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CEP > Adrenal 1 - The Clinical Context > Flashcards

Adrenal 1 - The Clinical Context Flashcards

1
Q

3 layers of the adrenal cortex

A
  • Zona glomerulosa (“salt”)
  • Zona fasciculata (“sugar”)
  • Zona reticularis (“sex”)
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2
Q

What regulates mineralocorticoid?

A

Renin-angiotensin-aldosterone system (RAAS)

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3
Q

Basic order of RAAS

A
  • Renin released to stimulate angiotensin 1 from angiotensinogen
  • Angiotensin 1 –> angiotensin 2 by angiotensin converting enzyme (ACE)
  • Angiotensin 2 receptor activated
  • Aldosterone release and secreted into blood
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4
Q

Signs of cortisol deficiency

A
  • Weight loss
  • Hyperpigmentation
  • Hyponatraemia
  • Hypercalcaemia
  • Hypoglycaemia
  • Anaemia
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5
Q

Signs of aldosterone deficiency

A
  • Hypotension
  • Hyponatraemia
  • Hyperkalaemia
  • Uraemia (toxins in blood)
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6
Q

Signs of DHEA/androgen deficiency

A

Loss of pubic hair (women)

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7
Q

Symptoms of cortisol deficiency

A
  • Weakness, fatigue
  • Anorexia
  • Muscle/joint paints
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8
Q

Symptoms of aldosterone deficiency

A
  • Nausea, vomiting, abdominal pain
  • Salt craving
  • Postural dizziness
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9
Q

Symptoms of DHEA/androgen deficiency

A

Loss of libido (women)

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10
Q

What are the 2 types of ACTH?

A
  • ACTH 1-39 (normal)
  • ACTH 1-24 (synacthen)
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11
Q

What does the Short Synacthen Test (SST) diagnose?

A

Adrenal insufficiency

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12
Q

Method of SST

A
  • 250µg synacthen given i.v. or i.m.
  • Blood cortisol levels rise if adrenal glands not insufficient
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13
Q

Order of diagnosing primary adrenal insufficiency

A
  • Measure adrenal auto-antibodies (autoimmune adrenalitis)
  • Measure very long chain fatty acids (adrenoleukodystrophy/adrenomyeloneuropathy)
  • CT adrenals (tuberculosis)
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14
Q

What is Addison’s disease?

A

Primary adrenal insufficiency

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15
Q

What is the most frequent causes of primary and secondary adrenal insufficiency?

A
  • P = autoimmune adrenalitis
  • S = pituitary tumours
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16
Q

Long-term treatment of adrenal insufficiency

A
  • Replace glucocorticoid with 15mg am and 10mg pm hydrocortisone
  • Replace mineralocorticoid with 100-200µg/day fludrocortisone
  • DHEA for women
17
Q

When would an adrenal insufficient patient double their daily glucocorticoid dose?

A
  • Fever
  • Infection requiring antibiotics
  • Minor surgery under local anaesthesia
18
Q

What can cause severe stress for an adrenal insufficient patient?

A
  • Trauma
  • Major surgery
  • Persistent vomiting
  • Colonoscopy
  • Active labour
19
Q

What dosage of what corticosteroids are needed when severe stress?

A
  • 100mg hydrocortisone i.v.
  • 200mg/day hydrocortisone continuous infusion
20
Q

Clinical features of Cushing’s syndrome

A
  • Purplish stretch marks (>1cm)
  • Thin skin, easy bruising
  • Proximal myopathy
  • Facial fullness and plethora
  • “Buffalo hump”
  • Osteoporosis
  • Decreased linear growth in children
21
Q

Types and percentage prevalence of Cushing’s syndrome

A
  • Pituitary dependent Cushing’s syndrome (= Cushing’s disease) (75%)
  • Ectopic Cushing’s syndrome (15%)
  • ACTH-independent (10%)
22
Q

What causes pituitary dependent Cushing’s syndrome?

A

ACTH-producing pituitary tumour

23
Q

What causes ectopic Cushing’s syndrome?

A

Ectopic ACTH source (eg. benign lung tumour producing ACTH)

24
Q

What causes ACTH-independent Cushing’s syndrome?

A

Cortisol-producing adrenal tumour

25
Q

3 tests for Cushing’s syndrome

A
  • Dexamethasone overnight suppression test
  • 24h urinary free cortisol
  • Midnight cortisol (serum or saliva)
26
Q

Method of dexamethasone overnight suppression test

A
  • 1mg dexamethasone tablet given 11pm
  • Blood for serum cortisol 8-9am
  • If cortisol levels remain high –> Cushing’s
27
Q

How does dexamethasone work?

A
  • Mimics cortisol by binding to glucocorticoid receptors but with longer half life
  • ACTH downregulated so cortisol levels should drop
28
Q

What urinary free cortisol levels diagnose Cushing’s?

A

> 130µg/24h

29
Q

How do you determine if a patient has ACTH-dependent or -independent Cushing’s syndrome?

A
  • 9am plasma ACTH
  • Suppressed = independent
  • Normal/high = dependent
30
Q

How do you determine if a patient has pituitary dependent or ectopic ACTH-dependent Cushing’s syndrome?

A
  • High dose dexamethasone test (2mg 6-hourly for 48h, if >50% decrease in serum cortisol/UFC from start then pituitary dependent)
  • CRH test (100µg i.v.)
  • Inferior petrosal sinus sampling (IPSS)
31
Q

What can be done if biochemistry doesn’t show what version of Cushing’s a patient has?

A

Imaging (CT adrenals or MRI pituitary)

32
Q

How can Cushing’s be treated?

A
  • Surgery
  • Drugs
33
Q

What mechanisms can drugs use to treat Cushing’s?

A
  • Block cortisol-producing adrenal enzymes
  • Block glucocorticoid receptors
  • Disrupt adrenal redox so steroidogenesis and cell proliferation
34
Q

What surgery options are there for Cushing’s?

A
  • Pituitary - transsphenoidal surgery
  • Bilateral adrenalectomy
  • Laparascopic adrenalectomy (adrenal adenoma)
  • Open adrenalectomy (adrenocortical carcinoma)

CEP (14 decks)

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