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Adrenal Gland Clinical Flashcards

1
Q

The adrenal, simply, controls what?

A

Salt
Sugar
Sex
Stress

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2
Q

What are the layers of the adrenal gland?

A

Zona Glomerulosa
Zona Fasciculata
Zona Reticularis
Medulla

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3
Q

When you have raised suspicion of adrenal dysfunction, how do you approach it?

A 
Is it functioning high or low?
Is it primary, secondary or tertiary?
What could be the cause?
If tumour: removable?
Deficiency: can it be fixed?
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4
Q

How is cortisol secretion stimulated?

A

CRH from hypothalamus

ACTH from anterior pituitary

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5
Q

Elevated cortisol inhibits what?

A

Secretion of CRH and ACTH

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6
Q

Hypofunction of the adrenal gland is usually due to what?

A

Adrenal dysgenesis
Adrenal dysfunction
Impaired steroidogenesis

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7
Q

What is the precursor to catecholamines?

A

Dopamine

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8
Q

What are the causes of Adrenal Hyposecretion?

A

Primary Adrenal Insufficiency

Adrenal Enzyme defects

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9
Q

What are the causes of primary adrenal insufficiency?

A

Addison’s Disease

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10
Q

What are the different causes of Addison’s disease?

A 
AUTOIMMUNE
Invasion
Infiltration
Infection
Infarction
Iatrogenic
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11
Q

Addison’s disease causes what?

A

Adrenal insufficiency

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12
Q

Which adrenal enzyme deficiency typically leads to hyposecretion?

A

21-hydroxylase

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13
Q

What is the role of 21-hydroxylase?

A

Formation of aldosterone and cortisol from progesterones

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14
Q

Autoimmune dysfunction usually attacks what in autoimmune addison’s?

A

Adrenal autoantibodies to 21-hydroxylase (70%)

Lymphocytic infiltrate of adrenal cortex

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15
Q

Which conditions are typically associated with Autoimmune Addison’s disease?

A 
Thyroid disease (20%)
T1DM (15%)
Premature ovarian failure (15%)
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16
Q

What are the common symptoms of primary adrenal failure?

A

Fatigue, weakness, anorexia, weightloss (100%)
Skin pigmentation/vitiligo
Hypotension
Unexplained Vom/diarrhoea

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17
Q

What are the rare symptoms of primary adrenal failure?

A

Salt craving

Postural symptoms

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18
Q

How does Primary Adrenal Failure cause skin pigmentation?

A

Excess ACTH co-stimulates melanocyte sytimulating hormone

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19
Q

Which other factors can give clues to adrenal failure?

A

Disproportionate illness severity and dehydration/hypotension
Unexplained hypoglycaemia
Other endocrine features
Previous depression

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20
Q

How is a diagnosis of adrenal insufficiency made?

A

Symptoms
Bloods
Cortisol (low)
Synacthen test

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21
Q

How do you treat a very unwell patient with high suspicion of Adrenal insufficiency?

A

Treat with steroids and do Synacthen test later

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22
Q

How do you treat a very unwell patient with high suspicion of Adrenal insufficiency?

A

Treat with steroids and do Synacthen test later

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23
Q

What is the short synacthen test?

A

Give 250ug Tetracosactrin
Push adrenal glands
Look at response
(Test for adrenal insufficiency)

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24
Q

How do you interpret cortisol levels in the short synacthen test?

A

Over 2hrs
>500nmol/l normal
<150nmol/l 2ndary adrenal insufficiency
<50nmol/l primary adrenal insufficiency

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25
How do short synacthen test results give a diagnosis of primary adrenal failure?
Impaired cortisol response with an elevated ACTH
26
How do short synacthen test results give a diagnosis of secondary adrenal failure?
Lesser cortisol response | ACTH stays low
27
How is congenital adrenal hyperplasia diagnosis?
Samples of cortisol taken and tested for 17-OH progesterone to exclude 21-hydroxylase deficiency
28
What does a normal response to rapid ACTH stimulation test tell you?
Excludes primary adrenocortical insufficiency
29
What should you test after an abnormal ACTH stimulation test?
Test Plasma ACTH
30
What does suppressed ACTH tell us?
Secondary Adrenocortical insufficiency
31
What does elevated ACTH tell us?
Primary adrenocortical insufficiency
32
You diagnose a patient with Addison's disease, what do you do next?
Check adrenal autoantibodies
33
What do you do with a patient with Addison's disease and positive for adrenal autoantibodies?
Screen for other features of APS (autoimmune polyendocrine syndromes)
34
What do you do with a patient with Addison's disease and negative for adrenal autoantibodies?
Men: Check VLCFA (FIRST) - If -ve, adrenal imaging Women: Adrenal imaging
35
A patient with Addison's disease, negative for adrenal autoantibodies and VLCFA positive has what?
Adrenoleucodystophy
36
What factors are looked for in adrenal imaging?
Infiltation Infarction Haemorrhage Infection
37
What therapies are given for adrenal hyposecretion?
Glucocorticoid treatment | Mineralocorticoid replacement
38
What is the typical glucocorticoid replacement therapy?
HYDROCORTISONE 20-30mg Prednisolone 7.5mg Dexamethasone 0.75mg Divided doses to mimic diurnal variation
39
What is the typical mineralocorticoid replacement therapy?
Synthetic steroid | Fludrocortisone 50-300ug
40
Which patients are likely to need steroid therapy?
Hypoadrenal Patients on steroids who suppress the pituitary adrenal axis 18/12 recent treatment
41
How should steroid therapy be changed for patients with short-lived illness?
Double glucocorticoid dose
42
How should steroid therapy be changed for patients with major illness/surgery?
100mg hydrocortisone IV | Reduce as stress abates
43
What are the endocrine causes of hypertension?
``` Primary Hyperaldosteronism Pheochromocytoma Cushing's disease Acromegaly Hyperparathyroidism Hypothyroidism Congenital Adrenal Hyperplasia ```
44
What conditions of the adrenal cortex cause hypersecretion?
Cushing's syndrome | Conn's syndrome
45
What conditions of the adrenal medulla cause hypersecretion?
Phaeochromocytoma
46
Phaeochromocytoma causes secretion of what?
Catecholamines
47
Cushing's syndrome causes secretion of what?
Cortisol | Androgens
48
Conn's syndrome causes the secretion of what?
Aldosterone
49
What is Cushing's syndrome?
Excess corticosteroids
50
What is the role of cortisol?
Tissue breakdown Sodium retention Insulin antagonism
51
What are the symptoms of Cushing's syndrome?
``` Central obesity Hypertension Glucose intolerance Moon face Striae Mood changes Amenorrhoea ```
52
Cushing's syndrome not caused by corticosteroid therapy is divided into which classes?
ACTH-dependent | ACTH-independent
53
What are the causes of ACTH-dependent Cushing's?
``` Pituitary tumour (Cushing's disease) Ectopic ACTH secretion ```
54
What type of tumour causes Cushing's disease?
Basophil adenoma
55
What are the causes of ACTH-independent Cushing's?
``` Adrenal tumour (adenoma, carcinoma) Primary nodular hyperplasia ```
56
What is the initial screen for hypercortisolism?
Overnight Dexamethasone suppression test | 24hr urine free cortisol
57
How is Hypercortisolism confirmed?
24hr urine free cortisol | Low dose dexamethasone test
58
How is ACTH dependent/independent hypercortisolism differentiated?
Paired morning-midnight ACTH cortisol
59
If hypercortisolism is confirmed to be ACTH dependent, what is the next step?
Determination whether or not in the pituitary | High dose dexamethasone test
60
How is an ACTH secreting tumour located?
MRI Sella CT adrenals/chest BIPSS
61
What sources produce the most abnormal ACTH?
Ectopic sources
62
What is the test for lateralising pituitary lesion?
Simultaneous bilateral inferior petrosal sinus and peripheral vein sampling
63
What is the typical cause of Conn's Syndrome?
Adenoma | Bilateral hyperplasia
64
Elevated aldosterone causes what?
Elevated blood volume Elevated blood pressure Elevated urine K+ ↓ Renin
65
How is suspected hyperaldosteronism screened?
Plasma PA/PRA ratio
66
What does a PA/PRA ratio > 20 tell us?
Primary hyperaldosteronism
67
What does PA/PRA ratio < 20 tell us?
(Less reliable) Secondary hyperaldosteronism Essential Hypertension
68
What do you test for in a patient with hypertension and hypokalemia?
Plasma renin activity (PRA) | Plasma aldosterone concentration (PAC)
69
↑Renin ↑Aldosterone in a patient with hypertension and hypokalemia tells us what?
Investigate for Secondary hyperaldosteronism
70
What are the causes of secondary hyperaldosteronism?
``` Renovascular hypertension Diuretic use Renin-secreting tumour Malignant hypertension Coarctation of the aorta ```
71
↑Aldosterone (PAC) ↓Renin (PRA) in a patient with hypertension and hypokalemia tells us what?
Investigate for primary hyperaldosteronism
72
↓Renin ↓Aldosterone in a patient with hypertension and hypokalemia tells us what?
Congenital adrenal hyperplasia Exogenous mineralocorticoid Cushings/Liddle's 11 beta HSD deficiency
73
How is hyperaldosteroneism confirmed?
Urinary Sodium 24hr urine aldosterone 4 days of salt loading
74
How is the source of aldosterone found?
CT adrenals Upright posture test Plasma 18-hydroxycorticosterone
75
What are the symptoms of phaeochromocytoma?
Hypertension | Paroxysmal attacks
76
How do paroxysmal attacks present?
``` Headache Sweating Palpitations Tremor Pallor Anxiety ```
77
What makes Phaeochromocytoma the 10% tumour?
10% extra adrenal 10% malignant 10% multiple 10% hyperglycaemic
78
How do you test for phaeochromocytoma?
24hr urine: Total metanephrines (solo in low suspicion) Catecholamines Plasma metanephrines
79
What should be done next ina | patient with Increased metanephrines or catecholamines?
Localisation | Adrenal/abdominal MRI/CT
80
What other tests should be performed in patients with phoechromocytoma?
Genetic testing | Tumour phenotype
81
What must never be performed on a pheochromocytoma?
Biopsy
82
What is the most common cause of congenital adrenal hyperplasia?
90% due to 21-hydroxylase deficiency
83
How does Congenital adrenal hyperplasia present?
Neonatal salt-losing crisis Ambiguous genitalia (girls) Pseudo-precocious puberty (boys) Hirsutism
84
What hormone changes are seen in 21-hydroxylase deficiency?
Decreased aldosterone, cortisol | Increased sex hormones

D&E Pathology (18 decks)

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