Adrenal Disorders Flashcards
Hypercortisolism can be used interchangeably with the term
Cushing syndrome
Cushing disease meaning
pituitary overproduction of ACTH
Hypercortisolism can also be from the ectopic production of ACTH from
_________ or from overproduction_______.
carcinoid or cancer
autonomously in the adrenal gland
Etiology of Hypercortisolism
Pituitary ACTH (Cushing disease) 70%
Adrenals 15%
Ectopic ACTH (cancer, carcinoid) 10%
Unknown source of ACTH 5%
men and woman particular cxfx of Hypercortisolism
Osteoporosis
Menstrual disorders in women
Erectile dysfunction in men
Due to inhibition of calcitriol synthesis by cortisol
Hypercortisolism results in inhibition of gonadotropin release
renal cxfx of Hypercortisolism
Polyuria: from hyperglycemia and increased free water clearance
neurological cxfx of Hypercortisolism
Cognitive disturbance: from decreased concentration to psychosis
Hypercortisolism the 2 Dx phases
- Establish the Presence of Hypercortisolism
2. Establish the Cause of Hypercortisolism
Hypercortisolism best initial test
24- hour urine
cortisol.
If this is not in the choices, then the answer is the 1 mg overnight
dexamethasone suppression test. THO this can give false +
“Low then high” low=low dose dexa supp. ACThen
The 1 mg overnight dexamethasone
suppression test should normally ______. If this
______ occurs, hypercortisolism can be excluded.
suppress the morning cortisol level
suppression
Causes of false positive 1 mg overnight suppression testing:
Depression
Alcoholism
Obesity
best initial test to determine the cause (source) or location of hypercortisolism
ACTH
Decreased ACTH level = adrenal source
ACTH level is elevated, the source could be from:
Pituitary (suppresses with high dose dexamethasone)
Ectopic production: lung cancer, carcinoid (dexamethasone does not
suppress)
You must always confirm the source of hypercortisolism with ______before you perform imaging studies. and why
biochemical tests
At least 10% of the population has an abnormality of the pituitary on
MRI. If you start with a scan, you may remove the pituitary when the
source is in the adrenals.
Once the ACTH level is elevated and does not suppress with high dose
dexamethasone, what to do?
scan the brain with an MRI.
what to do if If the MRI does not show a clear
pituitary lesion,
sample the inferior petrosal sinus for ACTH, possibly after
stimulating the patient with corticotropin-releasing hormone (CRH).
An elevated ACTH from the venous drainage of the pituitary ______the pituitary as the source.
confirms
The petrosal venous sinus must be sampled because
some pituitary lesions are too small to be detected on MRI
If the ACTH is elevated, and you cannot find a defect in the pituitary either by MRI or by sampling the petrosal sinus, what to do
scan the chest looking for an ectopic source of ACTH production.
Effects of hypercortisolism over glicemia lipids K pH Leukocytes
Hyperglycemia Hyperlipidemia Hypokalemia Metabolic alkalosis Leukocytosis from demargination of white blood cells
why is there Hypokalemia and metabolic alkalosis in hypercortisolism
there is some
aldosteronelike effect of cortisol that has an effect on the kidney’s distal tubule
of excreting potassium and hydrogen ions.
Hypercortisolism Tx
Surgically remove the source of the hypercortisolism
what kind of Qx treat Hypercortisolism
Transsphenoidal surgery
is done for pituitary sources
aparoscopic removal is done for adrenal
sources
what to do if Qx unsuccessful to treat Hypercortisolism
use pasireotide, which is a somatostatin
analog.
Pasireotide controls unresectable pituitary ACTH overproduction.
When hypercortisolism cannot be cured with surgery, give
mifepristone.
Mifepristone inhibits cortisol receptors throughout the body.
When adrenal
cancer cannot be fully resected or there is metastatic disease that can’t be
identified, give
mitotane.
an inhibitor of steroidogenesis that is also cytotoxic to adrenal tissue.
Mitotane cleans up adrenal cancer mets!
