1. Protects against hypoglycemia: Gluconeogenesis, proteolysis, lipolysis 2. Decrease insulin sensitivity 3. Anti-inflammatory 4. Immunosupression 5. Inhibits bone formation 6. Promotes increase in GFR 7. Maintain vascular responsiveness to NE/Epi

Adrenal Gland Flashcards by Morgan LaRoque

What is the cause of a primary disorder?

Target organ

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What is the cause of a secondary disorder?

Pituitary

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What is the cause of a tertiary disorder?

Hypothalamus

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What does the outer zone of the adrenal cortex produce?

Mineralocorticoids: Aldosterone

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What does the middle zone of the adrenal cortex produce?

Glucocorticoids: Cortisol

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What does the inner zone of the adrenal cortex produce?

Adrenal Androgens: (Dehydroepiandrosterine [DHEA])

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What the adrenal medulla produce?

Catecholamines: Epi & NE

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Effects of long-term high-dose glucocorticoid therapy?

Adrenal Atrophy

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Primary overproduction of cortisol by the adrenal glands inhibits the secretion of?

ACTH

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Effects of cortisol?

Protects against hypoglycemia: Gluconeogenesis, proteolysis, lipolysis
Decrease insulin sensitivity
Anti-inflammatory
Immunosupression
Inhibits bone formation
Promotes increase in GFR
Maintain vascular responsiveness to NE/Epi

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DHEA effects in females

Early development of pubic and axillary hair development

2. Masculinization in females

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When should you check cortisol levels?

Between 8 a.m. and 9 a.m

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What cortisol lab value would indicate adrenal insufficiency?

<3 mg/dL

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What cortisol lab value would NOT indicate adrenal insufficiency?

> 10 mg/dL

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What test is ideal for suspected hypercortisolism?

24-hour urine collection

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What can a plasma ACTH test with cortisol help you differentiate?

Differentiate primary (adrenal) from secondary (pituitary) and tertiary (hypothalamic) source of cortisol imbalance

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With an ACTH Stimulation Test, what does double the cortisol levels indicate?

Adrenal gland is functioning

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With an ACTH Stimulation Test, what does subnormal cortisol levels indicate?

Adrenal Insufficiency

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With a Dexamethasone Suppression Test, what does NO change in cortisol levels indicate?

Excess cortisol production

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With a Dexamethasone Suppression Test, what does suppressed cortisol levels indicate?

Adrenal gland is functioning

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What is the MC Exogenous cause for Cushing’s syndrome?

Chronic excess glucocorticoid (i.e. corticosteroid)

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What is the MC Endogenous cause for Cushing’s Disease?

Pituitary Adenoma

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Other causes for Cushing’s Disease?

Adrenal hyperplasia
Adrenocortical tumor
Neuroendocrine tumor (i.e. MEN I)
Ectopic production: Small cell lung CA, Ovarian CA

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Who is Cushing Disease MC in?

Females

What is the imaging of choice when evaluation for a pituitary tumor?

MRI of the pituitary gland

Cushing Syndrome Clinical Manifestations

1. HTN 2. Central Obesity: Moon facies, supraclavicular/cervical fat pad 3. Insulin Resistance 4. Purple Striae 5. Androgen excess: hirsutism, acne, menstrual irregularities

Diagnostic criteria/findings in Cushing's syndrome

1. 24-hour urinary free cortisol levels: Elevated 2. Midnight salivary cortisol level: Elevated on 2 separate nights 3. Dexamethasone suppression test: No change in cortisol levels

Adrenal Hyperplasia or tumor lab findings

High Cortisol levels | Low ACTH levels

ACTH producing tumor – pituitary or ectopic lab findings

High Cortisol levels | High ACTH levels

IF you suspect an ectopic ACTH secreting tumor, what would you order?

1. CXR: r/o lung mass (small cell lung CA) | 2. Pelvic US: r/o ovarian mass

Exogenous corticosteroid tx in Cushing's syndrome

Taper to lowest therapeutic dose

Pituitary adenoma tx in Cushing's syndrome

Transsphenoidal resection

Adrenal tumor tx in Cushing's syndrome

Adrenalectomy

Adrenal hyperplasia tx in Cushing's syndrome

Medical management

Ectopic ACTH Syndrome tx in Cushing's syndrome

Targeted at source of ectopic production

Pharmacological treatment/management of Cushing's syndrome

1. Adrenolytic Agents: Mitotane 2. Adrenal Enzyme Inhibitors: Ketoconazole, Metyrapone

In the US, what is the MC cause of primary adrenal insufficiency?

Autoimmune cortical destruction: Addison's disease= mineralocorticoid & glucocorticoid deficiencies

Worldwide, what is the MC cause of primary adrenal insufficiency?

What is the MC cause of secondary adrenal insufficiency?

Exogenous steroid

What can the abrupt withdrawal of steroids cause?

Addison's crisis

Adrenal Insufficiency Clinical Presentation

1. Nonspecific sx's: Weakness, fatigue, anorexia, wt. loss 2. Orthostatic Hypotension 3. Hypoglycemia 4. Salt Cravings 5. Hyperpigmentation* 6. GI complaints

Addison's Crisis Clinical Presentation

Sudden onset/rapid escalation: 1. Hypotension 2. Acute pain: Abdomen/low back 3. Vomiting 4. Diarrhea 5. Dehydration 6. AMS

Lab findings in Adrenal Insufficiency

1. Hyperkalemia 2. Hypercalcemia 3. Hyponatremia 4. Eosinophilia 5. Andi-adrenal antibodies= 70% of pt's d/t autoimmune destruction 6. Low plasma cortisol

Primary adrenal insufficiency treatment

Glucocorticoid (hydrocortisone) + Mineralocorticoid (fludrocortisone) replacement

Secondary/Tertiary adrenal insufficiency treatment

Glucocorticoid: hydrocortisone

What can be given to women with adrenal insufficiency?

DHEA

Adrenal crisis treatment

1. IV steroids 2. Correct electrolyte abnormalities 3. 50% dextrose 4. Volume resuscitation

Primary Hyperaldosteronism (Conn's Syndrome) etiology

1. Adrenocortical adenoma= 73% | 2. Cortical hyperplasia=27%

Primary Hyperaldosteronism Clinical Presentation

1. HTN 2. Hypokalemia 3. Muscular weakness 4. Paresthesias 5. Headache 6. Polyuria & polydipsia

Lab findings in Primary Hyperaldosteronism

1. Elevated plasma and urine aldosterone | 2. Low plasma renin levels

What imaging would you want to order in Primary Hyperaldosteronism? Why?

CT adrenals to evaluate for adrenal adenoma

Primary Hyperaldosteronism Mangement/treatment

1. Surgical: removal of adenoma | 2. Meds: Spironolactone + Antihypertensive agents

Define Pheochromocytoma

Rare tumor that arises from chromaffin cells: 1. Secrete catecholamines 2. Located in adrenal medulla= 80% to 90%

Pheochromocytoma Clinical Presentation

1. Paroxysmal Palpitations: Tachycardia 2. HA 3. Episodic sweating 4. HTN: Paroxysmal OR Sustained

When should you suspect Pheochromocytoma?

1. Classic paroxysmal “attacks” 2. Refractory HTN or onset <20 y/o 3. Idiopathic dilated cardiomyopathy 4. Abdominal mass 5. Family history 6. Incidentally discovered adrenal mass

What is the first line screening test in the diagnose of a Pheochromocytoma?

Metanephrine (catecholamine metabolite) 24-hour urine screen

What would you order to identify extra-adrenal tumors in Pheochromocytoma?

MIBG scintigraphy

Pheochromocytoma treatment

Surgical resection

Pheochromocytoma treatment prior to surgery

1. Alpha blocker: phenoxybenzamine | 2. Beta-Blocker: Propanalol