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Clin Med I - Endocrine > Adrenal Disease > Flashcards

Adrenal Disease Flashcards

1
Q

What hormones are produced by the adrenal cortex?

A

ZG: Mineralcorticoid, Aldosterone
ZF: Cortisol and Androgens
ZR: Under constant ACTH control “basal” secretion of cortisol (always some there just in case)

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2
Q

What is produced by the adrenal medulla?

A

Catecholamines: Epinephrine, Norepinephrine, Dopamine

These aren’t subject to hypothalamus action-required to act quickly

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3
Q

What do Mineralocorticoids stimulate?

A

Aldosterone stimulates sodium reabsorption = water retention and potassium excretion.

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4
Q

What are androgens excreted by the adrenal cortex precursors for?

A

testosterone and estrogen

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5
Q

What are adrenal medulla hormones responsible for?

A

catecholamines are responsible for fight or flight, sympathetic NS response. These are not under pituitary control, controlled by sympathetic NS via direct neural stim. Types:

  • norepinephrine
  • epinephrine
  • dopamine
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6
Q

Where is cortisol produced and what is it’s function?

A

Adrenal cortex
functions as another stress hormone.
receptors (glucocorticoid) are found in virtually all tissue functions as:
Stress response
Glucose metabolism (increases gluconeogenesis)
Regulates metabolism of proteins and fats
calcium homeostasis
suppresses immune response
Maintains circadian rhythm
peripheral vasc. tone
increases cardiac output

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7
Q

Diurnal excretion of cortisol?

A

cortisol is at it’s highest at 6:00am (when melatonin is lowest)
Cortisol is at it’s lowest at 12:00am (when melatonin is at it’s highest)

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8
Q

When is cortisol secreted?

A

Exercise and stress-increases C.O
Vascular tone-Increases Periph. resistance
Acute Trauma-regulates inflammation

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9
Q

What can occur if cortisol is given in excess or used chronically?

A 
HTN
Peptic ulcer
Decreased estrogen/testosterone
increased appetite
Decreased cognitive fxn.
euphoria
depression
irritability
Decreased immune response
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10
Q

Define Acute Adrenal insufficiency

A

Emergency caused by insufficient cortisol

Rapid tx is essential to save life (cardiac collapse)

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11
Q

What are the 2 types of adrenal insufficiency?

A

Primary (adrenal insufficiency)-adrenal failure to produce cortisol
Secondary (Pituitary insufficiency) -pituitary failure to produce sufficient ACTH

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12
Q

What is the MC cause of acute adrenal insufficiency?

A

Abrupt discontinuation of adrenocortical (prednisone)

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13
Q

What are possible triggers of latent adrenal insufficiency?

A 
Stress
Removal of hypercortisol secreting adrenal tumor w/suppression of other adrenal gland
Pituitary necrosis
Trauma
Adrenal hemorrhage
Anticoagulant (warfarin)
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14
Q

Clinical findings of Acute adrenal insufficiency

A

GI-abd pain/diarrhea, salt craving (mc in chronic)
Psych/neuro-HA, Confusion, coma/cerebral edema
Systemic-weakness, fever
CV-hypotension
Skin-hyperpig
Endocrine-Hypoglycemia
Lytes-hyponatremia, hyperkalemia,

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15
Q

Lab findings of Acute adrenal insufficiency

A

Low cortisol, and high ACTH, low aldosterone - dehydration and volume contraction

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16
Q

diagnostic tests for Acute adrenal insufficiency

A

-Co-synthropin ACTH stim test: After IM injection of co-synthropin, cortisol levels measured at 30 and 60,
Normal-~20mcg/dL
Abnormal (adrenal insuff)- < 20 mcg/dL because ACTH fails to tim adrenal glands.

-ACTH will also be very high because there is little or no negative feedback

17
Q

ddx for acute adrenal insufficiency

A

Shock
Hyperkalemia
hyponatremia

18
Q

tx for acute adrenal insufficiency

A

High index of suspicion-treat immediately!!!
Hydrocortisone (1st line)
Continuous IV saline 5% dextrose restore plasma volumen and hypoglycemia
tx infections empirically (don’t wait for cultures)
Rapid tx is essential and life saving!!!

19
Q

What is the most common cause of chronic adrenal insufficiency in the US?

A

Addison’s disease

20
Q

What are the causes of chronic adrenal insufficiency

A 
Addison's dz: autoimmune (idiopathic) - distraction of adrenal cortex
Infection-TB in developing nations
Fungal
Chronic use of steroids-blunting of ACTH/CRH response
Metastatic ca.
HIV
Iatrogenic (ketoconazole, steroids)
women>men
30-60yo
21
Q

t/f Addisons disease is characterized by HIGH ACTH and LOW glucocorticoid (cortisol)

A

T!

22
Q

signs and symptoms of chronic adrenocortical insufficiency

A

Intolerance to physical stress
constitutional sx-weakness, fatigue, low grade fever
skin-hyperpigmentation, creases
GI-anorexia, weight loss, abd. pain, Anorexia n/v, SALT craving, signs of dehydration
CV-Hypotension, orthostatic hypotension, shock, small heart
MSK-myalgias arthralgias
Neuro-delayed DTR’s, anxiety irritability
Psych-lethargy, confusion, psychosis

23
Q

diagnostics for chronic adrenocortical insufficiency

A

hpoglycemia
plasma ACTH elevated
Low serum sodium
Elevated potassium
Low plasma cortisol @8am w/ elevated plasma ACTH
antibodies for autoimmune dz
Co-synthropin (ACTH) stim test-failed adrenal response

24
Q

tx of chronic adrenocortical insufficiency

A

Replacement of glucocorticoids and mineralocorticoids

  • hydrocortison/prednisone-lowest effective dose to avoid Cushingoid s.e., increase dose at times of illness
  • Fludrocortison (aldosterone)-If there is hyponatremia, hypokalemia, dehydration, postural hypotension

Medical alert bracelet

25
Q

What disease is caused by adrenal excess?

A

Cushing’s dz.

26
Q

What is the cause of Cushing’s dz?

A

MC cause- Iatrogenic-chronic exposure to exogenous glucocorticoid such as prednisone

Adrenocortical tumors

non-pituitary ACTH secreting tumors (SCLCA)

Ectopic CRH

27
Q

What is the difference between Cushing’s dz and Cushing’s Syndrome?

A

Cushing disease refers to the excess pituitary secretion of ACTH (usually by a benign adenoma).
Cushing’s Sydrome is a subset of Cushing’s dz (40-70%) and is due to the hyercortisolism caused by either Cushing’s dz, or Adrenocortical tumors

28
Q

What are the two subcategories for Cushing’s syndrome?

A
  • ACTH dependendend hypercortisolim: Cushing’s Dz, non-pituitary secreting tumor, ectopic CRH
  • ACTH independent hypercortisolism: adrenocortical tumors
29
Q

signs and sx of Cushing’s syndrome:

A
  • Body fat maldistribution: Central obesity (90%), moon face, buffalo hump, Supraclavicular fat pads, thin extremities,
  • CV effects: HTN (85%)

-Endocrine effects: Decresed Glucose Tolerance (80%)
menstrual irregularity and infertility
masculinization in females (in ACTH dep.)-Hirsutism, virilzaiton, Hypogonadism in men and women

  • Const: Weakness
  • Lytes: K+excretion, Na+retention, CA++ loss
  • Immune: Immnosuppression
  • MSK: Prox muscle wasting, osteoporosis, aseptic necrosis of femoral head
  • Skin-purple straiae
30
Q

INITIAL labs diagnosis Cushing’s

A

24 hr urine free cortisol: 3 separate collections to dx Cushing’s

Late night salivary cortisol level (should be low at mid-night)

Low dose Dexamethasone (cortisol) suppression test:

  • Dexa 1mg at 1pm-check cortisol at 8am
  • Cortisol s because there was NO suppression with dexamethasone (further testing needs to be done to determine if CS or CD)
31
Q

FOLLOW UP labs and diagnosis of Cushing’s

A

High dose Dexa supression test.
Dexa 8mg at 11pm-check cortisol at 8am next day

Cushing’s disease (pituitary)
-level will result in >50% drop in cortisol baseline

NOT Cushing’s disease
-No or very mild cortisol suppression and cortisol and ACTH remain high (Ectopic ACTH tumor

ACTH must be measured after abnormal DEXA suppression test

32
Q

imaging for hypercortisolim (CS/CD)

A

Chest CT
Abdominal CT
Pituitary MRI

33
Q

DDX for Hypercortisolim

A

Alcoholism
pregnancy
Depression
Severe obesity

34
Q

tx of hypercortisolim

A

If caused by long term use of glucorticoid dosage is gradually reduced

Adrenal adenoma: adrenalectomy w/ prednisone replacement until other adrenal gland can take over

pituitary ademona: surgical resection / steroid replacement until pituitary recovers.

35
Q

What is 1st line for pituitary ademona tx?

A

Transsphenoidal surgery (newer technique q/ sterotactic radiosurgery or gamma knife)

36
Q

Complications of Cushings:

A

Visual field impairment
Death - d/t HTM, Diabetes, Infection
Osteoprosis, nephrolithiasis, psychosis

Clin Med I - Endocrine (6 decks)

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