Adrenal Gland Flashcards
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)
GHRH stimulates the anterior pituitary to secrete what?
GH (growth hormone)
CRH stimulates the anterior pituitary to secrete what?
ACTH (adrenocorticotropin hormone)
GHRH stimulates the anterior pituitary to secrete what?
GH (growth hormone)
GnRH stimulates the anterior pituitary to secrete what?
FSH (follicle-stimulating hormone)
LH (luteinizing hormone)
TRH stimulates the anterior pituitary to secrete what?
TSH (thyroid stimulating hormone)
GH affects what organ?
ACTH affects what organ?
FSH and LH affect what organ?
TSH affects what organ?
muscles
adrenals
ovaries
thyroid
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
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
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
Adrenal Cortex - 3 zones
Zona Reticularis
Secretes what?
androgens (dehydroepiandrosterone sulfate & androstenedione- precursors to estrogen & testosterone)
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
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
Adrenal insufficiency
Tertiary is caused by
Decreased CRH secretion in hypothalamus
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
Adrenal Insufficiency - Etiology
Secondary is?
Exogenous/endogenous glucocorticoids
Hypothalamus or pituitary tumors
Surgery or XRT
Head Trauma
Acute Clinical Manifestations of AI include
Nausea
Vomiting
Agitation/confusion
fever
abdominal pain
dehydration
tachycardia
hypotension
shock
hypoglycemia
Hyponatremia
Hyperkalemia
Hypercalcemia
Eosinophila
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
