Adrenal Disease

Question 1

What are the three zones of the adrenal cortex?

Answer 1

Zona glomerulosa
Zona fasciculata
Zona reticularis

Question 2

What is the role of the zona glomerulosa?

Answer 2

Aldosterone

Question 3

What is the role of the zona fasciculata?

Answer 3

Cortisol

Question 4

What is the role of the zona reticularis?

Answer 4

Adrenal androgens (DHEA, DHEA-S)

Question 5

What are the imaging findings for an adrenocortical adenoma?

Answer 5

< 3 cm, homogenous, <10 hounsfield units

Question 6

What investigations should be done for an adrenal mass?

Answer 6

on contrast CT adrenals, dexamethasone suppression test, aldosterone-renin ratio, fasting plasma metanephrines

Question 7

What is the management for a non functioning benign adrenal adenoma < 4cm?

Answer 7

No further ix/rx

Question 8

What is the management for an indeterminate adrenal mass by imaging?

Answer 8

Interval imaging or adrenalectomy

Question 9

What is the management for a likely malignant adrenal mass?

Answer 9

Adrenalectomy (laparoscopic if non invasive open if invasive)

Question 10

Are adrenal biopsies done?

Answer 10

No – risk of spread of ACC

Question 11

What is the most likely cause of bilateral adrenal tumours?

Answer 11

CAH (21 hydroxylase deficiency)

Question 12

What are the chracateristic features of adrenocortical carcinoma?

Answer 12

2 hormone excess, flank mass with pain

Question 13

What drug is used to treat adrenocortical carcinoma?

Answer 13

Mitotane

Question 14

What are the common symptoms of adrenal insufficiency?

Answer 14

Fatigue, nausea, weight loss, postural dizziness, hyperpigmentation

Question 15

Why do patients with secondary adrenal insufficiency not have hyperpigmentation?

Answer 15

Because hyperpigmentation is due to elevated ACTH which is not elevated in secondary adrenal insufficiency

Question 16

Do patients with secondary adrenal insufficiency have hyperkalaemia?

Answer 16

No because the zona glomerulosa is not involved whereas it is involved in primary adrenal insufficiency

Question 17

Do patients with secondary adrenal insufficiency have hyponatraemia?

Answer 17

Yes

Question 18

What are the clinical features of adrenal crisis?

Answer 18

Shock, syncope, abdominal pain, back and leg pain, delirium, obtundation, hyponatraemia, hyperkalaemia, hypoglycaemia, hypercalcaemia

Question 19

At what time of day is the cortisol peak and trough?

Answer 19

Peak at 8am trough at midnight

Question 20

What are the types of adrenal insufficiency?

Answer 20

Primary (adrenal)
Secondary (pituitary)
Tertiary (hypothalamus)
Exogenous (glucorticoids)

Question 21

What is the antibody in autoimmune addison’s disease?

Answer 21

21-hydroxylase antibody

Question 22

What investigations should be done for adrenal insufficiency?

Answer 22

21-hydroxylase antibody (in all patients over 6 months)
17-hydroxylase-progesterone (to diagnose CAH)
very long chain fatty acids (in males if antibody negative to diagnose adrenoleukodystrophy)
CT adrenals (if antibody negative)

Question 23

What are the main causes of primary adrenal insufficiency?

Answer 23

Autoimmune adrenal failure
Tuberculosis
Metastatic disease
Granulomas
Adrenal haemorrhage
Adrenoleukodystrophy
CAH
Congenital adrenal hypoplasia
ACTH resistance

Question 24

What are the main causes of secondary adrenal insufficiency?

Answer 24

Pituitary tumours
Other tumours of hypothalamic-pituitary region
Pituitary irradiation
Lymphocytic hypophysitis (pregnancy)
Isolated congenital ACTH deficiency (rare, genetic)

Question 25

What is the treatment of adrenal insufficiency?

Answer 25

Hydrocortisone (approx. 15-25mg per day) Or cortisone acetate (approx. 25-37.5mg per day) Usually given BD or TID PLUS fludrocortisone (50-300microg daily)

Question 26

What is the role of the 21-hydroxylase enzyme?

Answer 26

Involved in the pathways converting cholesterol to aldosterone and to cortisone

Question 27

Why do patients with a 21-hydroxylase deficiency have hirtsuitism?

Answer 27

Because the pathways are shunted to produce excess adrenal androgens

Question 28

Which patients should be screened for primary aldosteronism?

Answer 28

Severe HTN, hypokalaemia

Question 29

What is the screening test for primary aldosteronism?

Answer 29

Aldosterone renin ratio

Question 30

What things can alter the results of aldosterone renin ratio?

Answer 30

Diuretics, beta blockers, spironolactone, amiloride, eplerenone, renal impairment

Question 31

What is the diagnostic test for primary aldosteronism?

Answer 31

Seated saline suppression test | If have primary aldosteronism the renin will be suppressed but not the aldosterone

Question 32

How is unilateral vs bilateral primary aldosteronism differentiated?

Answer 32

Adrenal vein sampling

Question 33

What is the treatment of primary aldosteronism?

Answer 33

Medical (amiloride, spironolactone, eplerenone) | Surgical

Question 34

What are the examination findings of cushings?

Answer 34

Moon facies, bruising, striae, hirsuitism, central obesity, buffalo hump

Question 35

What are early features of cushings?

Answer 35

Central weight gain, hypertension, hyperglycaemia, hypertriglyceridaemia, oligomenorrhea, hirsuitism, mood changes

Question 36

What are the late features of cushings?

Answer 36

Thin skin, weakness, osteoporosis, infection

Question 37

What are the physiological causes of increased cortisol?

Answer 37

Stress (infection, trauma, psychological) Starvation Pregnancy

Question 38

What are the causes of cushings?

Answer 38

Pituitary Ectopic ACTH Adrenal tumour

Question 39

What tests are done for suspected cushing’s?

Answer 39

24 hour urinary free cortisol overnight dexamethasone suppression test late night salivary cortisol

Question 40

What investigations should be done to find out the type of cushings?

Answer 40

Plasma ACTH Adrenal imaging Pituitary MRI