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ABU Boards 2023 > Adrenal > Flashcards

Adrenal Flashcards

1
Q

Blood supply to the adrenal

A

superior adrenal (inferior phrenic)
middle adrenal (aorta)
Inferior adrenal (renal artery)

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2
Q

Venous drainage for the adrenal

A

Left - into left renal vein
Right - into cava

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3
Q

Layers of adrenal and function

A

Cortex
-Glomerulosa (aldosterone)
-Fasiculata (glucocorticoid)
-Reticularis (androgens)
Medulla
-catecholamines

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4
Q

Adrenalectomy approaches

A

Open
-Flank RP
-Anterior subcostal or chevron
-Posterior lumbodorsal
-Thoracoabadominal
Lab/robo
-Transabdominal
-Retroperitoneal

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5
Q

If an adrenal mass is <__HU on noncon, no further workup needed. If not, then ____

A

10
Washout study

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6
Q

Differential for Adrenal mass

A

Myelolipoma
ACC
Functional tumor
Mets

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7
Q

Adrenal washout study

A

> 60% relative washout is lipid-poor adenoma
40% relative washout is lipid-poor adenoma

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8
Q

Adrenal mass metabolic workup

A

BMP
Aldo – add renin if hypokalemia
Cortisol
17 ketosteroids
Metanephrines (plasma or urinary)
androgens only if ACC or virilization

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9
Q

Cholesterol to pregnenolone

A

StAR and cyp11a1

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10
Q

Pregnenolone to progesterone

A

3B-HSD

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11
Q

Androstenedione to T

A

17B-HSD

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12
Q

Progesterone to 17-OHP

A

Cyp17

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13
Q

Progesterone to corticosteroids

A

Cyp21 and Cyp11

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14
Q

Testosterone to estradiol

A

Aromatase

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15
Q

Imaging approach to adrenal masses

A

noncon CT
>10HU –> washout CT or MRI

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16
Q

Should adrenal masses be biopsied?

A

Nope

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17
Q

Adrenal functional workup

A

Low dose dexamethasone suppression
BMP/HTN -> renin/aldo ratio if low K
Plasma free or 24hr urine metanephrines
DHEAS or testosterone

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18
Q

Abnormal dex suppression - next steps

A

Check ACTH

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19
Q

Next steps if aldo/renin ratio abnormal

A

adrenal vein sampling

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20
Q

aldosterone mechanism

A

Acts at receptors in distal tubules/collecting ducts, wasting K

21
Q

Low dose dex suppression test process

A

Stop ACEI or ARB 4 weeks before test
1mg dex at 11pm, measure at 8am
>138 = cortisol hypersecretion

22
Q

When should androgens be tested for adrenal masses?

A

ACC or virilization

23
Q

Management of benign adrenal masses >4cm

A

repeat imaging, resect if growing >5mm/yr

24
Q

Causes of Cushing’s syndrome

A

ACTH dependent
-ACTH overproduction by pituitary (Cushing’s disease)
-Ectopic ACTH secretion by non-pituitary tumors
ACTH independent
-Cortisol-secreting adenoma

25
Q

Management of elevated ACTH

A

Brain MRI
Petrosal vein sampling
Neurosurgery consult

26
Q

Staging workup for suspected malignant adrenal mass

A

Chest imaging

27
Q

General steps for open adrenalectomy

A

Open gerota’s fascia
No touch technique for ACC
ligate/clip adrenal arteries
Ligate adrenal vein
Check for bleeding
Regional LND
No drain
Close

28
Q

Intraop complications from adrenalectomy

A

-Hypotension intraop - fluids
-Tear adrenal vein - compress, obtain proximal/distal control, oversew with 4-0 prolene
-Pleural leak - put red rubber inside, close, evacuate air, remove catheter

29
Q

Postop complications from adrenalectomy

A

PTX -> chest tube if large

30
Q

Management of pancreatic injury

A

-Close pancreatic capsule and place drain
-Distal - can staple distal panc
-Give TPN

31
Q

Management of liver injury

A

Horizontal mattress with bolster
Pringle if bad bleeding
Partial hepatectomy

32
Q

Management of duodenal injury

A

Repair in multiple layers with 4-0 silk
Omental flap
NGT

33
Q

Management of splenic injury

A

Control with hemostatics
If needed, splenectomy (divide short gastrics, divide splenic artery, splenic vein)

34
Q

Management of metastatic ACC

A

Mitotane, etoposide, doxorubicin, cisplatin

35
Q

aldo/renin interpretation

A

FIRST make sure off spironolactone!
High renin (low ratio) - think RAS, CHF, JG tumor
aldo/renin >30 = primary hyperaldo

36
Q

If hyperaldo, next steps

A

CT scan, adrenal vein sampling

37
Q

Bilateral symmetric aldo on renal veins in hyperaldo

A

adrenal hyperplasia - start spironolactone

38
Q

Side effects of aldo receptor antagonists like spironolactone

A

gynecomastia, ED, hyperkalemia

39
Q

What stimulates aldo secretion

A

RAAS
-blood loss, hyponatremia
-Inhibited by ANF

40
Q

What is MIBG

A

norepi precursor - taken up by chromaffin cells - marker for tumors

41
Q

Pheo appearance on MRI

A

T2 bright

42
Q

Indications for genetic testing for adrenal mass

A

Under 50, FMHx pheo, multiple lesions, bilateral, malignant

43
Q

Mutation with highest malignant risk in pheo

A

SDHD

44
Q

Pheo prep

A

alpha blockade with phenoxybenzamine (or CCBs)
THEN beta blockade
THEN fluids

45
Q

Symptoms of pheo (8)

A

Headache
Palpitations
Sweating
HTN
Pallor
Hyperglycemia
Fatigue
Anxiety

45
Q

Hereditary genetic forms pf pheo

A

Genes
-RET
-VHL
-NF1
-SDHD
-SDHB

46
Q

Syndromes associated with pheo

A

VHL
NF1
MEN2A
MEN2B
Familial paraganglioma 1/4

47
Q

Rules of 10s for pheo

A

10% bilateral, malignant, extra-adrenal, pediatric, familial

ABU Boards 2023 (33 decks)

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