Adrenal disease

Question 1

What is adrenal insufficiency

Answer 1

Adrenal gland doesn’t produce enough of hormones it is responsible for producing e.g. mineralo/glucocorticoids, androgens

Question 2

What are causes of primary adrenal insufficiency

Answer 2

Addison’s disease: autoimmune destruction of adrenal cortex giving decrease cortisol, aldosterone, and androgens

Congenital adrenal hyperplasia ?

TB, adrenal mets, and adrenal haemorrhage (Waterhouse-Friedrichsen syndrome) all cause primary adrenal insufficiency

Question 3

What are causes of secondary adrenal insufficiency

Answer 3

Decreased ACTH release e.g. iatrogenic steroid use interfering with HPA axis

Question 4

What are causes of tertiary adrenal insufficiency

Answer 4

Inadequate CRH

Question 5

What are Sx of adrenal insufficiency?

Answer 5

Anorexia and weight loss
Fatigue
Postural hypotension (due to decreased aldosterone): dizziness, low BP
Abdominal pain, D+V, nausea are common 
Salt craving 

Addison’s: skin pigmentation due to excess ACTH e.g. palmar creases, buccal mucosa

Question 6

What are risk factors for addisons?

Answer 6

Females
Autoantibodies, other autoimmune disease

Infections for adrenal insufficiency e.g. TB, meningitis, fungal,

Question 7

What are DDx for Addisons?

Answer 7

Other causes of adrenal insufficiency 
Haemochromatosis 
Hyperthyroidism 
Occult malignancy 
Anorexia

Question 8

What Ix in Addisons?

Answer 8

U+Es: low Na, high K.
Hypoglycaemia

Morning cortisol level: low
Short synacthen: measure cortisol before and after ACTH injection. In addisons, will be no change in cortisol post ACTH

ACTH increased

Renin increased, aldosterone decreased

Adrenal autoantibodies e.g. 21aOHase

Adrenal CT or MRI: once biochemical diagnosis confirmed, if cause is uncertain. Addisons, they may be small. Other causes they may be enlarged

Question 9

What is Rx of Addisons.

Answer 9

Hydrocortisone

Fludrocortisone

Patients should adhere to sick day rules are wear a steroid bracelet

Women may need DHEA replacement to help with libido

Question 10

What are complications of Addisons

Answer 10

Addisonian crisis (patients can present with this)

Tachycardia, postural hypotension, oliguria, confusion.

Patients nee IV hydrocortisone, IV fluid challenge, monitor blood glucose

Complications of steroid use e.g. osteopenia and OP, Cushing’s, hypertension

Question 11

What is phaeochromocytoma?

Answer 11

Tumour arising from catecholamine producing enterochromaffine cells of adrenal medulla (although 10% found ectopically e.g. aortic bifurcation)

Mostly benign, 10% malignant

Question 12

What are Sx of phaeochromocytoma?

Answer 12

Classical triad of headaches, diaphoresis, and palpitations in setting of paroxysmal hypertenion +/- tachycardia

Also SOB, visual disturbance, tremor, anxiety, abdominal pain

Question 13

What genetic syndromes are phaeochromocytoma associated with?

Answer 13

MEN2

Von-Hippel-lindau

Question 14

What Ix in phaeochromocytoma?

Answer 14

Bloods: U+Es etc

24 hour urinary catecholaemines, metanephrine, normetanephrines, and Cr (also in serum)

imaging: abdominal CT or MRI for tumour

Chromaffin cell radioisotope uptake scan can be done

Genetic testing for familial

Question 15

What is Rx for phaeochromocytoma?

Answer 15

Alpha blockade e.g. phenoxybenzamine and beta blocker to reduce BP, then laparoscopic adrenalectomy

If not fit for surgery, long term antihypertensives

Malignant tumours may need chemo or localised radiotherapy

Question 16

What is primary hyperaldosteronism? (Conn’s)

Answer 16

Excessive production of aldosterone, irrespective of RAAS, causing increased Na and water retention

Question 17

What is pathophys of hyperaldosteronism?

Answer 17

Increased Na reabsorption of Na via ENAC in distal nephron, causing hypertension and RAAS suppression

Urinary loss of K and H (exchanged for Na) causes metabolic alkalsosis and hypokalaemia

Question 18

What are Sx of primary hyperaldosteronism?

Answer 18

Usually none. May be Sx of hypokalaemia, weakness cramps and parasthesia, polyuria, polydipsia

Question 19

What are causes of primary hyperaldosteronism?

Answer 19

Adenoma or bilateral hyperplasia of adrenal cortex

Question 20

What Ix in primary hyperaldosteronism?

Answer 20

Hypertension, hypokalaemia, and alkalosis is classical finding.

Saline suppression test: give 2L saline over 4 hours and if aldosterone is still high, likely Conn’s

Aldosterone-renin ratio: raised

Fludrocortisone suppression test

CT to see if adenoma or bilateral adrenal hyperplasia

Question 21

What is Rx of primary hyperaldosteronism?

Answer 21

Surgery: adrenalectomy

Spironolactone post-op

MR antagonists e.g. spironolactone, eplerenone, amiloride