Adrenal Disease Flashcards
What is Addison’s Disease?
Destruction of entire adrenal cortex leading to glucocorticoid (cortisol), mineralocorticoid (aldosterone) and sex steroid deficiency
What are the causes of Addison’s disease?
Autoimmune condition TB Sepsis Lymphoma Metastatic cancer- lung/breast
What are the symptoms of Addison’s disease?
Fatigue Weight loss Loss of libido Nausea Abdo pain Syncope
What are the signs of Addison’s disease?
Hyperpigmentation of the skin (excess ACTH activates melanin cells)
Postural hypotension
Signs of dehydration
Hair loss
What investigations are needed in Addison’s disease?
Bloods
- FBC- anaemia
- U&Es- hyperkalaemia and hyponatraemia
- LFTs
- CRP
ABG- metabolic acidosis
Synacthen test
- give synthetic ACTH
- cortisol levels measured at baseline, 30mins and 60mins after administration
- failure for levels to at least double- shows insufficiency
Adrenal autoantibodies
CT/MRI adrenals- tumours
MRI head- pituitary pathology
What is the management of Addison’s Disease?
Replacement steroids
- hydrocortisone= cortisol
- fludrocortisone=aldosterone
In illness should double hydrocortisone and keep fludrocortisone the same
Patient must have a steroid card
What is Cushing’s Syndrome?
Excess cortisol production
What are the causes of Cushing’s?
Exogenous
-steroid intake in asthma or inflammatory arthritis
Endogenous
- pituitary adenoma secreting excess ACTH (Cushing’s disease)
- Adrenal adenoma secreting excess cortisol regardless of ACTH
- ectopic ACTH secretion- tumour not in the pituitary
What are the symptoms of Cushing’s?
Moon face Truncal obesity Hirsutism Depression Easy bruising Thin skin Hyperglycaemia symptoms
What are the signs of Cushing’s?
Buffalo hump Abdominal striae HTN Pathological fractures Muscle wasting
What investigations are needed in Cushing’s?
Bloods
- FBC- WCC can be raised
- U&Es
Urine cortisol- elevated
Dexamethasone suppression test
- to determine cause
- given at night time and cortisol levels are measured in the morning- should inhibit production (<50nmol/L)
- low dose test
- -1mg dexamethasone given
- -if levels are abnormal it suggests an endogenous cause
- high dose dexamethasone test
- -give 8mg
- -ACTH and cortisol suppressed= pituitary cause
- -ACTH suppressed but cortisol raised= adrenal adenoma
- -ACTH and cortisol not suppressed= ectopic cause
Imaging
- MRI adrenals- look for tumour
- Chest CT- lung cancer (small cell carcinoma of lung could cause this)
What is the management of Cushing’s?
Removal of underlying cause
If adrenal glands are removed then lifelong steroid supplementation is needed
What is Conn’s Syndrome?
High levels of serum aldosterone due to a adrenal tumour
What are the causes of hyperaldosteronism?
Primary
- Idiopathic
- Familial
- Conn Syndrome
Secondary
-High renin due to chronic heart failure
What are the symptoms of hyperaldosteronism?
Often asymptomatic
Treatment resistant HTN
Signs of hypokalaemia- cramp, weakness, polyuria
How is hyperaldosteronism investigated?
Bloods
- U&Es- hypernatraemia and hypokalaemia
- renin and aldosterone levels
- -high renin and aldosterone= secondary cause
- -low renin and high aldosterone= primary cause
ABG- metabolic alkalosis
CT/MRI adrenals- look for tumour
What is the management of hyperaldosteronism?
Potassium sparing diuretics
- e.g. spironolactone
- help to restore potassium levels, decrease circulating volume and inhibit aldosterone action
Removal of underlying cause
What is congenital adrenal hyperplasia?
Congenital deficiency in 21-alpha-hydroxylase
Involved in the production of cortisol and aldosterone
Leads to low levels of cortisol and aldosterone
Sex steroid pathway is only working pathway causing excessive production of sex steroids (therefore testosterone)
What are the symptoms of CAH?
Virilisation of female genitalia- labial fusion
Penile enlargement and scrotal pigmentation
What investigations are needed for CAH?
Bloods
- U&Es- hyperkalaemia and hyponatraemia
- ABG- metabolic acidosis
17-alpha-hydroxylase= low and is diagnostic
What is the management for CAH?
Lifelong hydrocortisone and fludrocortisone replacement
At risk of adrenal crises
What is phaeochromocytoma?
Tumour of the chromaffin cells leading to excess adrenaline production
Bursts of secretions causes periods of worsening symptoms and periods of stabilisation
Associated with MEN2
What are the symptoms of phaeochromocytoma?
Tachycardia Sweating Palpitations Tremor Pallor Anxiety Headache HTN
How is phaeochromocytoma diagnosed?
3 x24hr urine collections
-raised metadrenaline and normetadrenaline
MRI and CT to locate tumour
What is the management of phaeochromocytoma?
Alpha blockage with phenoxybenzamine
Once established then beta blocker too
Surgical excision of tumour
What is Addisonian Crises?
Also known as adrenal crises
Severely low cortisol
Either as 1st presentation or due to stress on body
What are features of Addisonian Crises?
Hypoglycaemia Hyponatraemia Hyperkalaemia N&V Fever Shock
How is Addisonian Crises managed?
IV fluids (5% dextrose or 0.9% saline)
IV hydrocortisone
Monitor electrolytes
