Adrenal

Question 1

What’s function of aldosterone?

Answer 1

NA retention, K excretion

Question 2

What’s hormonal workup for adrenal mass?

Answer 2

Urine metanephrine/VMA/catecholamine, urinary hydroxycorticosteroids, serum K w plasma renin/aldosterone, look for primaries

Question 3

What are suggestive of benign adrenal mass?

Answer 3

<4 cm, smooth, <10 HU, >60% washout on 15 minute delay phase, simple cyst, myelolipoma

Question 4

What is the cortisol regulatory axis?

Answer 4

CRH (Hypothalamus) -> ↑ACTH (ant pituitary) -> ↑Cortisol -> ↓CRH

Question 5

What mneumonic for congenital adrenal hyperplasia?

Answer 5

C A T
2 1 _ up
1 7 up _
1 1 up up
A: aldosterone
T: sex hormone

Question 6

How do you diagnose hyperaldosteronism?

Answer 6

Salt load suppression test (urine aldosterone remains high)
Plasma aldosterone:renin >20 (AR)

Question 7

How do you treat hyperaldosteronism?

Answer 7

Adenoma: adrenalectomy
Hyperplasia: spironolactone (suppresses aldosterone), CCB (nifedipine), K replace
Refractory: Bilateral adrenalectomy (give fludrocortisone postop)

Question 8

How do you workup low cortisol level?

Answer 8

Cosyntropin test (ACTH) to check for adrenal insufficiency

Question 9

How do you workup high cortisol level?

Answer 9

24H urine cortisol test (verify hypercortisolism) and ACTH
IF ACTH low: patient has a cortisol secreting lesion (adrenal hyperplasia/adenoma)
IF ACTH high, perform high dose dexamethasone suppression test
- If urine cortisol suppressed: pituitary adenoma
- If urine cortisol is not suppressed: ectopic ACTH

Question 10

How do you treat adrenal hyperplasia?

Answer 10

Metryrapone (11B hydroxylase inhibitor -> ↓cortisol synthesis), aminoglutethimide (inhibit steroid production), bilateral adrenalectomy if refractory

Question 11

What’s chemo agent for adrenal cancer? When is it used?

Answer 11

Mitotane. High grade (Ki67>10, >20 mitosis/50HPF, intraoperative tumor spillage, capsular invasion, recurrent/metastatic disease

Question 12

What’s the rate limiting step of catecholamine production?

Answer 12

Tyrosine hydroxylase

Question 13

What converts norepinephrine to epinephrine?

Answer 13

PNMT

Question 14

What is a notable point of extraadrenal neural crest tissue?

Answer 14

Organ of Zuckerkandl at aortic bifuration

Question 15

Which side if pheo more common in?

Answer 15

Right

Question 16

How do you test for pheo?

Answer 16

Screening with plasma metanephrine. Confirm with 24H urine metanephrine. Can also do urine VMA, MIBG scan, clonidine suppression test (clonidine will not suppress catecholamine secretion)

Question 17

What are critical periop element of pheo?

Answer 17

IVF, alpha-blocker (phenoxybenzamine, prazosin), beta-block once tachycardic or getting arrhythmia, metyrosine (tyrosine hydroxylase inhibitor)
Have nitroprusside, neosynephrine, antiarrhythmic agents available

Question 18

What hormones does posterior pituitary secrete?

Answer 18

ADH, oxytocin

Question 19

What’s blood supply for anterior pituitary?

Answer 19

portal venous supple from posterior pituitary

Question 20

What’s indication for treating prolactinoma? What’s the treatment?

Answer 20

Symptomatic or macroadenoma >10 mm.
Bromocriptine (safe in pregnancy), cabergoline
If failure/hemorrhage/visual loss/desiring pregnancy/CSF leak:
Transsphenoidal resection

Question 21

What’s Bromocriptine/Cabergoline’s mechanism?

Answer 21

Dopamine agonist

Question 22

What’s Conn’s? What’s Addison’s?”

Answer 22

Addison: hypoaldosterone
Conn: Hyperaldosterone