Adrenal Gland

Question 1

anatomy of the adrenal gland

Answer 1

has the medulla and the cortex. Cortex consists of 3 zones.

Question 2

Adrenal cortex hormones

Answer 2

1. Glucocorticoids, produced in Zona Fasciculata (Cortisol) 2. Mineralcorticoids, produced in Zona Glomerulosa (aldosterone) 3. Sex steroids, produced in Zona Reticularis (Androgens)

Question 3

Adrenal medulla hormones

Answer 3

produces catecholamines: epinephrine, NE and dopamine.

Question 4

Cortisol test

Answer 4

24 HOUR URINE TEST IS BEST A random cortisol sample collection tells you nothing because cortisol levels naturally fluctuate throughout the day.

Question 5

Dexamethasone Suppression Test

Answer 5

Dexamethasone is a synthetic glucocorticoid that is more potent than Cortisol Give a dose of dexamethasone and it should suppress pituitary activity. This test will tell you if the Cushings syndrome is adrenal or pituitary in nature.

Question 6

ACTH

Answer 6

In patients that have an abnormal Dexamethasone suppression test, you will do an ACTH test to determine if the Cushings is ACTH dependent or not.

Question 7

ACTH Stimulation Test

Answer 7

The most useful test for Adrenal Insufficiency It tests the adrenal response when pt given an ACTH-like substance. Normal response is a cortisol level greater than 20mg/dl, one hour later. Lack of a rise indicates adrenal insufficiency

Question 8

CRH Stimulation Test

Answer 8

CRH can be given to evaluate to Pituitary response to stimulation from the Hypothalamus. Give CRH and measure Cortisol and ACTH This test is used to differentiate primary vs. secondary adrenal insufficiency.

Question 9

Primary (Pituitary) Adrenal Insufficiency determined by CRH stim test

Answer 9

test will show elevated ACTH but no Cortisol production

Question 10

Secondary Adrenal Insufficiency determined by CRH stimulation test

Answer 10

test will show Low ACTH and Low Cortisol

Question 11

Aldostrone Concentration

Answer 11

Most important test to diagnose Hyper and Hypoaldosteronism. Can be measured in serum or in urine.

Question 12

Testing for Primary Aldostronism

Answer 12

order an aldostrone concentration and a Plasma renin activity (PRA)

Question 13

Plasma Renin Activity

Answer 13

when kidneys are stressed, PRA goes up. Elevated PRA seen in Hyperaldosteronism. This test measures the ability to convert Angiotensinogen to Angiotensin I

Question 14

Cushings Syndrome

Answer 14

Excess ACTH Not typically an endogenous disease process, usually caused by medications.

Question 15

Cushings Disease

Answer 15

Cushings syndrome but as a result of a pituitary adenoma. Get excess ACTH production from the pituitary.

Question 16

Cushings diagnosis

Answer 16

1. 24 hour urine cortisol (could also be 24 hour salivary cortisol) is the GOLD STANDARD. 2. Determine if the cortisol deficiency is ACTH suppressible or CRH sensitive by getting an ACTH suppression test and a CRH sensitivity test. This determines the level of the problem. 3. Get imaging for potential surgical fix.

Question 17

Primary Cortisol and ACTH defeciency

Answer 17

There is low production at the Adrenal Level

Addisons disease or Adrenal insuffeciency

Question 18

Secondary ACTH and Cortisol Defeciency

Answer 18

Because of some failure in the hypothalmic/Pituitary Axis

Question 19

Primary Addisons Disease

Answer 19

Destruction of the Renal Cortex

• autoimmune disorder
• TB
• Chronic infection

Cortisol and Aldosterone levels are low

When you to an ACTH stimulation test, there is no increase in cortisol, this is how you know it is primary.

Question 20

Secondary Addisons disease

Answer 20

Due to lack of ACTH

• Drugs
• Tumors
• infection of pituitary

Cortisol only is low

you do an ACTH stimulation test and you get an increase in cortisol

Question 21

Addisons manifestations

Answer 21

Hypoglycemia

Weight loss

Fatigue

Hypotension

Dizziness

N/V/D

Tanning of skin

Question 22

Diagnosing Addisons

Answer 22

1. Look for Low cortisol Level–> 24 hour urine cortisol, plasma aldosterone
2. Demonstrate if ACTH is sensitive–> ACTH sensitivity Test

If not ACTH sensitive –> Primary/Adrenal cause

If ACTH sensitive–> Secondary cause –> order CRH stimulation test: Hypothalmic or pituitary level.

3. look for treatable cause–> imaging.

Question 23

Primary Addisons treatment

Answer 23

Replacement therapy

Replace Cortisol levels with hydrocortisone.

Replace Aldosterone with Fludrocortisone.

Question 24

Secondary Addisons Treatment

Answer 24

Find/treat tumors

stop the offending drugs

treat the infection

Question 25

Conns Syndrome

Answer 25

Primary Hyperaldosteronism

Pts have hypertension, decreased blood potassium, and are tired, have muscle weakness and polyuria. Pts do not respond to hypertension drugs.

This is caused by an adrenal adenoma- treatment is surgical

Labs: aldosterone is high, potassium low, normal sodium, PRA is low

Question 26

Secondary Hyperaldosteronism

Answer 26

More common

oIncreased Aldosterone is due to decreased renal perfusion which causes elevated PRA
Commonly caused by: CHF, nephrotic syndrome, cirrhosis

Question 27

Primary hypoaldosteronism

Answer 27

o- Usually due to destruction of adrenal glands. Hypo is rare.
oCauses; misuse of steroids, TB, auto immune.

PRA is elevated.

Question 28

Secondary hypoaldosteronism

Answer 28

the problem is outside of the adrenal gland- usually a pituitary tumor.

Question 29

CAH

Answer 29

Congenital Adrenal Hyperplasia

Characterized by genital abnormalities due to adrenal gland defeciencies.

The adrenal gland is unable to make cortisol and aldosterone, so it makes the only other thing it knows how to make, and that is androgen. The body produces too much androgen. This causes male sex characteristics to appear innaproriately or early.

Question 30

21-Hydroxylase Deficiency

Answer 30

90–95% of CAH cases are caused by 21- OHD

Females affected with severe, classic 21- OHD are exposed to excess androgens prenatally and are born with virilised external genitalia–> ambiguous genitalia.

Males born with 21-OHD present early with a salt-wasting crisis –> dehydration.

Question 31

Best test for adrenal medulla

Answer 31

Plasma Metanephrine, or 24 hour urine metanephrine

Question 32

Phenochromocytoma

Answer 32

Benign or malignant chromaffin tumor of the Adrenal Medulla
Can be fatal if untreated, but is usually treatable with surgery.

Display the 5 P’s

1. Pressure (HTN)
2. Pain (headache)
3. Perspiration
4. Palpitation
5. Pallor