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Adrenal disorders Flashcards

1
Q

How does the adrenal gland develop embryologically?

A

Fetal medulla becomes encapsulated by fetal cortex

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2
Q

What is hyperaldosteronism?

A

Excess production of aldosterone by zona glomerulosa in adrenal glands

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3
Q

How are the causes of hyperaldosteronism categorised? What do they mean?

A

Primary - problem with adrenal cortex

Secondary - overactivity of RAAS

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4
Q

What are the causes of primary hyperaldosteronism? Which is the most common?

A

Bilateral idiopathic adrenal hyperplasia - most common

Conn’s syndrome

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5
Q

What is Conn’s syndrome?

A

Adrenal adenoma

secretes aldosterone

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6
Q

What are the causes of secondary hyperaldosteronism?

A

Renal artery stenosis

Renin producing tumour e.g juxtaglomerular tumour

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7
Q

How do you differentiate between primary and secondary hyperaldosteronism?

A

Primary
low renin levels
high aldosterone:renin ratio

Secondary
high renin levels
low aldosterone:renin ratio

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8
Q

What are the signs of hyperaldosteronism?

A

Hypertension

Hypernatraemia

Hypokalaemia

LV hypertrophy

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9
Q

How is hyperaldosteronism treated?

A

Conn’s syndrome - adrenal adenoma removed by surgery

Bilateral idiopathic adrenal hyperplasia + overactivity of RAAS - spironolactone

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10
Q

What does spironolactone do?

A

Mineralocorticoid receptor antagonist

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11
Q

What is Cushing’s syndrome?

A

Increased secretion of glucocorticoid cortisol

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12
Q

How are the causes of Cushing’s syndrome categorised?

A

External causes

Endogenous causes

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13
Q

What is the external cause of Cushing’s syndrome?

A

Prescribed glucocorticoids

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14
Q

What are the endogenous causes of Cushing’s syndrome?

A

Cushing’s disease

Adrenal Cushing’s

Non pituitary-adrenal tumours producing ACTH or CRH

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15
Q

What is Cushing’s disease?

A

Pituitary adenoma

secretes ACTH

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16
Q

What is Adrenal Cushing’s?

A

Adrenal tumour

produces excess cortisol

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17
Q

What is an example of a non pituitary-adenoma tumour that produces ACTH or CRH?

A

Small cell lung cancer

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18
Q

How do you differentiate between Adrenal cushing’s and Cushing’s disease/non pituitary-adrenal tumour?

A

Adrenal cushing’s - low ACTH
by negative feedback from excess cortisol

Cushing’s disease/non pituitary-adrenal tumour - high ACTH
being secreted by the tumour

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19
Q

What is the most common cause of Cushing’s syndrome?

What is the most rare cause?

A

Most common - external cause, prescribed glucocorticoids

Most rare - endogenous causes, non pituitary-adenoma tumour secreting ACTH or CRH

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20
Q

What are the signs and symptoms of Cushing’s syndrome?

A

Round pink face

Abdominal obesity

Buffalo hump

Skinny arms and legs

Purple striae on abdomen

Hypertension

Hyperglycaemia

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21
Q

What causes the pink round face in Cushing’s syndrome?

A

Redistribution of fat to face

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22
Q

What causes the abdominal obesity in Cushing’s syndrome?

A

Resdistribution of fat to abdomen

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23
Q

What causes the buffalo hump in Cushing’s syndrome?

A

Redistribution of fat to dorso-cervical fat pads

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24
Q

What causes the purple-striae on the abdomen in Cushing’s syndrome?

A

Cortisol stimulates proteolysis
proteins in skin break down, skin becomes thinner
leading to easy bruising

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25
What causes the skinny arms and legs in Cushing's syndrome?
Cortisol stimulating proteolysis in muscles | get wasting of muscles
26
What causes the hypertension in Cushing's syndrome?
High levels of cortisol may bind to aldosterone receptors gives sodium and water retention
27
What causes the hyperglycaemia in Cushing's syndrome?
Excess cortisol over-stimulates gluconeogenesis in liver
28
How is Cushing's syndrome treated?
External causes - reduce dosage gradually, don't stop suddenly Endogenous causes - surgically remove the tumour
29
What is Addisons's disease?
Condition of chronic adrenal insufficiency
30
What are the causes of Addison's disease? Which is the most common cause?
Autoimmune destruction of adrenal cortex - most common cause Infection - TB, fungal Infiltration - amyloid, haemachromatosis Malignancy Genetic - congenital adrenal hyperplasia Vascular - haemorrhage, infarction Iatrogenic - adrenalectomy, drugs
31
What are the symptoms and signs of Addison's disease?
Lethargy Anorexia Weight loss Postural hypotension - dizziness Increased skin pigmentation Hypoglycaemia
32
Why is there increased skin pigmentation in Addison's disease?
Decreased cortisol reduced negative feedback on anterior pituitary increased production of ACTH requires POMC broken down into ACTH and MSH (melanocyte stimulating hormone) MSH binds to melanocrotin receptors on melanocytes ACTH itself can bind to these and contribute
33
How is Addison's disease treated?
Lifelong glucocorticoid replacement e.g. hydrocortisone Lifelong mineralocorticoid replacement e.g. fludrocortisone
34
How can Addisonian's crises be prevented?
Increase dose of glucocorticoid replacement at times of stress e.g. illness because cortisol would naturally increase If vomiting, use injection instead of tablets because can't absorb tablets
35
What is an Addisonian crisis?
Life-threatening emergency | caused by adrenal insufficiency
36
What can trigger an Addisonian crisis?
Severe stress - trauma - infection - over exertion - abrupt steroid drug withdrawal
37
Why do Addisonian crises occur?
Cortisol is too low to cope with the stress
38
What are the signs and symptoms of Addisonian crisis?
Nausea, vomiting Fever Hypotension Vascular collapse
39
How is Addisonian's crisis treated?
Rehydration with fluids IV hydrocortisone - cortisol replacement Correction of hypoglycaemia
40
What inheritance pattern does congenital adrenal hyperplasia show?
Autosomal recessive
41
What is the cause of congenital adrenal hyperplasia?
Defect in 21-hydroxylase enzyme
42
What are the consequences of a lack of the enzyme 21-hydroxylase?
Low glucocorticoids e.g. cortisol Low mineralocorticoids e.g. aldosterone High androgens e.g. testosterone pathway redirected to here
43
How does congenital adrenal hyperplasia present?
Hypoglycaemia Hypotension Hyponatraemia Hyperkalaemia Virilisation - male characteristics ambiguity of genitalia
44
How is congenital adrenal hyperplasia managed?
Treat addisonian crisis Long term replacement of glucocorticoids, mineralocorticoid Determine sex of baby
45
What is a phaeochromocytoma?
Tumour of the adrenal medulla chromaffin cells secretes catecholamines, mainly noradrenaline
46
What is a paraganglioma?
Extra-adrenal tumour | chromaffin tissue origin
47
What are the symptoms of phaeochromocytoma and paraganglioma?
Severe hypertension Palpitations arrythmias Diaphoresis - excessive sweating Hyperglycaemia Weight loss Headaches
48
How are phaeochromocytomas and paragangliomas managed?
Alpha blockers - phenoxybenzamine Beta blockers
49
In which order should alpha and beta blockers be given? Why?
Alpha before beta | Because otherwise get vasoconstriction only, makes hypertension worse
50
What tests are done when an adrenal hormone deficiency is suspected?
Electrolytes 9am cortisol Stimulation test
51
What is the stimulation test for cortisol deficiency?
Inject synthetic ACTH, called synacthen Cortisol should increase in response
52
What are the test results when there is an adrenal hormone deficiency?
Electrolytes - hyponatraemia, hyperkalaemia 9am cortisol - low Stimulation test - cortisol remains low
53
What are the tests done when an adrenal hormone excess is suspected?
Electrolytes Midnight cortisol Suppression test
54
What is the suppression test for excess cortisol?
Give dexamethasone steroid drug Should negatively feedback on anterior pituitary, decreasing ACTH secretion Cortisol should decrease
55
What are the test results when there is an adrenal hormone excess?
Electrolytes - hypernatraemia, hypokalaemia Midnight cortisol - high when it should be low Suppression test - cortisol remains high
56
What tests are done to assess adrenal medulla function?
24h urine catecholamimes e.g. adrenaline, noradrenaline 24h urine metanephrines Plasma metanephrines
57
What are metanephrines?
Metabolites of adrenaline and noradrenaline Called metadrenaline and normetadrenaline
58
What are the test results of adrenal medulla function with phaeochromocytoma?
24h urine catecholamines - high 24h urine metanephrines - high Plasma metanephrines - high
59
What scans are done to look for adrenal tumours?
CT scan MRI scan PET scan
60
What are the causes of adrenal hormone deficiency?
Addison's disease ACTH deficiency from hypopituitarism Steroid induced ACTH suppression
61
What are the symptoms of ACTH deficiency?
Similar to primary adrenal failure - Addison's disease Except no hyperpigmentation as ACTH not raised No hyperkalaemia as no mineralocorticoid deficiency Hyponatraemia due to reduced cortisol meaning reduced diuresis
62
What are some examples of steroid drugs that suppress ACTH?
Dexamethasone Prednisolone
63
What are steroid drugs used to treat?
Inflammatory disorders - asthma - inflammatory bowel disease - rheumatoid arthritis Suppress immune response to organ transplantation.

Endocrinology (14 decks)

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