ABSITE Review - Adrenal

Question 1

What is the arterial supply to the adrenals?

Answer 1

Inferior phrenic artery, aorta and renal artery

Question 2

What is the venous drainage of the adrenals?

Answer 2

Left adrenal vein goe to left renal vein; and Right adrenal vein goes to IVC.

Question 3

When is an adrenalectomy indicated?

Answer 3

If mass has ominous characteristics (nonhomogenous) or is >4-6cm, functioning or enlarging

Question 4

What is th work up needed for an adrenal incidentaloma?

Answer 4

Serum K, urine metanephrines/VMA/catecholamines, urinary hydroxycorticosteroids, plasma renin and aldosterone levels if HTN or low K
CXR stool guaiac and colonoscopy, mammogram

Question 5

What are some common metastases to the adrenal gland?

Answer 5

Lung CA (#1), breast CA, melanoma, renal CA

Question 6

What are the layers of the adrenal cortex and what they produce?

Answer 6

Glomerulosa - aldosterone; Fasciculata - Glucocorticoids; Reticularis - Androgens/Estrogens

Question 7

What is the inital compound use by the adrenal?

Answer 7

Cholesterol

Question 8

What is the function of aldosterone?

Answer 8

Stimulates renal Na resorption and secretion of K , hydrogen ions and ammonia

Question 9

What stimulates the secretion of aldosterone?

Answer 9

Angiotensin II an hyperkalemia, and to some extent ACTH

Question 10

What is the MC enzyme deficiency in congenital adrenal hyperplasia? What is the MC symptoms?

Answer 10

21-hydroxylase deficiency
Sxs: Precocius puberty in males, virilization in females, increase in 17-OH progesterone lead to increase prod of testosterone, Salt-wasting

Question 11

What is the second MC enzyme deficiency in congenital adrenal hyperplasia? What is the MC symptoms?

Answer 11

11-hydroxylase deficiency

Sxs: precocious puberty in males, virilization in females, increase 11-deoxycortisone, Salt-saving

Question 12

What are some causes of Primary hyperaldosteronism?

Answer 12

Adenoma (80-90%), Hyperplasia (10-20%), ovarian tumors, cancer

Question 13

What are some causes of Secondary hyperaldosteronism?

Answer 13

More common than primary disease

CHF, renal artery stenosis, liver failure, pregnancy, diuretics, Bartter’s syndrome (renin-secreting tumor)

Question 14

What is the main diagnostic test to differentiate between Primary and Secondary Hyperaldosteronism?

Answer 14

Primary - low renin

Secondary - high renin

Question 15

What is the main diagnostic findings of Primary Hyperaldosteronism?

Answer 15

Urine aldosterone after salt-load (will stay high)
Low serum K, High urine K, High serum Na, Metabolic Alkalosis
Plasma renin activity will be low
Aldosterone:renin ratio > 20

Question 16

What are some localizing studies that can be used for Primary Hyperaldosteronism?

Answer 16

MRI, NP-59 scintigraphy (differentiate adenoma from hyperplasia), adrenal venous sampling

Question 17

What is the treatment for Primary Hyperaldosteronism?

Answer 17

Adenoma - resection
Hyperplasia - Medical therapy first with spironolactone, CCBs, K
If bilateral resection is performed (usually done for refractory hypoK), pt will need fludrocortisone postop

Question 18

What is the #1 cause of adrenal insufficiency?

Answer 18

Withdrawal of exogenous steroids

Question 19

What is the #1 primary disease of adrenal insufficiency?

Answer 19

Autoimmune disease

Question 20

What diagnostic findings are seen in adrenal insufficiency?

Answer 20

Low serum Na, High serum K, ACTH stimulation test

Question 21

What step by step work up done for hypercortisolism?

Answer 21

1st - 24-hour urine cortisol (most sensitive test)
2nd - low-dose overnight dexamethasone suppression test. If cortisol is low, the dx is Cushing’s disease; if high, go to 3rd.
3rd - measure serum ACTH. If high, dx is either ectopic ACTH or pituitary tumor –> go to 4th; if low, pt has cortisol-secreting tumor.
4th - High-dose overnight dexamethasone suppression test. Positive = pituitary origin; negatiove = ectopic origin of ACTH.
5th - CRH test –> pituitary adenomas will increase ACTH; ectopic producers will have no change in ACTH

Question 22

What is the #1 cause of noniatrogenic cause of Cushing’s syndrome?

Answer 22

Cushing’s disease (Pituitary adenoma) 70-80% cases

Question 23

What is the #2 cause of noniatrogenic cause of Cushing’s syndrome?

Answer 23

Ectopic ACTH - most commonly small cell lung CA

Question 24

When is an bilateral adrenalectomy needed?

Answer 24

Adrenal hyperplasia, pts with ectopic ACTH from tumor that is unresectable or from pituitary adenoma that cannot be found

Question 25

What is the AA needed for catecholamine production?

Answer 25

Tyrosine

Question 26

What is the reta-limiting step enzyme in catecholamine production?

Answer 26

Tyrosine hydroxylase (tyrosine to dopa)

Question 27

What is the enzyme tha converts norepinephrine to epinephrine?

Answer 27

PNMT which is only found in the adrenal medulla

Question 28

In addition to the adrenal gland, where can pheochromocytomas be found?

Answer 28

Organ of Zuckerkandl

Question 29

From which cells, the pheochromocytomas originate?

Answer 29

Chromaffin cells

Question 30

What is the 10% rule of pheochromocytomas?

Answer 30

10% malignant, 10% bilateral, 10% in children, 10% familial, 10% extra-adrenal

Question 31

Which side of adrenal gland are pheochromocytomas most commonly found?

Answer 31

Right side

Question 32

What diagnostic studies are used for pheochromocytoma?

Answer 32

VMA most sensitive
MIBG scan
Clonidine suppression test

Question 33

What preoperative preparation is need for pheochromocytoma?

Answer 33

Volume replacement, alpha-blockade first (phenoxybenzamine –> avoids HTN crisis); then beta-blocker if patient has tachycardia or arrhythmias

Question 34

What happens if you give beta-blockade before alpha-blockade?

Answer 34

HTN crisis that can leed to heart failure

Question 35

During surgery, what maneuver can be done to avoid spilling of catecholamines?

Answer 35

Ligate adrenal veins first

Question 36

What can falsely elevated VMA?

Answer 36

Coffee, Tea, Fruits, Vanilla, Iodine contrast, Labetalol, alpaha and beta-blockers