adrenal gland

Question 1

what us aldosterone regulated by?

Answer 1

renin-angiotensin system and plasma potassium

Question 2

what is the pathway to cortisol production?

Answer 2

hypothalamus–>ant. pituitary–>adrenal cortex
CRH ACTH
–> cortisol

Question 3

what are the 6 classes of steroid receptors?

Answer 3

Glucocorticoid
Mineralocorticoid
Progestin
Oestrogen
Androgen
Vitamin D

Question 4

what type of hormone is cortisol?

Answer 4

corticosteroid

Question 5

what are the CNS effects of cortisol?

Answer 5

mood lability
euphoria/psychosis
lowers libido

Question 6

what are the bone & connective tissue effects of cortisol?

Answer 6

accelerates osteoporosis
lowers Serum calcium
lowers collagen formation
lowers wound healing

Question 7

what are the immunological effects of cortisol?

Answer 7

lowers:
capillary dilatation/permeability
leucocyte migration
macrophage activity
inflammatory cytokine production

Question 8

what are the metabolic effects of cortisol?

Answer 8

carbohydrate: increases blood sugar
increases lipolysis, central redistribution
increases proteolysis

Question 9

what are the circulatory/renal effects of cortisol?

Answer 9

increased cardiac output
increased bp
increased renal blood flow and GFR

Question 10

what are the most common causes of primary adrenocortical insufficiency?

Answer 10

addison’s
congenital adrenal hyperplasia (CAH)
adrenal TB/malignancy

Question 11

what are the clinical features of addison’s disease?

Answer 11

anorexia, weight loss
fatigue
dizziness and low bp
abdominal pain, nausea and vomiting
skin pigmentation

Question 12

what causes addison’s disease?

Answer 12

autoimmune destruction of the adrenal cortex

Question 13

how do you diagnose adrenal insufficiency?

Answer 13

suspicious biochemistry- hyponatraemia and hyperkalaemia
short synacthen test- measure plasma cortisol before vs after iv or im ACTH injection
cortisol >500 after ACTH can pretty much rule out adrenal insufficiency

adrenal insufficiency also usually have high ACTH, high renin and low aldosterone

Question 14

what is the treatment for adrenal insufficiency?

Answer 14

hydrocortisone as cortisol replacement
fludrocortisone as aldosterone replacement

education- need more steroids if ill, cant stop suddenly

Question 15

what is the treatment for adrenal crisis?

Answer 15

fluids- normal saline
iv / im hydrocortisone
treat the underlying cause

Question 16

what is the treatment for secondary adrenal insufficiency?

Answer 16

hydrocortisone (aldosterone production intact so don’t need fludrocortisone)

Question 17

what is the diagnostic test of cushing’s syndrome?

Answer 17

low dose dexamethasone suppression test

Question 18

what is the most common cause of cortisol excess?

Answer 18

iatrogenic cushing’s syndrome sure to prolonged high dose steroid use

Question 19

what do you suspect if there is hypertension + hypokalaemia?

Answer 19

primary aldosteronism

Question 20

what is the definition of primary aldosteronism?

Answer 20

autonomous production of aldosterone independent of its regulators (angiotensin II + potassium)

Question 21

what are the CV actions of aldosterone?

Answer 21

increase BP
LVH
atheroma

Question 22

what is the most common cause of primary aldosteronism?

Answer 22

bilateral adrenal hyperplasia

Question 23

how do you diagnose primary aldosteronism?

Answer 23

1. confirm aldosterone excess
   measure plasma aldosterone and renin and express as ratio
   if ratio raised do saline suppression test
   failure of aldosterone to suppress by >50% with 2 litres confirms PA
2. confirm subtypes with CT and/or vein sampling

Question 24

what is the management of primary aldosteronism?

Answer 24

surgery- unilateral laprascopic adrenalectomy in adrenal adenoma

if bilateral use MR antagonists e.g. spironolactone

Question 25

what is the most common cause of congenital adrenal hyperplasia (CAH)

Answer 25

21alpha hydroxylase deficiency (full deficiency = classic presentation, partial = non classic)

Question 26

what is the classic presentation of CAH?

Answer 26

adrenal insufficiency seen at 2-3 weeks old
poor weight gain
biochemical pattern of addison’s disease
females have genital ambiguity

Question 27

what is the non-classic presentation of CAH?

Answer 27

typically in females
hirsutism
acne
ogliomenorrhoea
precocious puberty
infertility or sub-fertility

Question 28

what is the treatment of CAH in children?

Answer 28

glucocorticoid replacement
mineralcorticoid replacement in some
surgical correction
achieve maximal growth potential

Question 29

what is the treatment of CAH in adults?

Answer 29

control androgen excess
restore fertility
avoid steroid over-replacement

Question 30

what clues suggest paheochromocytoma?

Answer 30

labile hypertension
postural hypotension
paroxysmal swelling, headache, pallor, tachycardia