoiodal, XRT ```
36
Ectopic ACTH
MCC small cell lung CA Cortisol is NON-suppressable Localization - chest and abdominal CT Tx: Resection
37
Adrenal adenoma (cushing's syndrome)
Decreased ACTH - unregulated steroid production | Tx: Adrenalectomy
38
Adrenal hyperplasia (cushing's syndrome)
Medical tx: - Metyrapone (blocks cortisol synthesis) - Aminoglutethimide (inhibits steroid production) Bilateral adrenalectomy is medical treatment fails
39
Adrenocortical carcinoma
Before 5yo, after 50yo, more common in females 50% functioning - cortisol, aldosterone, sex steroids Viralization, androgeny Sx: abdominal pain, weight loss, weakness Tx: Radical adrenalectomy, debulking - Mitatane (adrenal-lytic) - residual, recurrent, metastatic
40
Catecholamine production
Tyrosine > dopa > dopamine > NE > Epi
41
Rate limiting step for catecholamine production?
Tyrosine hydroxylase
42
Origin of adrenal medulla?
Ectoderm - neural crest cells
43
Why can Epi only be produced in adrenal medulla?
PNMT (phenylethanolamine N-methyltransferase) Converts NE to EPi Only found in adrenal medulla
44
What breaks down catecholamines?
Monoamine oxidase (MAO) NE > normetanephrine EPI > metanephrine Then turned into vanillylmandelic acid (VMA)
45
Extra-adrenal rests of neural crest tissue locations?
Retroperitoneum | Organ of Zuckerkandl at the aortic bifurcation
46
Pheochromocytoma - 10% rule
Malignant, bilateral, in children, familial, extra-adrenal
47
Pheochromocytoma - associated syndromes
``` MEN IIa MEN IIb ZVon Recklinghausen's disease Tuberous sclerosis Struge-Weber disease ```
48
Pheochromocytoma - symptoms
HTN (episodic) Headache Diaphoresis Palpitations
49
Pheochromocytoma - Diagnosis
Urine metanephrines and VMA* MIBG scan (NE analogue) (localization) Clonidine suppression test (tumor does NOT respond) DO NOT DO venography - can cause HTN crisis
50
Pheochromocytoma - preoperative treatment
Volume replacement A-blocker first (phenoxybenzamine) then B-blocker (if needed for tachcyardia or arrhythmias)
51
What happens if you don't alpha blockade before giving a pheo b-blocker?
Unoppsed alpha stimulation --> HTN crisis, stroke, heart failure
52
Pheochromocytoma - treatment?
Adrenalectomy - ligate adrenal veins first to avoid spilling catecholamines during tumor manipulation Metyrosine - inhibits tyrosine hydroxylase\ Have ready - Nipride, Neo-=synephrine, antiarrhythmic agents (just in case)
53
Post-op conditions associated with Pheochromocytoma?
``` Persistent HTN Hypotension Hyperglecmia Bronchospasm Arrhythmias Intracerebral hemorrhage CHF MI ```
54
Other sites of pheo?
Organ of zuckerland (most common - inferior aorta near bifurcation) Vertebral bodies Opposite adrenal gland Bladder
55
What can cause falsely elevated VMA?
``` Coffee Tea Fruits Vanilla Iodine contrast Labetalol A- and b-blockers ```
56
Ganglioneuroma
Rare Benign Asymptomatic tumor of neural crest origin in adrenal medulla or sympathetic chain Tx: Resection

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