Adrenal Flashcards
Blood supply to the adrenal
superior adrenal (inferior phrenic)
middle adrenal (aorta)
Inferior adrenal (renal artery)
Venous drainage for the adrenal
Left - into left renal vein
Right - into cava
Layers of adrenal and function
Cortex
-Glomerulosa (aldosterone)
-Fasiculata (glucocorticoid)
-Reticularis (androgens)
Medulla
-catecholamines
Adrenalectomy approaches
Open
-Flank RP
-Anterior subcostal or chevron
-Posterior lumbodorsal
-Thoracoabadominal
Lab/robo
-Transabdominal
-Retroperitoneal
If an adrenal mass is <__HU on noncon, no further workup needed. If not, then ____
10
Washout study
Differential for Adrenal mass
Myelolipoma
ACC
Functional tumor
Mets
Adrenal washout study
> 60% relative washout is lipid-poor adenoma
40% relative washout is lipid-poor adenoma
Adrenal mass metabolic workup
BMP
Aldo – add renin if hypokalemia
Cortisol
17 ketosteroids
Metanephrines (plasma or urinary)
androgens only if ACC or virilization
Cholesterol to pregnenolone
StAR and cyp11a1
Pregnenolone to progesterone
3B-HSD
Androstenedione to T
17B-HSD
Progesterone to 17-OHP
Cyp17
Progesterone to corticosteroids
Cyp21 and Cyp11
Testosterone to estradiol
Aromatase
Imaging approach to adrenal masses
noncon CT
>10HU –> washout CT or MRI
Should adrenal masses be biopsied?
Nope
Adrenal functional workup
Low dose dexamethasone suppression
BMP/HTN -> renin/aldo ratio if low K
Plasma free or 24hr urine metanephrines
DHEAS or testosterone
Abnormal dex suppression - next steps
Check ACTH
Next steps if aldo/renin ratio abnormal
adrenal vein sampling
aldosterone mechanism
Acts at receptors in distal tubules/collecting ducts, wasting K
Low dose dex suppression test process
Stop ACEI or ARB 4 weeks before test
1mg dex at 11pm, measure at 8am
>138 = cortisol hypersecretion
When should androgens be tested for adrenal masses?
ACC or virilization
Management of benign adrenal masses >4cm
repeat imaging, resect if growing >5mm/yr
Causes of Cushing’s syndrome
ACTH dependent
-ACTH overproduction by pituitary (Cushing’s disease)
-Ectopic ACTH secretion by non-pituitary tumors
ACTH independent
-Cortisol-secreting adenoma
Management of elevated ACTH
Brain MRI
Petrosal vein sampling
Neurosurgery consult
Staging workup for suspected malignant adrenal mass
Chest imaging
General steps for open adrenalectomy
Open gerota’s fascia
No touch technique for ACC
ligate/clip adrenal arteries
Ligate adrenal vein
Check for bleeding
Regional LND
No drain
Close
Intraop complications from adrenalectomy
-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
Postop complications from adrenalectomy
PTX -> chest tube if large
Management of pancreatic injury
-Close pancreatic capsule and place drain
-Distal - can staple distal panc
-Give TPN
Management of liver injury
Horizontal mattress with bolster
Pringle if bad bleeding
Partial hepatectomy
Management of duodenal injury
Repair in multiple layers with 4-0 silk
Omental flap
NGT
Management of splenic injury
Control with hemostatics
If needed, splenectomy (divide short gastrics, divide splenic artery, splenic vein)
Management of metastatic ACC
Mitotane, etoposide, doxorubicin, cisplatin
aldo/renin interpretation
FIRST make sure off spironolactone!
High renin (low ratio) - think RAS, CHF, JG tumor
aldo/renin >30 = primary hyperaldo
If hyperaldo, next steps
CT scan, adrenal vein sampling
Bilateral symmetric aldo on renal veins in hyperaldo
adrenal hyperplasia - start spironolactone
Side effects of aldo receptor antagonists like spironolactone
gynecomastia, ED, hyperkalemia
What stimulates aldo secretion
RAAS
-blood loss, hyponatremia
-Inhibited by ANF
What is MIBG
norepi precursor - taken up by chromaffin cells - marker for tumors
Pheo appearance on MRI
T2 bright
Indications for genetic testing for adrenal mass
Under 50, FMHx pheo, multiple lesions, bilateral, malignant
Mutation with highest malignant risk in pheo
SDHD
Pheo prep
alpha blockade with phenoxybenzamine (or CCBs)
THEN beta blockade
THEN fluids
Symptoms of pheo (8)
Headache
Palpitations
Sweating
HTN
Pallor
Hyperglycemia
Fatigue
Anxiety
Hereditary genetic forms pf pheo
Genes
-RET
-VHL
-NF1
-SDHD
-SDHB
Syndromes associated with pheo
VHL
NF1
MEN2A
MEN2B
Familial paraganglioma 1/4
Rules of 10s for pheo
10% bilateral, malignant, extra-adrenal, pediatric, familial
