Adrenal cortex Flashcards
What are the 3 zones of the adrenal gland
Zona glomerulosa
Zone Fasiculata
Zona reticularis
Where are glucocorticoids made
in the zona fasiculata
What is made in the zona reticularis
androgens
What is cortisol used for
glucose production
BP regulation
anti-inflammatory
What is aldosterone used for
controls sodium/potassium/water balance
regulation of blood volume
BP regulation (RAAS)
What are glucocorticoids and mineralocorticoids used for
physiologic stress response
BP regulaation
Electrolyte homeostasis
What is the precursor to adrenal androgen
Hehydroepiandrosterone (DHEA)
*then converted into sex steroids in gonads or target tissue
What is the job of epi/norepi in the body
regulates heart rate
regulates contractility
vasodilation/constriction
BP regulation
bronchodilation
glycogenesis
What is the 4S’s for the adrenal hormones
Aldosterone = salt
Costrisol = sugar
androgens = sex
epi/norepi= stress
What causes hyper functioning adrenal glands
neoplasms
autoimmune disorders
exogenous administration
What causes hypo functioning adrenal glands
glandular destructions
*autoimmune, infection, surgery, tumor, hemorrhage
What are some hyperfunctioning adrenal disorders
cushings syndrome
pheochromocytoma
adrenal adenoma
adrenal cancer
multiple endocrine neoplasia
What are some hypo functioning adrenal disorders
Addisons disease
adrenal deficiency
Which gender is at higher risk of developing cushings syndrome
Females
What is the most common etiology of cushings syndrome
increased ACTH production (ACTH dependent)
What can cause an increase of ACTH production
pituitary adenoma
ectopic ACTH production
What are some causes of ectopic ACTH production
carcinoid tumor of lung, thyroid, pancreas
small cell lung cancer
pheochromocytoma
What are causes of ACTH independent causes of cushings syndrome
Adrenal adenoma
adrenocortical carcinoma
adrenal hyperplasia
What is cushings syndrome
unchecked cortisol
What are the side effects of cushings syndrome
excess in blood glucose production
increase in lipolysis
increase protein metabolism
decrease in insulin production
increased glucagon production
How do those with Cushings syndrome typically present
central obesity
moon facies
buffalo humo
abdominal striae
What PE findings give you a high clinical suspicion for cushings syndrome
thin, brittle skin
easy bruising (>1cm)
purple striae
proximal muscle weakness
What are screenings for cushings syndrome
Elevated 24 hr urine free cortisol
Elevated midnight plasma
dexamethasone suppression test
What is a positive dexamethasone suppression test
low dose = plasma cortisol >5
High dose = <50% reduction
If a screening test for cushings is positive, how do you determine if it is ACTH dependent or independent
plasma ACTH
How do you localize the source of cushings syndrome
CT of adrenals if ACTH independent
*generally benign unless >4cm and there are atypical densities
If a screening for cushings is positive and ACTH dependent, how do you localize the source
MRI of pituitary
CT of chest, abdomen, thymus, pancreas, or adrenal
How do you treat cushings syndrome
If pituitary source: transsphenoidal resection of mass
If ectopic ACTh scripting tumor: local surgical resection
How do you treat a benign adrenal adenoma
laparoscopic resection
How do you treat an adrenal carcinoma
surgical resection
Who is at higher risk for negative prognostic factors
older age at dx
higher pre-op ACTH
longer disease presence
What is a pheochromocytoma
sympathetic nervous system tumor arising from the adrenal medulla
What is the average age at dx for pheochromocytoma
40
What is the classic triad of a pheochromocytoma
palpitations
headache
episodic sweating
What is a common presentation in those with a pheochromocytoma
innapropriate fight of flight responses
catastrophic HTN crisis
fatal arrhythmias
pulmonary edema / HF
What lab tests are preformed for pheochromocytoma
plasma fractionated free metanepherines (most sensitive)
When is plasma fractionated free metanepherines drawn
after a patient has been sitting quietly for 15 min
*if positive retest after patient has been supine for 30-90 minutes
If lab testing is positive for a pheochromocytoma, what type of imaging do you obtain
non-contrast CT to look for tumor
What is the treatment of choice for a pheochromocytoma
surgical resection
What percent of pheochromocytoma are malignant
10%
What meds do those with a pheochromocytoma need to be on pre-op
alpha or CCB
Beta blockers
If the pheochromocytoma is malignant, what needs to be monitored
serum chromogranin (CgA)
What is multiple endocrine neoplasia (MEN)
inherited tumor syndromes
*autosomal dominant
When can MEN-1 be detected
14-18years old
*clinical symptoms dont appear until 20-30
What is the mean life expectancy in someone with MEN 1
55 years because most tumors will be malignant
What is the triad of tumors in MEN1
parathyroid
pancreatic islets
anterior pituitary
What is the initial presenting symptom for MEN 1
hyperparathyroidism
How common is a pheochromocytoma in MEN 1
rare
What is the classic tried for MEN 2
medullary thyroid carcinoma
pheochromocytoma (often bi-lat)
parathyroid tumor
What is the presentation of MEN 3
mucosal neuromas
Marfan-like habits
pheochromocytoma
medullary thyroid carcinoma
What is the most rare MEN syndrome
4
What is the primary diagnostic tool for MEN
genetic testing
What is the primary cause of adrenal insufficiency
adrenal gland disfunction
What is the secondary cause of adrenal insufficiency
ACTH deficiency due to hypothalamus or pituitary disfunction
What type of disease is Addisons disease
primary adrenal disease
What is the classic presentation for adrenal insufficiency
fatigue
reduced stamina
weakness
anorexia
weightloss
akin hyperpigmentation
What are signs of an acute adrenal crisis
profound hypotension
N/V
fever
dehydration
How can you confirm adrenal insufficiency
cosyntropin stimulation test (Synthetic ACTH)
*should rise>20mcg/dL
What helps differentiate between primary and secondary adrenal insufficiency
plasma ACTH
Low/normal = Secondary
High=primary
How can you treat adrenal insufficiency
Glucocorticoid replacement therapy
*hydrocortisone in 2-3 doses/day
*increase dose under stress
When do the glucocorticoid replacement therapy need to be reduced in patients
when taking antifungals, HIV meds, and some antidepressants
What type of mineral corticoid replacement can be given with adrenal insufficiency
fludrocortisone acetate
*generally only with PRIMARY insufficiency
*helps reduce falls
How do you treat an adrenal crisis
loading dose of hydrocortisone
rehydrate with saline
broad spectrum abx
How can you help prevent adrenal crisis
patient education
extra doses
plenty of refills
stress dose steroids
dose adjust in hot weather
antiemetics
