Adrenal Disorders part II Flashcards
How far should you go in the evaluation of an unexpected, asymptomatic
adrenal lesion found on CT?
for adrenal “Incidentaloma”
- Metanephrines of blood or urine to exclude pheochromocytoma the 1ST
- Renin and aldosterone levels to exclude hyperaldosteronism
- 1 mg overnight dexamethasone suppression test
what % of the population has adrenal “incidentaloma.”
4% of the population has adrenal “incidentaloma.” Do not start with a scan or you will remove the wrong organ.
why urinary or blood catecholamines or metanephrines are the first for incidentaloma
because operating on a pheochromocytoma without proper premedication such as phenoxybenzamine (alpha blocker) is dangerous.
Features of Incidental Adrenal Masses. Beningn VS Malignancy
Size
density
contrast washout speed
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)
Adrenal hypercostisolism labs ACTH level Petrosal sinus High-dose dexamethasone
ACTH level Low
Petrosal sinus Not done
High-dose
dexamethasone No suppression
pituitary hypercortisolism labs ACTH level Petrosal sinus High-dose dexamethasone
ACTH level High
Petrosal sinus High ACTH
High-dose
dexamethasone Suppresses
Ectopic hypercortisolism labs ACTH level Petrosal sinus High-dose dexamethasone
ACTH level High
Petrosal sinus Low ACTH
High-dose
dexamethasone No suppression
Hypoadrenalism. Chronic hypoadrenalism is also called
Addison disease.
Acute adrenal
insufficiency is also called
adrenal crisis
Addison disease >F etiology
Addison disease is caused by autoimmune destruction of the gland in more than
80% of cases
Addison disease less common causes
Infection (tuberculosis)
Adrenoleukodystrophy
Metastatic cancer to the adrenal gland
Acute adrenal crisis is caused by
hemorrhage, surgery, hypotension, or trauma
that rapidly destroys the gland.
sudden removal of chronic high-dose
prednisone
hypoadrenalism cx fx acute
Weakness, fatigue, altered mental status, nausea, vomiting, anorexia,
hypotension, hyponatremia, and hyperkalemia are common in both acute and
chronic presentations.
hypoadrenalism cx fx chronic
Hyperpigmentation
Acute adrenal crisis cx fx
profound hypotension, fever, confusion, and coma
hypoadrenalism labs? glycemia K pH Na BUN Eosinophils
opposite of the tests previously described in hypercortisolism. Hypoglycemia Hyperkalemia Metabolic acidosis Hyponatremia High BUN Eosinophilia
If hypoadrenalism is from pituitary failure, the ACTH level is ___. A ___
ACTH level means the etiology of adrenal insufficiency is a primary adrenal failure
low. A high
The most specific test of adrenal function is the
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.
hypoadrenalism tx
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.
best choice if
the patient still has evidence of postural instability
Fludrocortisone
what should be used in primary adrenal insufficiency when the
patient is on oral steroids ?
Mineralocorticoid
supplements such as cortisone
Primary Hyperaldosteronism Etiology
aldosterone-producing adrenal adenoma (Conn’s syndrome) 80%
bilateral hyperplasia
rarely malignant
Primary Hyperaldosteronism concept
autonomous overproduction of aldosterone
despite a high pressure with a low renin activity
.
.
Primary Hyperaldosteronism
CxFx
High BP + hypokalemia
Primary Hyperaldosteronism best initial test
to measure the ratio of plasma aldosterone to plasma renin.
An elevated plasma renin excludes primary hyperaldosteronism.
Primary Hyperaldosteronism. most accurate test to confirm the presence of a unilateral adenoma or
unilateral hyperplasia
sample of the venous blood draining the adrenal. It will show a high aldosterone level.
All forms of secondary hypertension are more likely in those whose onset:
- Is under age 30 or above age 60
- Is not controlled by 3 antihypertensive medications
- Has a characteristic finding on the history, physical, or labs
CT scan of the adrenals should only be done after
after biochemical testing
Hyperaldosteronism biochemical testing results: K Aldosterone after high-salt diet plasma Renin level Aldosterone-to-renin ratio pH
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.
Hyperaldosteronism tx.
Unilateral adenoma
Bilateral hyperplasia
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
Spironolactone side effects
gynecomastia and decreased libido
because it is antiandrogenic
Pheochromocytoma Definition
nonmalignant lesion of the adrenal medulla
autonomously overproducing catecholamines despite a high blood pressure
Pheochromocytoma is the answer when there is:
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
Pheochromocytoma best initial test
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.
Pheochromocytoma imaging?
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
Pheochromocytoma TX best initial therapy
Phenoxybenzamine is an alpha blocker
Calcium channel blocker and beta blockers are used
afterward.
Pheochromocytoma TX final
Pheochromocytoma is removed by laparoscopic surgery.
a good first initial tes for addison’s D is
cortisol meadure at the morning. should be low
high renin and high aldo means…
and tx?
FMD:Fibromuscular dysplasia ->stent
or
AS:atherosclerotic disease-> treat the blood pressure
what to do with incidentaloma?
R/O Cnns, Chushing and Pheo
with a 24 h imaging
