Adrenal

Question 1

What 3 things are secreted form the Adrenal Cortex? Where are they located and what regulates them?

Answer 1

Aldosterone – the outer layer, regulated by Renin-Aldosterone Angiotensin System

Cortisol (major glucocorticoid) – middle & inner layer, regulated by ACTH from pituitary

Androgens (testosterone, androstenedione, DHEA, and estradiol) – the inner adrenal cortex, regulated by ACTH

Question 2

What is the function of cortisol?

Answer 2

• Inhibits insulin secretion, increase hepatic gluconeogenesis, decreases protein stores
• Dampens defense mechanisms
• Inhibits production or action of inflammatory mediators
  * Required for production of angiotensin II (without it leads to hypotension & death)
• Lowers serum Calcium
  * Necessary for normal bodily function

Question 3

When is cortisol secreted?

Answer 3

response to stress, trauma, infection, and major surgery

Question 4

What happens if there are excessive amounts of corticosteroids?

Answer 4

Cushing Syndrome

Question 5

What are the 2 sources for Cushings syndrome?

Answer 5

Endogenous – tumors secreting cortisol or ACTH

Exogenous – glucocorticoid administration (drugs) *Most common

Question 6

What types of endogenous tumors are there?

Answer 6

Adrenal tumors – secreting excess cortisol (ACTH suppressed)

Or Non-pituitary (lung CA)

Question 7

What is the most common disorder of endogenous glucocorticoids in excess?

Answer 7

Pituitary adenoma secreting excess ACTH = Cushings DISEASE

Question 8

When you hear “moon face” or “buffalo hump” what diagnosis do you think of?

Answer 8

Cushings Syndrome

Question 9

What other signs & symptoms may a person with cushings syndrome present with?

Answer 9

Abdominal protuberance, striae, thin extremities, muscle wasting, acne, hirsutism, glucose intolerance, hypertension, osteopenia or osteoporosis, and increased thirst

Question 10

What lab findings would you see with cushings syndrome?

Answer 10

hyperglycemia, elevated cortisol

Question 11

If you see the elevated cortisol levels, what diagnostic test would you order?

Answer 11

Dexamethasone suppression test = 1mg give at 11PM, AM cortisol should be

Question 12

What can happen if Cushing syndrome is left untreated?

Answer 12

Significant morbidity from diabetes, hypertension, susceptible to infections, and fractures.

Question 13

How do you treat Cushings syndrome?

Answer 13

Transphenoidal resection of pituitary adenoma or laparoscopic resection of adrenal tumors

Question 14

What medications can be used for metastatic adrenal CA?

Answer 14

Ketoconazole & metyrapone

Question 15

Again, what is the most common cause of exogenous glucocorticoid excess?

Answer 15

Prolonged administration of synthetic glucocorticoids (steroids - prednisone)

Leading to chronic suppression of ACTH & the adrenals

Question 16

What must we always remember about taking patients off of steroids?

Answer 16

MUST TAPER

Question 17

What differential diagnosis must you always think of in a patient with fatigue, weakness, and hypotension?

Answer 17

adrenal insufficiency

Question 18

What patients are at risk for adrenal insufficiency?

Answer 18

Those taking exogenous corticosteroids with suppression of hypothalamic pituitary axis

Steroids tapered too rapidly & requirement for cortisol increases

Question 19

What type of diagnostic testing can you do for adrenal insufficiency?

Answer 19

Cosyntropin (synthetic ACTH) test – cosyntropin 250ug given IV, test serum cortisol 30-60minutes later, a NORMAL response would be a rise in serum cortisol to at least 20

Gives us an understanding of adrenal reserves
*If a patient is on oral steroids, they must hold for 8 hours

Question 20

What disease is known as chronic adrenal insufficiency, and is also autoimmune?

Answer 20

Addison’s disease

Question 21

What is occurring in Addison’s disease?

Answer 21

Autoimmune destruction of the adrenal cortex that can develop over time, resulting in chronic deficiency of cortisol, aldosterone, and adrenal androgens

Question 22

What are the signs & symptoms of chronic adrenal insufficiency?

Answer 22

*Low BP, orthostasis, and hyperpigmentation of skin = must have a suspicion since sxs are non-specific

Question 23

What does the lab work up look like for chronic adrenal insufficiency?

Answer 23

Neutropenia, lymphocytosis, eosinophilia;

LOW AM CORTISOL (

Question 24

What diagnostics would you order is you see low AM cortisol levels?

Answer 24

Abdominal CT – showing small non-calcified adrenals

Question 25

How do you treat chronic adrenal insufficiency?

Answer 25

Glucocorticoid replacement – hydrocortisone 15-20 in AM & 5-10mg in PM

If cortisol doesn’t rise with cosyntropin, must also give fludrocortisone

Must increase maintenance cortisol dose during stress

Question 26

What must you have a high index of suspicion for in a patient taking exogenous glucocorticoids?

Answer 26

Acute Adrenal insufficiency

Question 27

What is key for preventing acute adrenal insufficiency?

Answer 27

MUST TAPER OFF STEROIDS

Question 28

What are the signs & symptoms of acute adrenal insufficiency?

Answer 28

HA, N/V, abdominal pain, diarrhea, temp, severe hypotension, and hemodynamic collapse

Question 29

When do we consider acute adrenal insufficiency?

Answer 29

Hypotension/ shock that is unresponsive to IV fluids and pressors

Question 30

How do we treat acute adrenal insufficiency?

Answer 30

Isotonic fluids, IV hydrocortisone (every 6 hours), treat underlying physiologic stress

Question 31

If a patient has hypertension, severe headaches, sweating, and palpitations – what diagnosis do you think of?

Answer 31

Phenochromocytoma

Question 32

What is phenochromocytoma?

Answer 32

Rare, tumor on the adrenal medulla releasing excess norepinephrine/epinephrine

Question 33

How do you diagnose phenochromocytoma?

Answer 33

24 hour urine for catecholamines & metanephrines

Question 34

If catecholamines & metanephrines are present in the urine, what do you do next?

Answer 34

Abdominal CT/MRI

Laparoscopic removal of tumor – DO NOT BIOPSY