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Adrenal > Adrenal > Flashcards

Adrenal Flashcards

1
Q

Superior adrenal

A

inferior phrenic artery

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2
Q

Middle adrenal

A

aorta

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3
Q

Inferior adrenal

A

renal artery

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4
Q

Left adrenal vein

A

drains into left renal vein

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5
Q

Right adrenal vein

A

drains into IVC

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6
Q

Hypothalamus - Anterior Pituitary - Adrenal Gland

A

CRH - ACTH - Cortisol

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7
Q

Asymptomatic Adrenal Mass

A

1-2% of abdominal CT scans show incidentaloma (5% mets or primary adrenal tumors); benign adenomas are common; surgery indicated if > 4cm, ominous characteristics (nonhomogenous), functioning or enlarging; need to f/u every 3months for 1 year, then yearly; dx serum K, urine metaneprhines / VMA / cathecholamines, urinary hydroxycorticosteroids, plasma renin & aldosterone levels if HTN or decrease K; CXR, stool guaiac & c-scope, mammogram; cancer history with asymptomatic adrenal mass need biopsy

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8
Q

Common mets to adrenal

A

Lung cancer > breast CA > melanoma > renal CA

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9
Q

Adrenal Cortex

A

from mesoderm; GFR (salt, sugar, sex steroids)
Glomerulosa: aldosterone
Fasciculata: glucocorticoids
Reticularis: androgens / estrogens
no innervation to cortex
lymphatics drain to subdiaphragmatic & renal LNs

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10
Q

Cortisol

A

diurnal peak at 4-6am

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11
Q

Aldosterone

A

stimulates renal Na resorption & secretion of K, hydrogen ion and ammonia; secretion is stimulated by angiotensin II & hyperkalemia and to some extent ACTH

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12
Q

Excess estrogens and androgens by adrenals

A

almost always cancer

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13
Q

Congenital Adrenal Hyperplasia

A

enzyme defect in cortisol synthesis

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14
Q

21-hydroxlase deficiency

A

most common 90%
precocious puberty in males, virilization in females
increase 17-OH progesterone leads to increase production of testosterone
salt wasting (decrease Na, increase K); hypotension
tx: cortisol, genitoplasty

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15
Q

11-hydroxylase deficiency

A

precocious puberty in males, virilization in females
increase in 11-deoxycortisone (acts as mineralocorticoid)
salt saving; causes HTN
tx: cortisol, genitoplasty

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16
Q

17-hydroxylase deficiency

A

ambiguous genitalia in males at birth

salt saving

17
Q

Hyperaldosteronism (Conn’s syndrome)

A 
HTN 2/2 Na retention without edema; hypokalemia; weakness, polydipsia, polyuria
Primary disease (low renin):  adenoma (85%), hyperplasia (15%), ovarian tumors (rare), cancer (rare)
18
Q

Secondary Hyperaldosteronism

A

high renin; more common than primary disease

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

19
Q

Dx hyperaldosteronism

A

urine aldosterone after salt load (will stay high); decrease serum K, increase urine K, increase serum Na, metabolic alkalosis; plasma renin activity will be low; aldosterone:renin ratio > 20
localizing studies: MRI, NP-59 scintigraphy (shows hyperfunctioning adrenal tissue, differentiates adenoma from hyperplasia; 90% accurate), adrenal venous sampling

20
Q

Tx Hyperaldosteronism

A

adenoma - resection
hyperplasia - seldom cured, increased morbidity with b/l resection, try medical tx using spironolactone, Ca channel blockers, K
if bilateral resection is performed (usually done for refractory hypokalemia) pt will need fludrocortisone

21
Q

Hypocortisolism (adrenal insufficiency, Addison’s disease)

A 
#1 cause withdrawal of exogenous steroids; #1 primary disease is autoimmune disease
also caused by pituitary disease, infection, adrenal hemorrhage, adrenal metastasis, surgical resection or injury
get decrease cortisol and aldosterone, decrease serum Na, increase serum K, ACTH stim test
22
Q

Acute adrenal insufficiency

A

hypotension, fever, lethargy, abdominal pain, decrease glucose, AMS, N/V, increase K
tx: dexamethasone, fluids

23
Q

Hypercortisolism (Cushing’s syndrome)

A

most commonly iatrogenic; 24 hour urine cortisol is most sensitive test; dexamethasone suppression test

24
Q

Dexamethasone Suppression Test

A

low dose: if low cortisol then Cushing’s disease (pituitary adenoma was suppressed); if cortisol remains high measure ACTH:
if low pt has cortisol secreting tumor (i.e., adrenal tumor or adrenal hyperplasia)
if high have either ectopic ACTH or pituitary tumor that was not suppressed, give high dose overnight dexa suppresion test:
if suppresses then pituitary origin if not ectopic origin of ACTH
in 20% still cannot tell proceed with CRH test:
pituitary adenomas will increase ACTH; ectopic producers will have no change in ACTH

25
Q

Pituitary Adenoma (Cushing’s disease)

A 
#1 noniatrogenic cause of Cushing's Syndrome 70-80%; mostly microadenomas; need petrosal sampling to figure out which side; MRI can help
tx: transsphenoidal approach; unresectable or residual tumors treated with XRT
26
Q

Ectopic ACTH

A 
#2 noniatrogenic cause of Cushing's syndrome; most commonly from small cell lung Cancer; CT chest / abd help to localize
tx: resection of primary if possible; medical suppression or bilateral adrenalectomy for inoperable lesions
27
Q

Adrenal Adenoma

A 
#3 noniatrogenic cause of Cushing's syndrome; decrease ACTH; unregulated steroid production; does not suppress
tx:  adrenalectomy
28
Q

Adrenocortical Carcinoma

A

rare cause of Cushing’s syndrome; bimodal distribution (before age 5 and in 5th decade); more common in females; 50% are functioning tumors (cortisol, aldosterone, sex steroids); children display virilization 90% of time (precocious puberty in boys, virilization in females)
sxs: abdominal pain, weight loss, weakness
80% have advanced disease at time of dx
Tx: radical adrenalectomy; debulking can help pt and prolong survival; mitotane for residual or recurrent disease
20% 5 year survival rate

29
Q

Adrenal hyperplasia

A

macro or micro; Tx: bilateral adrenalectomy

30
Q

Medical Tx for ectopic ACTH production or adrenocortical ca with residual or mets after resection

A

ketoconazole & metyrapone (inhibit steroid formation)
Aminoglutethimide (inhibits cholesterol conversion)
Op-DDD aka mitotane (adrenal lytic; used for mets)
give steroids post op

31
Q

Adrenal Medulla

A

from ectoderm neural crest cells; cathecholamine production: tyrosine* –> dopa –> dopamine –> NE** –> epi
*tyrosine hydoxylase rate limiting step
**PNMT enzyme is found only in adrenal medulla
only adrenal pheochromocytomas will produce epi

32
Q

Monoamine oxidase (MAO)

A

converts NE to normetanephrine and Epi to metanephrine; VMA produced from these

33
Q

Organ of Zuckerkandl

A

chromaffin body derived from neural crest located at the bifurcation of the aorta or at the origin of IMA; can be the source of pheochromocytoma or paraganglioma

34
Q

Pheochromocytoma

A

chromaffin cells, slow growing; arise from sympathetic ganglia or ectopic neural crest cells; right > left
10% rule: malignant, bilateral, in children, familial, extra-adrenal (more likely malignant)
assoc with MEN IIa/b, von Recklinghausen’s disease, tuberous sclerosis, Sturge-Weber disease
Sxs: HTN, headache, diaphoresis, palpitations
Dx: plasma metanphrines, urine metanephrines & VMA (most sensitive); MIBG scan can help localize; CT / MRI; if unable to localize still proceed with laparotomy

35
Q

Pheo pre-op

A

volume replacement, alpha blocker first (phenoxybenzamine) then B-blocker if pt has tachycardia or arrhythmias

36
Q

Pheo surgery

A

check for other tumors at resection; ligate adrenal veins first to avoid spilling cathecholamines during tumor manipulation; debulking helps symptoms in pts with unresectable disease; metyrosine inhibits tyrosine hydroxylase causing decrease synthesis of cathecholamines; should have Nipride, neo-synephrine, and anti-arrhythmic agents ready during time of surgery

37
Q

Falsely elevated VMA

A

coffee, tea, fruits, vanilla, iodine contrast, labetalol, alpha & beta blockers

38
Q

Indications for Unilateral Adrenalectomy

A 
aldosteronoma
cortisol-secreting adenoma (Cushings)
unilateral pheo
virilizing or feminizing tumors
nonfunctioning unilateral tumor --> size > 4cm; adrenocortical ca; solitary adrenal mets
39
Q

Indications for Bilateral Adrenalectomy

A
  • b/l pheo
  • Cushing’s syndrome from b/l nodular adrenal hyperplasiia or ectopic ACTH-producing tumor unresponsive to primary therapy
  • Cushing’s disease (pituitary tumor) unsuccessfully treated by surgery or radiation

Adrenal (1 decks)

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