adrenal diseases

Question 1

What would you think if a female patient presents with hypertension, central obesity and purple striae?

Answer 1

Cushings

Question 2

What is the most common screening tool for cushings?

Answer 2

1mg overnight dexamethasone suppression test– 1 mg dex at 11PM, 8AM cortisol level- <2mcg/dl is normal

Question 3

What are two other screening tests for cortisol?

Answer 3

24 hour urine free cortisol level

Midnight salivary cortisol level

Question 4

What do you think when you see hypertension with hypokalemia?

Answer 4

hyperaldosteronism

Question 5

What are the two etiologies of hyperaldosteronism?

Answer 5

adenoma or bilat hyperplasia

Question 6

What is a positive screening test for hyperaldosteronism?

Answer 6

aldosterone/renin ratio >30 with pt not taking diuretics, beta blockers, nifedipine

Question 7

What are the two localizing tests used to identify the cause of hyperaldosteronism?

Answer 7

CT scan- sensitive but not specific since nodules are common in patients >40 years old Bilateral adrenal vein sampling- aldo/cort Iodocholesterol scans

Question 8

What are the treatments for hyperaldosteronism?

Answer 8

Surgical– laparoscopic adrenalectomy Medical– spironolactone, amiloride, epleronone

Side note: spironolactone causes gynecomastia

Question 9

Hypertension with abdominal bruit?

Answer 9

renal artery stenosis

Question 10

what does renal artery stenosis lead to?

Answer 10

secondary hyperaldosteronism

Question 11

In secondary hyperaldosteronism, is renin high or low?

Answer 11

high! As opposed to primary where it is low compared to aldosterone (30:1)

Question 12

Hypertension with Headaches, Sweats, and Palpitations?

Answer 12

pheochromocytoma

Question 13

are a-receptors more sensitive to norepi or epi? What does this cause internally?

Answer 13

NE > Epi

Arteriolar constriction
Sweating

Question 14

are b-receptors more sensitive to norepi or epi? What does this cause internally?

Answer 14

EPI > Norepi

Arteriolar dilatation
increased contractility / rate
increased BG (blood glucose)

Question 15

What will you see in more than 98% of people with pheochromocytoma?

Answer 15

a change in blood pressure….could be in the form of the following:
Sustained HTN
Paroxysmal HTN
Orthostatic change
Paradoxal change in BP:from b-blockers, anesthesia

Question 16

what are some other signs?

Answer 16

Tachycardia / Arrhythmia / CHF / Shock

Facial pallor / tremor

Question 17

what is the most common screening test for pheochromocytoma?

Answer 17

24 hour urine catechols, . metanephrines, or VMA

Question 18

What are two other screening tests?

Answer 18

Plasma fractionated metanephrine

Clonidine suppresion test

Question 19

what are localizing tests for pheochromocytoma?

Answer 19

MRI (best) or CT

MIBG Scan- nuclear medicine test

Question 20

What do you administer pre-op for pheochromocytoma?

Answer 20

Selective a1 –blockade: Doxazosin & Prazosin

Less reflex tachycardia
Shorter T½
Less postoperative hypotension

Question 21

What is the most common cause of Addison’s disease? other causes?

Answer 21

autoimmune disorder- most common but still very rare

Tuberculosis
HIV, CMV
Ketoconazole rx
Adrenal hemorrhage– heparin, meningococcemia

Question 22

In Addison’s disease, of the following, which will increase and which will decrease? Cortisol, ACTH, aldosterone, K+, Na+, b.p.

Answer 22

cortisol (dec.) ACTH (inc.) aldosterone (dec.) K+ (inc.) Na+ (dec.) b.p. (dec.)

Question 23

what are some other autoimmune diseases seen with Addison’s disease?

Answer 23

vitiligo, hypothyroidism, pernicious anemia, type 1 diabetes, hypoparathyroidism

Question 24

What test is used to diagnose Addison’s disease?

Answer 24

Cortrosyn stimulation test—to test how well adrenals respond to ACTH administration. subnormal cortisol level at 30 minutes («18 mcg/dl

Question 25

What are the treatments for Addison’s disease?

Answer 25

Prednisone 5/2.5 or cortisone 25/12.5
Fludrocortisone 0.1 mg qd
Increased steroids during severe stress– hydrocortisone 100 mg IV q8h

Question 26

Are adrenal masses common as incidental findings on CT, MRI, echo?

Answer 26

yes

Question 27

What are the four possibilities you are thinking if you find an adrenal incidentaloma?

Answer 27

adrenal adenoma, adrenal carcinoma, pheo, metastasis

Question 28

when would you biopsy an incidentaloma?

Answer 28

If the pt. has another known primary tumor to r/o metastases

Question 29

when would surgery be indicated?

Answer 29

if the mass is >4 cm or enlarging