Adrenal Diseases

Question 1

What are the histological layers of the adrenal gland from superficial to deep?

Answer 1

Zone Glomerulus - Mineralocorticoid - Aldosterone
Zona Fasciculata - Glucocorticoids - Cortisol
Zone Reticularis - Androgens
Adrenal Medulla - Catecholamines - adrenaline / noradrenaline

Question 2

What are the functions of cortisol?

Answer 2

Protein and carb metabolism
Increase insulin resistance
supresses immune response
Upregulates A1 on arterioles - vasoconstriction
increase osteoclast activity

Question 3

What is the function of aldosterone

Answer 3

salt and water homeostasis

Question 4

What is Conn’s Syndrome

Answer 4

Primary hyperaldosteronism - independent of RAAS activations

Causes:
Idiopathic - 80%
Adrenal adenoma causing excessive release of aldosterone

Question 5

What is secondary hyperaldosteronism

Answer 5

Excess release of aldosterone due to abnormal RAAS activations

Causes: Aortic stenosis, HF, renal artery stenosis

Question 6

What would increased aldosterone do?

Answer 6

Increase water reuptake = Increased sodium reuptake + K+/H+ excretion
= Hypokalaemia and secondary HTN

Question 7

How would someone with conns syndrome present?

Answer 7

Sign
Refractory HTN

Symptoms:
Hypokalemia: Lethargy, Mood disturbance, Paraesthesia , Muscle cramps
Polydipsia

Question 8

Conns Syndrom DX

Answer 8

Renin: Aldosterone ratio:
Primary hyperaldosteronism - Low:High ———-> CT Abdomen
Secondary hyperaldosteronism - High:High ————> Doppler US

Serum U/E - Hyperatremia, Hypokalemia (ECG - LONG PR, U WAVE, INVERTED ST)

+ Serum aldosterone not supressed w/saline

Question 9

Conns Syndrome TX

Answer 9

Singular adrenal affected - Laparoscopic adrenalectomy
Bilateral hyperplasia - - Spironolactone - Aldosterone antagonist

Question 10

What is adrenal insufficiency and list possible causes?

Answer 10

Significant reduction in mineralocorticoid and glucocorticoid release as a consequence of adrenal destruction

Primary cause - ACTH Independant
In developed world - Addison’s disease - Autoimmune Anti-21hydroxylase Ab
In developing world - TB

Secondary Cause - HPA Suppresions
Steroid use

Question 11

What are the SX of adrenal insufficiency

Answer 11

LEAN TANNED TIRED AND TEARFUL

SX
lethargy / weakness
nausea/ vomiting
wt loss

Signs
postural hypotension
hyperpigmentation (addisons)

Question 12

Why do you get tanning only with primary adrenal insufficiency?

Answer 12

ACTH stimulates melanocyte’s - underlying cause behind hyperpigmentation

In primary - ACTH is high / Adrenals secretions is low

In secondary - ACTH is low / Adrenal secretions is low

Question 13

Addisons DX

Answer 13

1st - U/E -Hyperkalemia, hyponatremia, hypoglycemia
Morning cortisol level - low in Addison’s

Short SyncACTHen Test - syncathen ACTH analogue
- Cortisol level before/after: Addison - Cortisol level LOW

Adrenal Ab
Aldosterone:Renin DOWN

Question 14

ADDISONS TX

Answer 14

Replace hormones
Mineralocorticoids- Fludrocortisone
Glucocorticoids - hydrocortisone

Double dosage of hydrocortisone if acutely unwell

Question 15

What an adrenal/addisonian crisis

Answer 15

Occurs in ~40% of patients - Acute insufficiency of adrenal hormones

Question 16

What can cause an adrenal crisis?

Answer 16

Steroid withdrawal
severe dehydration
sepsis (Waterhouse friederichsen syndrome)

Question 17

How would adrenal crisis presenty?

Answer 17

Acute onset of sx
N/V
Abdo pain

Hypovolemic shock
Hypotension
Reduced GCS

Question 18

How would an adrenal crisis present

Answer 18

Well due to reduced aldosterone = more h20/na excretion + K+/H+ absorbtion

U/E = Hypovolemia, hyponatremia, hyperkalemia, Metabolic acidosis
ECG - Flatp P, Wide QRS, Tall tented T wave, long PR

Question 19

Treating adrenal crisis?

Answer 19

Double hydrocortisone
IV Fluid
Dextrose if hypoglycaemic