Adrenal causes of Hypertension

Question 1

Zona glomerulosa

Answer 1

Outermost functional section of the adrenal cortex
- Contains closely packed cells

Produces mineralocorticoids—> aldosterone

Question 2

Zona fascicularis

Answer 2

Middle function layer of the adrenal cortex
- Contains clear cells in cords.

Produces glucocorticoids–> Cortisol

Question 3

Zona reticularis

Answer 3

Innermost functional layer of the adrenal cortex
- Contains small, darkly stained cells.

Produces adrenal androgens—> Testosterone

Question 4

Pheochromocytoma

- Defintion

Answer 4

Tumour of the adrenal medulla.

- Excess production of catecholamines= hypertension

Question 5

Pheochromocytoma

- Presentation

Answer 5

Headaches
Sweating
Pallor
Palpitations
Anxiety

Hypertension

Family history

Question 6

Genetic conditions associated with pheochromocytoma

Answer 6

Neurofibromatosis T1 [NF1]

Multiple endocrine neoplasia T2 [MEN 2]

Von Hippel- Lindau syndrome

Question 7

Biochemical diagnosis of phaechromocytoma

Answer 7

24 hr urine

• Normetanephrines [NA metabolite]
• Metanephrines [Adrenaline metabolite]
• Methoxythyromine [metabolite of 5-HT]

Plasma

• NA and ADR
• Metanephrines

Question 8

Other conditions that elevate catecholamines in the urine/ blood [4]

Answer 8

Obstructive sleep apnoea

Amphetamine-like drugs

L-DOPA

Labetalol [antihypertensive]

Question 9

Imagining of phaos

Answer 9

MIBG scan [Meta-iodibenzylguanidine]

Question 10

Medical and surgical management of Phaos

Answer 10

Medical

• Alpha adrenergic blockers: phenoxybenzamine, doxazocin
• Beta blocks: Propranolol

Surgical
- Laparoscopic adrenalectomy

Question 11

Primary hyperaldosteronism

• Defintion
• Presentation

Answer 11

Conn’s syndrome

• Excess production of aldosterone due to hyperactive cortex
• Specifically glomerulosa.

Presentation

• Hypertension [increased Na+ absorption= increased fluid absorption]
• Fatigue
• Polyuria
• Flank pain
• Muscular weakness/ pain

Question 12

Primary hyperaldosteronism causes

Answer 12

Bilateral idiopathic adrenal hyperplasia

Adrenal adenoma

Unilateral adrenal hyperplasia

Genetic

Question 13

Individuals at high risk of primary hyperaldosteronism [requiring screening]

Answer 13

Young patients
- Less likely to have hypertension

Hypokalemia
- Indicates increased excretion of K+

Resistant hypertension
- Requiring 3 antihypertensive drugs

Question 14

Diagnostic biochemical tests for primary hyperaldosteronism

Answer 14

Initially

• Renin [will be suppressed, negative feedback from RAS].
• Aldosterone levels- high/normal
• Alkalosis

Confirmatory
- Oral/ IV Na+ solution given—> Levels of Na+ will not drop.

Question 15

Aetiological tests for primary Hyperaldosteronism

Answer 15

Adrenal CT scan

Adrenal venous sampling

Metomidate PET CT

Question 16

Management of primary hyperaldosteronism

Answer 16

If unilateral adrenal adenoma
- Laparoscopic adrenalectomy

Bilateral adrenal hyperplasia
- Aldosterone antagonist: spironolactone, eplerinone.

Question 17

Post adrenalectomy care

Answer 17

Genetic screening
- nearly a third of primary hyperaldosteronism are due to genetics

Annual assessment of metanephrines

Additional treatment if tumour is malignant.