Adrenal disorders Flashcards
Name what they produce:
Zona Glomerulosa
Zona Fasiculata
Zona Reticularis
Zona Glomerulosa
- Aldosterone
Zona Fasiculata
- Cortisol
Zona Reticularis
- Androgens
Using the Hypothlamaic pituitary adrenal axis, describe the production of cortisol, aldosterone, and adrenal androgens
- Hypothalamus makes CRH + AVP
- ACTH is made from the pituitary gland
- Signals the adrenal glands to make cortisol, aldo, androgens
RAAS
- Adrenal gland makes aldosterone
- Signals the kidney to make Renin
- Renin converts Angiotensinogen (which is made in liver) to Angiotensin I
- ACE (in lungs) converts Angiotensin I to Angiotensin II
- AG II causes vasoconstriction (increase BP)
Causes of Primary Adrenal insufficiency
- Autoimmune:
- Infectious:
- Infiltrative
- Other
- Autoimmune:
- Addison’s dz - Infectious:
- TB, Fungi, HIV - Infiltrative:
- Amyloid - Other
- Hemorrhage
- Metastatic
- Metabolic
- Surgery
*All will result in lower amts of cortisol, aldo, androgens
Symptoms of Adrenal insufficiency
Non specific
- Fatigue, weakness, myalgias, arthralgias, anorexia, n/v, HA, abdominal pain, weight loss, postural dizziness, salt cravings
Signs of Adrenal insufficiency
SIgns of primary adrenal insufficiency
ALL:
- Hypotension, Tachycardia
Primary:
- Vitiligo, pigmentation
Labs of Adrenal insufficiency
- HYPERkalemia (primary only)
- HYPOnatremia
- HYPOglycemia
- Azotemia (high BUN + sr Creatinine)
- Anemia
- Eosinophilia
How to dx Primary adrenal insufficiency
- Serum cortisol
100 pg/ml - Adrenal CT Scan
Small: autoimmune, metabolic
Large: all other causes
Hashimoto’s thyroiditits (causing hypothyroidism) is it APS 1 or APS 2?
APS-2
HLA associated
Best imaging for adrenal insufficiency
CT
Small: autoimmune, metabolic
Large: all other causes
Secondary adrenal insufficiency is due to what?
- Glucocorticoids
- Opioids
- Tumor
- Surgery
- Radiation
- Infectious
- Hemorrhage
- Infiltrative
- Metastatic
*Low CRF, Low ACTH –>
Low cortisol, NL aldosterone (no hyperkalemia), low adrenal androgens
How to dx secondary adrenal insufficiency
Almost same as primary:
1. Serum cortisol
Tx for adrenal insufficiency
Glucocorticoid replacement
- Hydrocortisone
- Prednisone
- Dexamethasone
Mineralocorticoid Replacement
- Fludrocortisone
Triad of Primary aldosteronism
- HTN
- Hypokalemia
- Metabolic alkalosis
Two types of primary aldosteronism
- Aldosterone producing adenoma (APA)
34% - Idiopathic Hyperaldosteronism (IHA)
66%
Who to screen for primary aldosteronism?
Hypertensive patients with:
- Hypokalemia
- Severe HTN (>160/100)
- Resistant HTN
- HTN onset
Positive screen for primary aldosteronism
Confirming test
Positive screen: 1. Morning plasma aldosterone (PA) >15 ng/dl AND 2. PA/Plasma renin activity (PRA) ratio >20
Confirmation test:
- Oral salt load > 12 ug on urine aldosterone on 3rd day
- IV saline infusion(2L NS over 4 hrs)
Medication restriction for primary aldosteronism
Spirinolactone
- aldosterone antagonist
What is a surgical disease? What is medical management only?
APA vs IHA?
APA: surgical management is option
- start with abdominal CT scan
- If cant visualize, do adrenal vein sampling
IHA: medical management only
Direct aldosterone antagonist on kidney
Spirinolactone
Eplerenone
Tx for primary aldosteronism (APA)
preop: Aldosterone antagonist (spirin, epleren)
Adrenalectomy:
Laparoscopic/open
Tx for primary aldosteronism (IHA)
preop: Aldosterone antagonist (spirin, epleren)
BP medication:
CCB
ACE I
ARB
Pheochromocytoma triad (4)..
HTN +
HA +
Sweating +
Palpitation
Due to excess catecholamine production
Rule of 10s for pheochromocytoma
10% are malignant
10% are familial
10%are bilateral
10% are extra adrenal
Familial syndromes that can lead to pheochromocytoma
- MEN type 2A/2B
- Von Hippel Lindau Syndrome
- Neurofibromattosis Type I
- Familial paragangliomas (Succinyl dehydrogenase SDH mutation)
Who to screen for pheochromocytoma
Hypertensive patients with:
- SPells
- HA, sweating, palpitations - Severe HTN (>160/100)
- Resistant HTN (>2 drugs)
- Adrenal incidentaloma
- Familial syndrome
Best screening test for pheochromocytoma
Urine metanephrines and catecholamines
sensitivity 90%
specificity 98%
What can cause false positives for pheochromocytoma (cause elevated catecholamines)
- Levodopa
- Ethanol
- TCA
- Buspirone (antipsychs)
- Acetaminophen
- Amphetamines, Opioids
- Clonidine withdrawl
- Renal failure
- Sleep apnea
- Physical stress
Preop management for pheochromocytoma prior to adrenalectomy
Hypertensive, but hypovolemic (cant suddenly vasodilate them)
- Alpha blockers (1st)
- block norepi (Phenoxybenzamine, prazosin, terazosin, Doxazosin) - Beta blockers (2nd after alpha blockade)
- CCB (alone)
Tx effects:
- volume expansion, vasodilation, rate control
Cushing syndrome is due to what?
Exogenous steroids - most common cause
The rest are adenoma-like:
80% are due to ACTH secreting pituitary tumor (cushing disease)
- increase cortisol, NL aldosterone, increase adrenal androgens
- ACTH dependent cushing syndrome
10% is due to cortisol secreting adrenal tumor (not ACTH secreting)
- ACTH independent cushing syndrome
Symptomes of cushing syndrome
Signs
Santa Claus:
- facial plethora
- easy bruising
- Fatigue, weakness, HA, weight gain
Signs:
- HTN
- Central obesity
- Purple stretch marks
- Muscle weakness
- Thin skin
- Hirsutism
“cushingoid”
Cataracts, Ulcers, Skin: (striae, thinning, bruising), Hypertension/ hirsutism/ hyperglycemia, Infections, Necrosis, Glycosuria, Osteoporosis, obesity, Immunosuppression, and Diabetes
Lab findings for cushing syndrome
Hyperglycemia
Hyperlipidemia
- commonly caused by corticosteroids/excess cortisol
- need more E, gluconeogenesis, break down lipids - find in blood
Adrenal incidentaloma
Frequent finding on abdominal imaging
- usually benign
- usually non functioning
Benign vs malignant adrenal incidentaloma
benign
- High lipid CT scan (low HU)
- Low uptake FDG PET
Malignant tumor
- Low lipid (high HU)
- High uptake FDG uptake
Surgical Management of adrenal incidentaloma if…?
Surgical removal:
- size >4.5 cm
- Progressive growth
- Hormone secretion
*note: malignant adrenal tumors are ~ 6cm
