Adrenal Disorders part II

Question 1

How far should you go in the evaluation of an unexpected, asymptomatic
adrenal lesion found on CT?

Answer 1

for adrenal “Incidentaloma”

1. • Metanephrines of blood or urine to exclude pheochromocytoma the 1ST
2. • Renin and aldosterone levels to exclude hyperaldosteronism
3. • 1 mg overnight dexamethasone suppression test

Question 2

what % of the population has adrenal “incidentaloma.”

Answer 2

4% of the population has adrenal “incidentaloma.” Do not start with a scan or you will remove the wrong organ.

Question 3

why urinary or blood catecholamines or metanephrines are the first for incidentaloma

Answer 3

because operating on a pheochromocytoma without proper premedication such
as phenoxybenzamine (alpha blocker) is dangerous.

Question 4

Features of Incidental Adrenal Masses. Beningn VS Malignancy
Size
density
contrast washout speed

Answer 4

Favoring Benign Status
Size <4 cm
Low density (<10 Hounsfield units)
High/rapid contrast washout

Suspicious for Malignancy
Size >4 cm
High density (>10 Hounsfield units)
Low/slow contrast washout
Rapid rate of growth (>1 cm/year)

Question 5

Adrenal hypercostisolism labs
ACTH level
Petrosal sinus
High-dose
dexamethasone

Answer 5

ACTH level Low
Petrosal sinus Not done
High-dose
dexamethasone No suppression

Question 6

pituitary hypercortisolism labs
ACTH level
Petrosal sinus
High-dose
dexamethasone

Answer 6

ACTH level High
Petrosal sinus High ACTH
High-dose
dexamethasone Suppresses

Question 7

Ectopic hypercortisolism labs
ACTH level
Petrosal sinus
High-dose
dexamethasone

Answer 7

ACTH level High
Petrosal sinus Low ACTH
High-dose
dexamethasone No suppression

Question 8

Hypoadrenalism. Chronic hypoadrenalism is also called

Answer 8

Addison disease.

Question 9

Acute adrenal

insufficiency is also called

Answer 9

adrenal crisis

Question 10

Addison disease >F etiology

Answer 10

Addison disease is caused by autoimmune destruction of the gland in more than
80% of cases

Question 11

Addison disease less common causes

Answer 11

Infection (tuberculosis)
Adrenoleukodystrophy
Metastatic cancer to the adrenal gland

Question 12

Acute adrenal crisis is caused by

Answer 12

hemorrhage, surgery, hypotension, or trauma
that rapidly destroys the gland.

sudden removal of chronic high-dose
prednisone

Question 13

hypoadrenalism cx fx acute

Answer 13

Weakness, fatigue, altered mental status, nausea, vomiting, anorexia,
hypotension, hyponatremia, and hyperkalemia are common in both acute and
chronic presentations.

Question 14

hypoadrenalism cx fx chronic

Answer 14

Hyperpigmentation

Question 15

Acute adrenal crisis cx fx

Answer 15

profound hypotension, fever, confusion, and coma

Question 16

hypoadrenalism  labs?
glycemia
K
pH
Na
BUN
Eosinophils

Answer 16

opposite of the tests previously described in hypercortisolism.
Hypoglycemia
Hyperkalemia
Metabolic acidosis
Hyponatremia
High BUN
Eosinophilia

Question 17

If hypoadrenalism is from pituitary failure, the ACTH level is ___. A ___
ACTH level means the etiology of adrenal insufficiency is a primary adrenal failure

Answer 17

low. A high

Question 18

The most specific test of adrenal function is the

Answer 18

cosyntropin test

Cosyntropin is
synthetic ACTH. You measure the cortisol level before and after the
administration of cosyntropin.

In a patient whose health is otherwise normal,
there should be a rise in cortisol level after giving cosyntropin.

Question 19

hypoadrenalism tx

Answer 19

1.- Replace steroids with hydrocortisone.** can be life saving
2.- Fludrocortisone is a steroid hormone that is particularly high in
mineralocorticoid or aldosterone-like effect.

Question 20

best choice if

the patient still has evidence of postural instability

Answer 20

Fludrocortisone

Question 21

what should be used in primary adrenal insufficiency when the
patient is on oral steroids ?

Answer 21

Mineralocorticoid

supplements such as cortisone

Question 22

Primary Hyperaldosteronism Etiology

Answer 22

aldosterone-producing adrenal adenoma (Conn’s syndrome) 80%
bilateral hyperplasia

rarely malignant

Question 23

Primary Hyperaldosteronism concept

Answer 23

autonomous overproduction of aldosterone

despite a high pressure with a low renin activity

Question 24

.

Answer 24

.

Question 25

Primary Hyperaldosteronism

CxFx

Answer 25

High BP + hypokalemia

Question 26

Primary Hyperaldosteronism best initial test

Answer 26

to measure the ratio of plasma aldosterone to plasma renin.

An elevated plasma renin excludes primary hyperaldosteronism.

Question 27

Primary Hyperaldosteronism. most accurate test to confirm the presence of a unilateral adenoma or
unilateral hyperplasia

Answer 27

sample of the venous blood draining the adrenal. It will show a high aldosterone level.

Question 28

All forms of secondary hypertension are more likely in those whose onset:

Answer 28

1. • Is under age 30 or above age 60
2. • Is not controlled by 3 antihypertensive medications
3. • Has a characteristic finding on the history, physical, or labs

Question 29

CT scan of the adrenals should only be done after

Answer 29

after biochemical testing

Question 30

Hyperaldosteronism biochemical testing results:
K
Aldosterone after high-salt diet
plasma Renin level
Aldosterone-to-renin ratio
pH

Answer 30

Low potassium
High aldosterone despite a high-salt diet**
Low plasma renin level
Aldosterone-to-renin ratio > 20:1 and aldosterone > 15 =
hyperaldosteronism
Metabolic alkalosis is common in hyperaldosteronism.

Question 31

Hyperaldosteronism tx.
Unilateral adenoma
Bilateral hyperplasia

Answer 31

Unilateral adenoma is resected by laparoscopy.
Bilateral hyperplasia and patients who cannot have surgery are treated with
eplerenone or spironolactone.
Amiloride will have less efficacy

Question 32

Spironolactone side effects

Answer 32

gynecomastia and decreased libido

because it is antiandrogenic

Question 33

Pheochromocytoma Definition

Answer 33

nonmalignant lesion of the adrenal medulla

autonomously overproducing catecholamines despite a high blood pressure

Question 34

Pheochromocytoma is the answer when there is:

Answer 34

Hypertension that is episodic in nature
Headache
adrenergic symps: Sweating, Palpitations, tremor, and tachycardia

5Ps:paroxismal, pain, pressure, palpitation, perspiration.
que pheo

and… Orthostatic hypotension occurs
between hypertension episodes

Question 35

Pheochromocytoma best initial test

Answer 35

level of free metanephrines in plasma.** better for emergencies

This is confirmed with a 24-hour urine collection for metanephrines. This is more sensitive than the urine vanillylmandelic acid level. Direct easurements of epinephrine and norepinephrine are useful as well.

Question 36

Pheochromocytoma imaging?

Answer 36

CT or MRI is done only after biochemical
testing

MIBG scanning: This is a nuclear isotope scan that detects the location of
pheochromocytoma that originates outside the adrenal gland. Scan if the CT or
MRI is negative after biochemical confirmation of pheochromocytoma

Question 37

Pheochromocytoma TX best initial therapy

Answer 37

Phenoxybenzamine is an alpha blocker
Calcium channel blocker and beta blockers are used
afterward.

Question 38

Pheochromocytoma TX final

Answer 38

Pheochromocytoma is removed by laparoscopic surgery.

Question 39

a good first initial tes for addison’s D is

Answer 39

cortisol meadure at the morning. should be low

Question 40

high renin and high aldo means…

and tx?

Answer 40

FMD:Fibromuscular dysplasia ->stent
or
AS:atherosclerotic disease-> treat the blood pressure

Question 41

what to do with incidentaloma?

Answer 41

R/O Cnns, Chushing and Pheo

with a 24 h imaging