Adrenal Causes of Hypertension Flashcards
What is endocrinology about?
- Too much hormone - single nodule, multiple nodules, generalised increase in tissue (…)
- Not enough hormone
- Gland too big - which … … …
- Exclusion of … in a single nodule
- Too much hormone - single nodule, multiple nodules, generalised increase in tissue (hyperplasia)
- Not enough hormone
- Gland too big - i.e. squashes surrounding tissue
- Exclusion of cancer in a single nodule
What is shown in this image?
Adrenal gland section - note the shape
below is CT image of it
Layers of adrenal gland (GFR) and medulla
Cortex is divided into:
- Zona Glomerulosa - makes …
- Zona Fasciculata - makes …
- Zona Reticularis - makes …
Medulla makes … (adrenaline, noradrenaline, dopamine)
- Zona Glomerulosa - makes aldosterone
- Zona Fasciculata - makes cortisol
- Zona Reticularis - makes adrenal androgens
- Medulla makes catecholamines (adrenaline, noradrenaline, dopamine)
Causes of Hypertension?
- … hypertension
- renal hypertension - primary renal …, renal artery …
- … causes
- essential hypertension
- renal hypertension - primary renal disease, renal artery stenosis
- endocrine causes
Adrenal causes of Hypertension
- Primary …
- zona glomerulosa - produces too much … due to either an …, hyper… or rare … causes
- …chromocytoma
- tumour of the adrenal …
- some forms of … adrenal hyperplasia - … defect - uncommon
- Primary Hyperaldosteronism
- zona glomerulosa - produces too much aldosterone due to an adenoma, hyperplasia or rare genetic causes
-
Phaeochromocytoma
- tumour of the adrenal medulla
- some forms of congenital adrenal hyperplasia - enzyme defect - uncommon
What pathway is this? (what does it secrete)
Pathway for aldosterone secretion
Pharmacology - hypertension
- Renin …
- ACE …
- A2 receptor …
- Aldosterone …
- Renin inhibitors
- ACE inhibitors
- A2 receptor blockers
- Aldosterone antagonists
Primary Hyperaldosteronism - why screen?
- Individuals with PA have more … and … pathology than people with essential hypertension and similar blood pressure
Individuals with PA have more vascular and renal pathology than people with essential hypertension and similar blood pressure
Hypertension - is it Primary Hyperaldosteronism? Who do we screen?
- younger or older people?
- people with hypo….
- people with … hypertension - control on … drugs or more
- younger or older people?
- people with hypokalaemia
- people with resistant hypertension - control on 4 drugs or more (inadequate control on 3 drugs)
- What is resistant hypertension?
- Inadequate control on … drugs, control on … drugs or more
- Resistant hypertension is high blood pressure that does not respond well to aggressive medical treatment.
- Inadequate control on 3 drugs, control on 4 drugs or more
What is shown here? (hypertension)
High aldosterone exists across the spectrum of hypertension
How to find out if someone has Primary Hyperaldosteronism
- Initial screening tests:
- suppressed …
- normal/high …
-
Confirmatory tests
1. Oral or IV … suppression test
- Initial screening tests:
- Suppressed Renin
- normal/high aldosterone
- Confirmatory tests
1. Oral or IV Na+ suppression test - aldosterone should go down, but if it doesn’t, you have diagnosis
Primary Hyperaldosteronism - Tests for specific Aetiology:
- Adrenal … scan
- Adrenal … sampling - is the aldo secretion uni….?
- Metomidate … CT
- Adrenal CT scan
- Adrenal venous sampling - is the aldo secretion unilateral?
- Metomidate PET CT
- What is adrenal venous sampling?
- When may it be done?
- In AVS, adrenal veins are cannulated and from each a blood sample is drawn
- Used to determine cortisol and aldosterone
CT scan - what diagnosis? (A)
Conn’s syndrome (primary hyperaldosteronism)
What is this showing? (adrenal ….)
Adrenal venous sampling
What kind of scan is this? (for Primary Hyperaldosteronism)
11C Metomidate PET scan
Primary Hyperaldosteronism - Treatment
-
Unilateral Adenoma
- Laparoscopic …
- Medical Treatment (sometimes)
-
Bilateral Hyperplasia
- medical treatment - aldosterone … such as
- …lactone
- eplerinone
- medical treatment - aldosterone … such as
- Unilateral Adenoma
- Laparoscopic Adrenalectomy
- Medical Treatment (sometimes)
- Bilateral Hyperplasia
- medical treatment - aldosterone antagonists (such as….)
- spironolactone
- eplerinone
- medical treatment - aldosterone antagonists (such as….)
Adrenal medulla - secreting catecholamines
- …. neurons in spinal cord
- Adrenal medulla -> Tyrosine
- Tyrosine converted to L-….
- This is converted to - Dopamine
- Dopamine - excreted or converted to …
- this is converted to -> ….
- Sympathetic neurons in spinal cord
- Adrenal medulla - Tyrosine
- Tyrosine - L-DOPA
- L-DOPA - Dopamine
- Dopamine - excreted or converted to noradrenalin
- noradrenalin -> adrenalin
- What genetic condition is this? (Associated with phaeochromocytoma)
- Neurofibromatosis Type 1 (NF1)
The picture below shows Axillary freckling - what condition is this present in? (associated with phaeochromocytoma)
Neurofibromatosis Type 1 (NF1)
What do people in a MEN2a family develop? (3 things)
- Medullary carcinoma of the thyroid
- Develop bilateral pheochromocytoma
- Also may develop primary hyperparathyrodism
- What is this image showing? (can get it in Von Hippel-Lindau syndrome)
- What is it often associated with?
- Retinal Hemangioglioblastoma
- often associated with a cerebellar haemangioglioblastoma (shown below)
Pathology of adrenal medulla - what is shown?
Phaeochromocytoma - larger than adenomas in Conn’s syndrome (average 4cm)
To be sure of a phaeochromocytoma. we do a … scan
To be sure of a phaeochromocytoma. we do a MIBG scan
Other imaging for phaeochromocytoma
- …. … scan to show extra-adrenal “phaeos” or metastases
- PET CT scan
