Adrenal disease Flashcards

1
Q

Function of adrenal cortex

A

Glomerulosa-
Mineralocorticoid production: aldosterone.
- Increases fluid abnormal, controls Na and K balance.

Fasciculata-
Glucocorticoid production: cortisol
- Increases fat, carb and protein metabolism.

Reticularis-
Androgen production: DHEA, DHEA-S, androstenedione
- Development of secondary sex organs.

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2
Q

Adrenal cortex control

A

Hypothalamus releases CRH to anterior pituitary.

Anterior pituitary releases ACTH to adrenal cortex
- Stimulates release of cortisol, aldosterone and androgens.

Increase in corticosteroids suppresses release of ACTH and CRH.

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3
Q

Primary adrenal insufficiency

- Definition

A

Addison’s disease
- Low cortisol and mineralocorticoid release due to destruction of adrenal cortex.

Causes

  • Autoimmune destruction (most common)
  • TB
  • Adrenal metastasis
  • Adrenal haemorrhage
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4
Q

Investigations for adrenal insufficiency

A

FBC

  • Anaemia
  • Eosinophilia

U+E

  • Hyponatraemia
  • Hyperkalaemia
  • Uraemia

Calcium
- Hypercalcaemia

Glucose
- Hypoglycaemia

SynACTHen test

  • Measure cortisol before and 0.5 hours after synACTH.
  • Exclude Addison’s if cortisol >550nmol/L

9am ACTH
- Will be high (>300ng/L) due to no negative feedback

21-hydroxylase adrenal autoantibodies
- Positive in autoimmune

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5
Q

Addison’s treatment

A
  1. Replacement
    - Hydrocortisone (15-25mg in 2-3 doses)
  • Fludrocortisone PO (50-200 micrograms)

Do not stop steroids abruptly due to addisonian crisis risk. Must be weened off

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6
Q

Secondary adrenal insufficiency

  • Definition
  • Causes
A

Suppression of adrenal corticosteroid release arising from a non-adrenal cause.

Excess stimulation of pituitary/ hypothalamus can inhibit CRH/ ACTH release.

Causes

  • Long term steroid use.
  • Hypothalamus/ pituitary tumour.
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7
Q

Addisonian crisis

  • Signs and symptoms
  • Causes
A

Signs and symptoms that arise from lack of corticosteroid production (aldosterone and cortisol)

Signs and symptoms

  • Abdominal pain
  • Vomiting and nausea
  • Dizziness and fatigue

Causes

  • Untreated addison’s
  • Abrupt cessation of long term steroids.
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8
Q

Cushing’s syndrome

  • Definition
  • Features
A

Excess of cortisol, leading to the loss of negative feedback control.
- Produces syndrome of signs and symptoms

Features

  • Weight gain, central obesity, moon face, buffalo neck lump
  • Supraclavicular fat
  • Mood changes
  • Proximal weakness
  • Increased risk of infectiion
  • Poor healing
  • Gonadal dysfunction
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9
Q

Cushing’s syndrome

- Causes

A

Prolonged oral corticosteroid use

Cushing’s disease
- Pituitary adenoma

Ectopic ACTH production

Adrenal dysfunction
- Adenoma/ carcinoma

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10
Q

Investigations into Cushings

A

Overnight Dexamethasone suppression test

  • Serum cortisol elevated
  • High dose dexamethsone identifies if cortisol stimulation is external of pituitary (ectopic ACTH)

24 urinary free cortisol

Pituitary MRI

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11
Q

Adrenal insufficiency

- Presentation

A

Symptoms

  • Fatigue, weakness, malaise
  • Weight loss/ anorexia
  • Dizziness/ faint
  • Tanned skin
  • Abdominal pain, vomitting, nausea

Signs

  • Dehydration
  • Hyperkalemia, hyponatraemia
  • Hypoglycaemia
  • Postural hypotension
  • Pigmented palmar creases (due to ACTH increase)
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12
Q

Adrenal insufficiency

- Investigations

A

SynACTHen test
- Cortisol levels will not raise signficantly

9am ACTH
- Elevated

Bloods
U+Es
- Hyperkalaemia
- HypoNa+
- Glucose= low
- HyperCa2+
- FC: anaemia, eosinohilia
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13
Q

Addison’s management

A

Replacement therapy

  • Hydrocortisone (cortisol)
  • Fludrocortisone (mineralocorticol)

Do not stop steroid abruptly
- Wean off due to risk of crisis

For injury, illness/ stress
- Double steroid doses

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14
Q

Primary aldosteronism

  • Definition
  • Causes
  • Presentation
A

Excess aldosterone production independent of RAAS
- Causes Na+ and water retention

Causes

  • Conn’s syndrome= adrenal, aldosterone producin adenoma
  • Adrenal carcinoma

Presentation

  • Hypertension
  • Hypokalaemia: weakness, cramps, paraesthesiae
  • Alkalosis
  • Polydipsia/ polyuria
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15
Q

Primary hyperaldosteronism

- Investigations

A

Bloods

  • U+Es: hypokalaemia
  • Renin= depressed (affected by diuretics, hypotensivves, steroids)

Genetic testing

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16
Q

Hyperaldosteronism management

  • Conn’s syndrome
  • Hyperplasia
  • Carcinoma
A

Conn’s syndrome

  • Adrenalectomy (Lap)
  • Spiro pre-op

Hyperplasia
- aldosterone inhibitors: spiro/ amiloride/ eplerenone

Carcinoma
- Surgery

17
Q

Secondary hyperaldosteronism

  • Definition
  • Causes
A

High levels of renin due to decreased renal perfusion
- Causes increase of aldosterone

Causes

  • RA stenosis
  • Diiuretics
  • CCF
  • Hepatic failure