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Adrenal Clinical Flashcards

1
Q

What causes primary adrenal insufficiency (life threatening as adrenal gland damaged)

A

Addison’s = 85%
Congenital adrenal hyperplasia
Destruction of gland

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2
Q

What is most common cause of congenital

A

AR 21 hydroxylase deficinecy

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3
Q

What does it lead too

A

Low cortiosol and aldosterone
AP secretes high ACTH to try stimulate

This stimulates adrenal androgens
= Neonatal salt loss / ambitious genitalia / female civilisation / precocious puberty

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4
Q

What destroys gland

A 
Meningococcal septicaemia (Waterhouse-Fridrichsen
Infection
- TB = most common in developing
- HIV 
- Fungal
Anti-phospholipid 
Mets
Atrophy from prolonged steroid use (can also cause tertiary if suppress CRH from hypothalamus)
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5
Q

What causes secondary adrenal insuffieicny (inadequate ACTH stimulating gland)

What causes tertiary (not enough CRH from hypothalamus)

A 
Iatrogenic due to long term (apparent on withdrawal of steroid) 
Pituitary tumour
Surgery 
Pituitary infiltration / infections 
Pituitary radiation
Sheehan = post partum haemorrhage
Loss of blood

Tertiary
- Usually long term steroid

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6
Q

What causes an adrenal / Addisonian crisis

A

1st presentation of adrenal insufficiency
If stop steroids too quickly
Don’t double hydrocortisone dose in acute illness

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7
Q

What does this result in

A 
Severe hypoglycaemia
Hypotension
Hyponatraemia
Hyperkalaemia
Pyrexia
Shock
Renal failure 
Circulatory collapse
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8
Q

How of you investigate

A

ABCDE
VBG show hypoNa, hyperK, hypoBg
Cortisol / ACTH / BG
Don’t wait to do investigate need to ask fast

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9
Q

How do you treat

A

Senior and ITU help
IV hydrocortisone and saline till BP improves
- Will act on cortisol and aldosterone in acute
Correct hypo with IV dextrose10-20%
Careful monitoring of electrolyte and fluid balance
Search for cause

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10
Q

What is Addison’s

A

Autoimmune destruction of adrenal cortex leading to cortisol and aldosterone deficiency

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11
Q

What Ab

A

+ve 21-OHase autoAb

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12
Q

What is associated

A

Thyroid
Type 1 DM
Premature ovarian failure

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13
Q

What are the features

Electrolyte features

A 
Can be undetected till stress precipitates a crisis 
Muscle weakness
Fatigue
Anoreixa
Weight loss
N+V
Hypotension - particularly postural leading to syncope / dizzy 
Skin pigmentation in primary as ACTH stimulates melanocytes
Buccal mucosa hyperpigment in primary as ACTH stimulates melanocytes 
Vitiligo
Loss of pubic hair
Reduced libido 
Depression
Salt craving 
Postural drop in BP 
Hypoglycaemia
Hyponatraemia due to high levels of ADH 
Hyperkalamia
Metabolic acidosis
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14
Q

What are clues to Dx

A

Disproportion between severity of illness and circulatory collapse

Hyponatraemia - can sometimes be only presentaiton

Unexplained hypo ??

+ other endocrine - hypothyroid/ hair loss / amenorrhoea

Previous depression or weight loss

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15
Q

How do you investigate in primary care

A

Bloods - FBC, glucose, U+E, urinanalyis, BP
Can do CXR / ECG
Random cortisol / early morning will give Dx

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16
Q

Random cortisol results

A

If >700 = NOT

If <700 = perform SYnacthen (ACTH stimulation test) = 1st line test

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17
Q

What is Synthacten and what other test in secondary care

A

Give synthetic ACTH IM or IV and take blood for cortisol and ACTH level before and after
Should double
If doesn’t = Addison’s as gland can’t make
Adrenal auto Ab - anti-21 hydroxyls if autoimmune
CT or MRI for haemorrhage / tumour esp if old
MRI pituitary

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18
Q

Results of Synthacten and what do you do after

Cortisol
ACTH

A

If normal = not
If abnormal = do ACTH to differentiate between primary and secondary

If suppressed = secondary as pituitary not producing
If elevated = primary as pituitary trying to stimulate gland

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19
Q

What do you do if high suspicion

A

Treat with steroid and do synacathen later

IV steroid + IV fluid

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20
Q

How do you Rx

A 
Glucocorticoid replacement
- Hydrocortisone
- Prednisolone
- Dexamethasone
Mineralocorticoid replacement
- Fludrocortisone
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21
Q

What do you adjust dose according too

A

BP
Oedema
U+E
Plasma renin

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22
Q

How do you follow up

A

ACTH levels monitored
Steroid education
Steroid card

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23
Q

What is steroid education

A 
Never miss a dose
Double dose of hydrocortisone in illness
Maintain fludrocortisone at same dose 
Use IM hydrocortisone when vomiting
If severe D+V = get help
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24
Q

What do you need to have special care when doing

A

Withdrawing chronic glucocorticoid Rx due to -ve feedback on exogenous
Become hypoadrenal due to atrophy

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25
What causes primary hyperaldosterone What causes secondary
Adrenal hyperplasia = 70% Adrenal adenoma = Conn's Secondary - High renin from decreased renal perfusion e.g. renal artery stenosis / diuretics / CCF o rheumatic failure
26
What are features of primary hyperaldosterone
``` Hypertension HYpernatraemia Hypokalaemia Alkalosis Increased albumin Muscle weakness, nocturne, polyuria, tetnay due to hypokalameia ```
27
What is 1st line investigation
Aldosterone / renin ratio = 1st line
28
What will results show if primary hyperaldosterone
High aldosterone Low renin as high BP If renin is high then renin is driving force of aldosterone e.g. secondary hyperaldosterone If both low = other causes of hypertension
29
What other test
``` BP = hypertension U+E = hypokalaemia ABG = alkalosis Adrenal vein sampling if imaging shows adenoma - if one side revels increased ratio compared to other suspect adenoma Urinary catecholamines Renal USS to look for stenosis which would be 2nd cause Dex suppression to rule out Cushing's CT to look for adenoma ```
30
How do you treat
Surgery if adenoma | Aldosterone antagonist if hyperplasia
31
What is Cushing's syndrome
S+S of hypercortisol after prolonged abnormal elevation
32
What are primary causes of hypercortisol (ACTH independent due to -ve feedback)
Adrenal adenoma | Adrenal hyperplasia
33
What are secondary causes (ACTH dependent)
Pituitary adenoma - Cushing's disease = 2nd most common to corticosteroid Ectopic ACTH- SCLC
34
What is pseudo-cushings
Alcohol / severe depression All the signs of Cushing's Normal but can have increased dex suppression or 24 hour urinary free cortisol
35
How do you differentiate
Insulin stress test
36
What do high levels of cortisol cause
Round in middle with thin limbs High levels of stress hormone Extra
37
What does round in middle with thin limbs / tissue breakdown cause
``` Round moon face Facial plethora Central obesity Abdominal striae Oedema Proximal limb muscle wasting Proximal myopathy Skin atrophy Easily bruised Spontaneous purpura ```
38
What are affects of stress hormone
``` Hypertension Cardiomyopathy CCF due to Na retention Hyperglycaemia Depression Insomnia Osteoporosis ```
39
What are other features
``` Hirsutism Poor wound healing Headache Growth arrest Hypokalaemia metabolic alkalosis ```
40
How do you screen
Overnight low dose dex suppression test (1mg) | 24 hour urinary free cortisol
41
What is Dex suppression
``` 1mg dexamethasone Test cortisol and ACTH next morning Should be low as endogenous switched off If high = Cushing's syndrome (hypercortisol) so do high dose dex suppression If normal = excludes Cushing's ```
42
What are Ddx
Cushing's disease PCOS Congenital adrenal hyperplasia
43
What tests can you do
FBC - raised WCC U+E - high Na as reabsorbed and low K as secreted if aldosterone involved Glucose Testosterone to see if sex steroids involved 17a hydroxylase enzyme for congenital BP
44
What do you do if low dose dex abnormal
High dose
45
If due to adrenal tumour (primary cause) what is the result
Low ACTH (differentiates from others) as adrenal tumour making cortisol with no stimulation from ACTH so ACTH suppressed by cortisol but cortisol will still be high as independent Others will all have high ACTH Cortisol not suppressed
46
If due to Cushing's disease (secondary from pituitary)
Not suppressed by low Cortisol suppressed by high dose as still some -ve feedback Both low
47
If ectopic
ACTH and cortisol NOT suppressed by his or low dose as completely independent
48
If not suppressed by low or high
Ectopic as completely independent
49
If CRH
Pituitary - cortisol rises | Ectopic / adrenal = no change
50
How do you localise lesion
Plasma ACTH - if low suggest adrenal MRI brain for pituitary adenoma CT chest for SCLC Abdo CT for adrenal
51
How can you give steroid
Systemic - oral or IV | Local - cream / inhaler / eye drop / intra-articular
52
What type of activity fludrocrotsione (replace aldosterone)
High mineral | Low glucocorticoid
53
What type of activity in hydrocortisone (replace cortisol)
High mineral and glucocorticoid | - Used in crisis as both
54
What type of activity in prednisiolone
High glucocorticoid Minimal mineral Use long term
55
What type of activity in dexamethasone
High glucocorticoid No mineral - used to reduce swelling in brain as mineral would cause fluid retention Use short term
56
What are SE of glucocorticoid ``` Endocrine MSK Immune Psych GI Eye Other ```
``` Cushing's Endocrine - DM - Appetite / weight - Hirsutism - Hyperlipid MSK - AVN femoral - Osteoporosis Infection Reactivation TB Psych - Insomina - Mania / depression / psychosis GGI - Ulcer - Pancreaitits Eye - Glaucoma - Cataract Suppressed growth Benign Intracranial hypertension / papilloedema Neutrophilila ```
57
What are SE mineralocortioicd
Fluid retention | Hypertension
58
When do you need to gradually withdrawal
If >40mg for >1 week
59
What is a pheochromocytoma
Rare catecholamine secreting tumour of adrenal medulla | Release adrenaline
60
What is associated with
MEN2A+B | Neurofibromatosis
61
What are features
``` Persistent hypertension Episodic attacks due to sudden release Hyperglycaemia Headache Palpitations Tachycardia AF Sweating Anxiety DM Weight loss ```
62
How do you Dx
24 hour urine metanephrine | CT / MRI
63
How do you treat
Surgery
64
What do you give before surgery
A blocker + BB to control HTN as catelchoamines increase BB A blocker 1st = phenoxybenzamine Labetalol = Rx of choice once controlled on A blocker Must do A blocker first as if unopposed alpha will get hypertensive crisis IV fluid Surgery to remove tumour once established on medical to prevent hypertension in surgery
65
What are other tumours of adrenal gland
Adenoma cortex | Carcinoma cortex - mets from lung or breast
66
If functioning or malignant what do you do
Surgery
67
If non-functioning
Surveillance
68
What are endocrine causes of hypertension
Primary hyperaldosterone - adenoma/ hyperplasia = most common Pheochromocytoma = 24 hour urine metanephrine Cushing's = dex suppression Acromegaly Hyperparathyroid Hypothyroid Renal USS for stenosis
69
What are DDX of hypokalaemia alkalosis
Primary hyperaldosteronism Cushing Phaeochromocytoma
70
How do you Rx Cushing's syndrome
Surgery to remove cause | or remove adrenal gland and give replacement steroid
71
What can occur after bilateral adrenelectomy
Nelon syndome -ve feedback as no cortisol causing pituitary adenoma to enlarge Monitor ACTH and MRI 3-6 months post surgery
72
What is risk of taking anabolic steroid
Hypogonadism and low sperm count when stop

Endocrine (17 decks)

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