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KC Endocrine > #8: Adrenal > Flashcards

#8: Adrenal Flashcards

1
Q

Effects of Cortisol in the body:

A

1- metabolic: increases insulin and gluconeogenesis; inhibits growth and reproduction; increases tissue breakdown
2- CV: increases cardiac output & vascular tone; increases sodium retention
3- Calcium homeostasis: stimulates bone and CT loss
4- immunity: suppresses inflammatory response; increases leukocytes intravascularly

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2
Q

When are cortisol levels lowest:

A

In the middle of the night

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3
Q

As little as __________ can precipitate glucosteroid withdrawal

A

2 weeks

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4
Q

MC steroids that cause withdrawal symptoms

A

Dexamethasone (Decadron)
Prednisone
Less likely w/ inhaled corticosteroids

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5
Q

Addison’s disease is characterized by:

Accounts for _____% adrenal insufficiency in the US, and _____% in the industrialized world

A

Autoimmune destruction

- 80%; 65%

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6
Q

70% of pt with Addison’s dz have__________

A

Anti-adrenal antibodies

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7
Q

Two different ways Addison’s dz can occur: (2)

A

Alone or as part of a polyglandular autoimmune syndrome

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8
Q

PGA Type 1:

A 
HAM
Hypoparathyroidism
Addison’s Dz
Mucocuteaneous candidiasis
—>first decade of life
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9
Q

PGA type 2:

A 
AAT
Autoimmune thyroid dz (Grave’s/Hashimoto’s)
Addison’s Dz
Type-1-DM
—> teens to 20s
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10
Q

Random serum cortisol level excluding adrenal insufficiency

A

> 25 mcg/dL

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11
Q

1st screening test in adrenal insufficiency dx

A

Random serum cortisol level

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12
Q

Diagnostic test in adrenal insufficiency

A

Cosynotropin stimulation test (not level!!!!)

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13
Q

Describe the process of the cosynotropin stimulation test:

A

1- baseline cortisol and aldosterone levels are drawn.
2- give IM or IV cosynotropin (0.25 mg synthetic ACTH) and measured blood levels after 30 and 60 minutes
3- (+): levels unaffected & no changes in cortisol levels after 30 or 60 minutes
4- (-): levels rise appropriately

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14
Q

Differential dx for adrenal insufficiency: (6)

A 
1- malignancy
2- anorexia
3- tanning beds
4- GI problems: n/v and weight loss 
5- hematochromatosis
6- hiv/aids
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15
Q

W/ a minor illness (n/v; fever >100.5) rq:

A

Doubling glucocorticoid tx & close outpt. F/u

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16
Q

Major stressful events (surgery w/ general anesthesia & trauma) rq.—>

A

Parenteral hydrocortisone (cortex) 50-100 mg Q6 hrs

17
Q

Patients w/ adrenal insufficiency rq. Caution w/ these:

A

Stressors which may precipitate adrenal crisis; most pts require lifelong tx

18
Q

Adrenal Crisis RF (6)

A

1- Inciting stressful event in pt. W/ mild adrenal insufficiency
2- Sudden Withdrawal of corticosteroid
3- destruction of pituitary gland
4- B/L destruction of adrenal glands via injury
5- Adrenal surgery
6- Temporary insufficiency due to exogenous suppression

19
Q

Differential Dx for adrenal crisis: (4)

A

1- acute abdomen (typically with high neutrophils)
2- hyponatremia via fluid loss
—> vomiting, diuretics, HF, hypothyroidism
3- hyperkalemia
—> GIB, spironolactone/ACEI meds, rhabdo
4- Shock
—> septic, hemorrhagic, cardiogenic

20
Q

Tx in adrenal crisis:

A
  • medical emergency! Must tx condition prior to labs
    1- steroid replacement:
  • 100 mg hydrocortisone IV bolus and continuous infusion of 10-12 mg/hr OR 100 mg IV Q6-8hrs
  • reduced to total of 100-150 mg/day within 2-3 days
  • reduced even more to < 100 mg within 4-5 days and PO form; add mineralcorticoid
    2- aggressive IV hydration!!!
    3- Correct electrolyte deficiencies
    4- Empiric abx; adders thyroid status; endocrine referral
21
Q

Labs to order in adrenal crisis:

A
  • ACTH; cortisol level; aldosterone & renin
22
Q

S/S of adrenal crisis:

A
  • acutely ill
  • hypotension and dehydration
  • metabolic acidosis
  • N/V and abdominal pain
  • HA, confusion, & coma
  • cyanosis
23
Q

Adrenal crisis prognosis:

A
  • frequently unrecognized and untreated
  • however, when txed early—> favorable outcomes
  • mortality dependent on stress of the event, degree of adrenal insufficiency
24
Q

MC endogenous etiology of Cushing’s syndrome

A

Pituitary adenoma w/ ACTH hypersecretion

25
Q

Renin released w/

A

Low BP or

Hyperkalemia

26
Q

Explain RAAS:

A
  • Renin secreted via kidneys: Angiotensionogen—>Ang 1 in the liver
  • Ang I—> Ang 2 by ACE in the lungs
  • Ang 2:
    1- vasopressor and vasoconstricts vessels
    2- also stimulates aldosterone release via adrenal gland (retains sodium and secretes H+ and K+)
  • negative feedback to kidneys to inhibit renin release
27
Q

MC pathophysiology associated w/ hypoaldosteronism

A

Low aldosterone commonly secondary to low renin production from kidney dz; rarely w/ adrenal gland aldosterone production problem
—> Aka hyporeninemic hypoaldosteronism

28
Q

MC cause of hypoaldosteronism:

A
  • Diabetic nephropathy
  • also ass. W/ chronic tubulointerstitial kidney dz
  • also w/ meds: NSAIDs; ACEI; heparin; LMWH; cyclosporin
29
Q

Hypoaldosteronism presents w/:

A

Low aldosterone—> so hyperkalemia and hyponatremia

- non-anion gap metabolic acidosis

30
Q

MEN 1 syndrome:

A
  • Parathyroid adenoma
  • pituitary tumor
  • enteropancreatic tumors (gut tumors: carcinoid, gastronomes, insulinomas)
  • skin tumors
31
Q

MEN 2A syndrome:

A

Medullary Thyroid ca, pheochromocytoma, parathyroid hyperplasia

32
Q

MEN 2B syndrome:

A

Pheochromocytoma, medullary thyroid ca, marfanoid habitus, GI tumor

33
Q

Dx of Pheochromocytoma:

A

24 hour urinary creatinine total catecholamines, vanillylmandelic acid levels, & metanephrine

34
Q

Preferred imaging test for pheochromocytoma:

A

Abdominal MRI (only after biochemical testing)

35
Q

Treatment for Pheochromocytoma: 1st line and 2nd line

A

HT resistant to med tx

1: pre-op alpha-blockade—> phenoxybenzamide (dibenzamine) 2: beta blockade added if needed
- After 1-2 weeks, laparoscopic or adrenalectomy (or larger surgery) is performed
- W/ surgery IVF and beta-blockers are used to control HTN swings w/ tumor manipulation
- Post-op serum free metanephrine normalizes and checked w/in 2 weeks & yearly for 5 years
- if inoperable, lifetime alpha blockers

36
Q

Loss of adrenal androgens in men presents w/

A

Does not cause clinical dz (aka testes)

37
Q

Loss of adrenal androgens in women presentation and tx

A

Decreased libido, decreased sex drive, & general feeling of well-being
Tx: supplementation w/ DHEA 50 mg QD helpful for s/s
- converted peripherally to testosterone

38
Q

What is an incidentaloma?
Rq testing?
Tx?

A
  • Clinically apparent adrenal mass; Some secrete small amounts of cortisol
  • All pts rq. dexa suppression testing and ACTH levels when discovered
  • HT pts w/ w/u for pheo & primary hyperaldosteronism
  • Surgical removal if >5 cm or hormonally active, if not, repeat monitoring

KC Endocrine (12 decks)

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