Adrenal Disorders

Question 1

Workup for adrenal incidentaloma

Answer 1

1. Check if hormonally funcitonin: 1-mg overnight dexamethasone, 24 hr urine metanephrine, plasma renin/aldosterone (if hypertensive)
2. Check for malignancy: >4cm diameter is suspicious for primary malignancy, <4cm may be mets

Question 2

Suspicious CT findings for adrenal mass

Answer 2

Unenchanced CT attenuation >10 Hounsfield units; CT contrast medium washout <50% at 10 mins

Question 3

Types of Adrenal Insufficiency

Answer 3

1. Cortisol deficiency: high ACTH, low AM cortisol. Due to Addison disease (autoimmune, TB, granuloamotus disease, trauma, anticoagulants, malignancy. Defects in glucocorticoid and mineralocorticoid function.
   2: ACTH deficiency: low ACTH, low AM cortisol (due to error in HPA axis from tumor, infiltrative disease, postpartum necrosis) RAAS system is OK
2. Exogenous glucocorticoid use: most common, a secondary insufficiency

Question 4

Diagnosis of AI

Answer 4

Screening: AM cortisol <3ug/dl (random level is NOT helpful because of diurnal variation in cortisol secretion)

IF am cortiosl test in indeterminate (3-15ug/dl) then do cosyntropin stimulation test for confirmation

Confirmatory: cosyntropin stimulation testing. Post cosyntropin plasma cortisol <18ug/dl

ACTH level >2x ULN is suggestive of primary AI

Question 5

Once primary AI is susepcted, what testing to get?

Answer 5

Adrenal antibodies, CT abdomen, review meds

Question 6

Once secondary AI is suspected, what testing to get?

Answer 6

Pituitary MRI, pituitary hormones

Question 7

Tx for AI

Answer 7

Glucocorticoid replacement: with hydrocortisone (divided doses) or prednisolone (single dose)

Mineralocorticoid replacement: fludrocortisone with monitoring of electrolytes

Question 8

What if a patient has AI and an intercurrent acute illness?

Answer 8

Patient will need to be educated on increasing dose of GC based on temperature (double for temp >38C, triple for temp >39C) or give subcu or inttramuscular dos

Question 9

Perioperative GC management in AI patient undergoing surgery?

Answer 9

Minor surgery: triple dose of GC for procedure duration and post-op.

Major surgery: 100mg hydrocortisone IV at time of surgery, with 50mg q6hours until eating/drinking

Double/triple dose of oral GC when frist eating/drinking until discharge

Question 10

Primary hypercortisolism

Answer 10

Adrenal adenoma. Elevated cortisol, low ACTH

Question 11

Secondary hypercortisolism (Cushing disease)

Answer 11

benign ACTH secreting pituitary tumor, high cortisol, high/normal ACTH

Question 12

Diagnostic testing for hyperrcortisolism

Answer 12

24 hr free urinary cortisol

1mg overnight dexamethasone supression test(cortisol >5 is suggestive)

midnight salivary cortisol >550ng/dl

Imaging: adrenal, pituitary, ectopic, inferior petrosal sinus sampling

Question 13

Primary hyperaldosteornism features

Answer 13

Mostly due to b/l idiopathic hyperadlosteornism or adenoma

Hypokalemia
Resistant HTn
Adrenal incidentalma
Young age
Family h/o HTN/stroke

Question 14

Primary hyper aldosteronism diagnosis

Answer 14

PAC/PRA OR plasma renin concenration and plasma adlosterone-to-renin ratio (PRC/ARR)

ARR>20 and PAC >10ng/dL is confimratory

*test when K is in normal ragne and nto on spirnolactone/antihypertensives

Real confirmation: suppression tests (salin, fludrocortisone, sodium loading) . NOT needed if there is spontaneus hypokalmeia, undetectable PRA or PAC >20

Question 15

Tx for hyperaldosteronism

Answer 15

Unilateral: adrenalectomy
Bilateral: MIneralocorticoid receptor antagonist (spironolactone/eplerenone)

Question 16

Pheochromocytoma/paragaglionoma

Answer 16

Most are benign or genetic

Triad: Headache, sweating, tachycardia

Dx: plasma metanephrines or urinary metanephrines (plasma is better) + CT with contrast imaging for dense/vascular, hetergennous lesion with poor washout

Tx: Surgical