21 ADRENAL CRISIS

Question 1

Definition

Answer 1

ADRENAL CRISIS is an acute, life-threatening, extreme decompensated state of adrenal insufficiency leading to vascular collapse and shock refractory to volume rescucitation and vasopressors.

On the other hand, Adrenal Insufficiency refers to the deficiency of adrenal gland hormone production in the CORTEX.

Question 2

Adrenal Insufficiency can be classified into 2 types:

Answer 2

1. Primary Adrenal Insufficiency (Addison’s Disease)
2. Secondary Adrenal Insufficiency
3. Primary Adrenal Insufficiency (Addison’s Disease) - occurs as a result of intrinsic adrenal gland dysfunction leading to decreased cortisol, aldosterone and sex hormone production
4. Secondary Adrenal Insufficiency - primarily due to hypothalamic-pituitary dysfunction —> decreased secretion of corticotropin-releasing hormone and/or adrenocorticotropic hormone

Question 3

PHYSIOLOGY

Answer 3

The adrenal gland is made up of the cortex and medullar producing steroid hormones and catecholamines, respectively

The adrenal cortex produces 3 categories of steroids:

1. Mineralocorticoids (Aldosterone) - Zona glomerulosa
2. Glucocorticoids (Cortisol) - zone fasciculata
3. Gonadocorticoids (sex hormones) - zona reticularis

The Adrenal medulla produces Epping Efron norepinephrine and small amounts of dopamine in response to sympathetic stimulation.

Cortisol is secreted in response to direct stimulation by ACTH from the anterior pituitary gland.

In turn, ACTH secretion is stimulated by CRH from the hypothalamus. Cortisol secretion occurs in a diurnal rhythm with higher levels secreted in the morning and lower levels in the evening.

It facilitates the stress response by affecting the heart, vascular bed, water excretion, electrolyte balance, potentiation of catecholamine action and control of water distribution.

It affects carbohydrate metabolism by stimulating glycogenolysis and gluconeogenesis

It is involved in immunologic an inflammatory responses and affects calcium metabolism

It promotes growth and development but in excess interferes with the maintenance of GI mucosa leading to peptic ulcer

Aldosterone secretion is controlled primarily by the RAAS and serum potassium. RAAS controls aldosterone levels in response to changes in volume, posture and sodium intake

On the other hand, high serum potassium directly influences the adrenal cortex to increase aldosterone secretion

Hence, aldoesterone maintains sodium and potassium plasma concentration and regulates water balance.

Gonadocorticoids include androgens and estrogen.

Androgens produced include testosterone, dihydroepiandrosterone (DHEA) and DHEA sulfate, which are present in both men and women.

In women, androgens are produced in the adrenal glands as well as the ovaries and promote the development of secondary sexual characteristics such as axillary and pubic hair and libido.

In men, most androgens are produced in the testes and androgens made by the adrenal glands are less important for normal sexual function

Question 4

Etiopathogenesis