Adrenal Gland Flashcards by Andrew Kreutzer

The Hypothalamus secretes what hormones to the anterior pituitary?

GHRH (growth hormone-releasing hormone)
CRH (corticotropin-releasing hormone)
GnRH (gonadotropin releasing hormone)
TRH (thyrotropin-releasing hormone)

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GHRH stimulates the anterior pituitary to secrete what?

GH (growth hormone)

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CRH stimulates the anterior pituitary to secrete what?

ACTH (adrenocorticotropin hormone)

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GHRH stimulates the anterior pituitary to secrete what?

GH (growth hormone)

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GnRH stimulates the anterior pituitary to secrete what?

FSH (follicle-stimulating hormone)
LH (luteinizing hormone)

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TRH stimulates the anterior pituitary to secrete what?

TSH (thyroid stimulating hormone)

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GH affects what organ?
ACTH affects what organ?
FSH and LH affect what organ?
TSH affects what organ?

muscles
adrenals
ovaries
thyroid

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ACTH stimulates the adrenals to secrete what?
FSH and LH stimulates the ovaries to secrete what?
TSH stimulates the thyroid to secrete what?

Cortisol DHEA
Estrogens
T4 –> T3

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Adrenal Cortex - 3 zones
Zona Glomerulosa
Located where?
Produces what?
Aldosterone production stimulated by what?
Aldosterone targets what?

outermost region
Mineralocorticoids (primarily aldosterone
hypotension & hyponatremia > triggers RAAS
kidneys (distal nephrons) causing retention of Na & H2O, K excretion

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Adrenal Cortex - 3 zones
Zona Fasciculata
Produces what?
Production stimulated by what?
Levels are highest when? and falls to nadir when?

glucocorticoids (primarily cortisol)
ACTH from anterior pituitary; ACTH is secreted from ant. pituitary in circadian rhythm in response to CRH
highest in am, lowest at midnight

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Adrenal Cortex - 3 zones
Zona Reticularis
Secretes what?

androgens (dehydroepiandrosterone sulfate & androstenedione- precursors to estrogen & testosterone)

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Adrenal Insufficiency
Primary is the…
Inability of what?
Failure of what?
Resulting in what deficiency?

inability of adrenal gland to produce steroid hormones
Failure of adrenal gland itself
corticosteroid & mineralocorticoid

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Adrenal Insufficiency
Secondary is the…
Inability of what?
Decreased ACTH secretion causes what?
What deficiency?

hypothalamic-pituitary unit to deliver CRH or ACTH
hypofunction of adrenal glands
corticosteroids only

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Adrenal insufficiency
Tertiary is caused by

Decreased CRH secretion in hypothalamus

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Adrenal Insufficiency - Etiology
Primary is ?

Autoimmune destruction (Addison’s disease)
AIDS, CMV< mycobacterial infection
Malignancy
Adrenal hemorrhage d/t anticoagulation, HTN sepsis trauma
Drugs (ketoconazole)
Granulomatous disorders (TB, histo)
Familial glucocorticoid deficiency

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Adrenal Insufficiency - Etiology
Secondary is?

Exogenous/endogenous glucocorticoids
Hypothalamus or pituitary tumors
Surgery or XRT
Head Trauma

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Acute Clinical Manifestations of AI include

Nausea
Vomiting
Agitation/confusion
fever
abdominal pain
dehydration
tachycardia
hypotension
shock
hypoglycemia
Hyponatremia
Hyperkalemia
Hypercalcemia
Eosinophila

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Chronic Clinical Manifestations of AI

Weakness/fatigue
Loss of appetite/weight loss
Orthostatic Hypotension
Hyperpigmentation
Salt Cravings; unusual food preferences
Nonspecific GI symptoms
Myalgia/arthralgia
Headache
Hyponatremia
Hyperkalemia
Hypercalcemia
Eosinophila

Common Secondary & Tertiary AI Clinical Manifestations

Weakness
Myalgias/arthralgias
Hypoglycemia
Hyponatremia

Less Common Secondary & Tertiary AI Clinical Manifestations

Hyperpigmentation
Dehydration
Hypotension
GI complaints
Hyperkalemia

Differential Dx for AI includes

Adrenal Crisis
Hypotension
Shock
Acute Abdomen

AI diagnosis is done by performing what?

ACTH stimulation test
Check baseline cortisol level
Admin cosyntropin 250 mcg IV x1
Check cortisol level 60 min after admin
AI: peak cortisol level < 500 nmol/L (18 ug/dL)

ACTH level > 2 fold of upper limit is c/w what?

Primary AI

What test assess for destruction of adrenal glands?

21-hydroxylase antibodies

What imaging can assist in diagnosis?

CT scan of adrenals

AI Management - Acute

Glucocorticoid (Hydrocortisone 100mg IV x 1, then 200mg/d in 4 divided doses) Fluid resuscitation Treat underlying cause

AI Management - Chronic

Glucocorticoids (15-25mg in divided doses 2-3 x/d, highest dose in am) Mineralocorticoid (primary AI) (Fludrocortisone (0.05 mg - 0.1mg qd) Pt education; steroid emergency card, medical alert ID, steroid injection kit Perioperative stress dose steroids /

AI Management in Stress Minor procedure: usual dose vs what? Moderate procedure: give what? POD #1: give what? Major Procedure: give what? Mild Illness what rule?

hydrocortisone 25mg hydrocortisone 50-75mg IV; usual dose 50-100mg hydrocortisone IV/q8hrs, taper over 48hrs 3x3 rule ( take 2-3 x glucocorticoid dose x 3 days)

Septic Shock CIRCI Management

Hydrocortisone 200mg IV per day (continuous infusion or divided doses q6h) w/ or w/o fludrocortisone 50 ug enteral daily for 7 days or until ICU d/c

Early ARDS CIRCI Management (w/n 24 hrs)

Dexamethasone 20mg IV daily for 5d, then 10mg daily for 5d until extubation

Early ARDS CIRCI Management (w/n 72hrs) Days 1-14 Days 15-21 Dy=ays 22-25 Days 26-28 If extubated between days 1 and 15 then advance to what day of regimen?

Methylprednisolone 1mg/kg IV bolus then 1mg/kg/d continuous infusion 0.5mg/kg/d 0.25mg/kg/d 0.125mg/kg/d day 15

Unresolving ARDS CIRCI Management (w/n 72hrs) Days 1-14 Days 15-21 Days 22-28 Days 29-30 Days 31-32 If extubated before day 14 then advance to what day of regimen?

Methylprednisolone 2mg/kg/d IV bolus then 2mg/kg/d divided q6h 1mg/kg/d 0.5mg/kg/d 0.25mg/kg/d 0.125mg/kg/d day 15

Severe CAP CIRCI Management Hydrocortisone 7 day 8 or 14 day

200 mg IV once, then 10mg/hr IV infusion for 7d 200mg IV daily (for 4 or 8d based on clinical improvement), then taper (for a total of 8 or 14d) D/c on ICU discharge

Severe CAP CIRCI Management Methylprednisolone w/ 36 hrs of hospital admission and CRP > 150mg/L 20 day: bolus? Days 1-7 Days 8-14 Days 15-17 Days 18-20 Admin while in ICU vs after ICU d/c

Methylprednisolone 0.5mg/kg IV every 12h for 7d 40mg IV bolus 40mg/d 20mg/d 12mg/d 4mg/d via continuous infusion in ICU, then changed two divided doses BID, via IV or enteral, after ICU d/c

Cushing's disease caused by? Cushing's Syndrome caused by?

pituitary adenoma resulting in excess ACTH production glucocorticoid excess (including that from adenoma)

Cushing's Etiology - ACTH Dependent Hypersecretion of ACTH by? Ectopic secretion of ACTH by? Ectopic secretion of CRH by?

pituitary nonpituitary tumors nonhypothalamic tumors

Cushing's Etiology - ACTH Independent Exogenous admin of what? Adrenocortical what? Adrenal _________?

glucocorticoids adenomas & carcinomas macronodular hyperplasia Most common

Cushing's Clinical Manifestations

Truncal Obesity Moon face Buffalo Hump Purple striae Poor wound healing HTN Weakness Thin Skin Osteoporosis Hirsutism Amenorrhea Easy bruising Freq infections Acne Impotence Headache

Differential Dx of Cushing's includes

Polycystic ovarian syndrome Metabolic syndrome Obesity Fibromyalgia Psychiatric d/o

Cushing's Diagnosis Can be difficult b/c what? Exclude exogenous glucocorticoids in what possible forms?

cortisol secretion is variable, may be intermittent PO Inhaled Injected Topical Megestrol acetate Skin lightening (bleach)

Cushing's Diagnosis >/= 2 measurements of 24h urine free cortisol if cortisol excretion normal x3, what? Values 3-4 fold greater than Upper limit of normal is what?

Cushing's unlikely Diagnostic for Cushing's

Cushing's Diagnosis 1mg overnight dexamethasone suppression (given at 11p) Normal: AM cortisol suppresses to what? C/w Cushing's: serum cortisol > what?

<5.0 nanogram/dL >1.8 nanogram/dL

Cushing's Diagnosis 2 measurements of 11pm salivary cortisol Normal is what? Abnormal is what?

<145 ng/dL >145 ng/dL

Cushing's Management Patient needs a? Establish what? Patient needs to be what? Monitor/manage what? Goals are what? 1st line treatment is what? Post surgical replacement of what?

Endocrinologist Cause Educate Cortisol dependent co-morbidities (DM, HTN, HL, Psych d/o, etc.) Reduce cortisol levels to normal, Eradicate tumor if present, Avoid permanent hormone deficiency surgical resection of primary lesion glucocorticoid