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Clin Med II Liza > Adrenal gland disorders > Flashcards

Adrenal gland disorders Flashcards

0
Q

ACTH independent CYshing SYnd

A

High cortisol but low ACTH (due to negative FB)

1) Adrenal tumor produces high cortisol directly ->negative FB on ACTH so ACTH is low
2) nueroendocrine tumore
3) PHEOchromocytoma

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1
Q

ACTH dependent Cushings Synd

A

High cortisol and high ACTH due to ACTH producing tumor (pit or ectopic)
1) Pit Adenoma is #1 cause - secretes high ACTH -> high cortisol
2) Ectopic ACTH - small cell LUNG CA is #2
but also ovary, pancreatic , thymus CA
3) HypoThalamus produces high CRH -> high ACTH -> high cortisol

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2
Q

Dx work up for cushing syndrome

A

Plasma Cortisol level (looking for high cortisol):
Abnormal is >25 at 8 am and doesn’t drop by 1/3-2/3 at 4pm
(if at 8 am its’ 75, at 4 pm should be 50)

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3
Q

Serum ACTH level in cushing syndrom

A

should be low in ACTH independent
high if ACTH dependent: at 8 am >80, at 4 pm >50 or
low is ACTH indep: <20 at any time

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4
Q

how is 11-deoxycortisol measured and why

A

it’s a precursor to cortisol

measure by radioimmunoassay

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5
Q

Dexamethasone suppression test

A

suppress cortisol with DST (can’t gell ACTH levels)

Abnormal if cortisol > 5 in am -> cushings

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6
Q

24 hr urine free cortisol

A

definitive confirmation
measures 17 OCHS
MAIN STAY for Dx
Abnormal if cortisol >125

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7
Q

what is the gold standard for screening of cushings

A

DST suppression test

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8
Q

what is the main stay for dx of cushing

A

24 hr urine cortisol - confirmation

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9
Q

4 Dx work ups for Cushings synd

A

1) Plasma cortisol (8 am and should decrease by 1/3-2/3 at 4 pm) and Serum ACTH (8 adn 4)
2) Dexamethasone suppression test (Gold standard - only tests cortisol)
3) 24 hr urine for cortisol (definite confirmation of dx)
4) salivery samples bf brushing teath (9 am x 3 days for adrenal insuff and 11 pm x 3 days for Cushings)

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10
Q

Salivary sampling

A

before brush teeth,
9 AM x 3 day for adrenal insuff (cortisol should be high, if low -> adrenal insuff)
11 pm x 3 day for Cushings ( cortisol should be low, if high -> cushings)

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11
Q

How to Dx cushings

A

1) exclude exogenous use of cortisol (for autoimmune dz, ashthma)
2) Is cushings due to pituitary tumor (ACTH dep’t)
3) Is it due to ectopic ACTH producing tumor?
- get clinical clue from hx, maybe CXR to rule out lung mass ((Small cell LUNG CA #2 cause of ACTH dept, pituitary adenoma is #1), PELVIC U/S for OVARIAN CA
4) Is it adrenal tumor (ACTH indep’t/ high cortisol -> low ACTH):
- palpate abdomen for masses
- maybe CT abdomen

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12
Q

If cushings due to pituitary adenoma - what tx

A

pit adenoma (ACTH dept) - do trans-sphenoidal resection (ENT surgery)

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13
Q

If adrenal tumor causing cushings

A

(ACTH indept) - do adrenalectomy (general surgery)

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14
Q

if exogenous corticoid use is the cause of cushings

A

taper to lowest effective dose that can tx pt’s sx

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15
Q

if adrenal hyperplasia (ACTH independent) or inoperable ectopic

A

do medical tx - oncology

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16
Q

Most common cause of cushings is

A

ACTH producing pituitary adenoma

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17
Q

most common cause of cushingoid sx is

A

exogenous stroid use (but not tumor, why if adenoma is #1 cause?)

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18
Q

Sx of cushings

A

Central obesity, stretch marks, moon face
Spontaneous ecchymosis (bruises), virilization
unexplained OSTEOPOROSIS, HTN
NEW onset insulin resistance/DM

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19
Q

Cushings Tx

A

Mitotane - kills cortisol producing cell
Kenoconazole - antifungal in high dose but major SE: liver tox
Metyrapone - inhibits cortisol synthesis

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20
Q

what is the major SE of ketokonazole

A

LIVER TOXicity

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21
Q

Mitotane is used to tx which disorder

A

Cushings

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22
Q

Metyrapone is use to tx what

A

cushings

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23
Q

ketoconazole is used to tx what

A

cushings

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24
Q

what is the first line tx for cushings

A

surgery

25
Q

which test is used for definitive dx of cushings?

A

24 hr urine cortisol

26
Q

which is the easiest test for cushings

A

DExamethasone suppression test but for definite dx do 24 hr cortisol urines

27
Q

which test to use to ddx ACTH dept from independent cushings?

A

Comparison of ACTH and Cortisol levels at 8 and 4 pm

28
Q

Adrenal INsuff

A

any age,

decreased production of glucocorticoids (cortisol), mineralocorticoids (ALDO) and/or sex androgen (testosterone)

29
Q

Anatomic descruction of adrenal cortex (adrenal gland) can be due to
(primary - problem in adrenal gland, secondary - elsewhere and affects gland)

A

MOst: autoimmune = Addison’s Dz (ABs destroy gland)
Surgical adrenalectomy
Infection (coccidiodomycosis, histoplasmosis, TB disseminated to gland and didn’t clear)
Hemorrage or Infarct
Mets or CA
AIDS

30
Q

Metobolic failuer in hormone prod of adrenal gland can be due to

A

Congenital adr hyperplasia

ALD - adredoleukodystrophy (Susan Serandon)

31
Q

What is the secondary etiology of adr insufficiency

A

MOSTLY: ABRUPT cessation of exogenous cortisol tx: will suppress both hypoth and pit for about 12 months
hypopotuitarism/pit dz
stroid producing tumor (why would it not cause increase in cortisol?)

32
Q

which drugs reduce cortisol production

A

opiates, KETOCONAZOLE (tx for cushings), rifampin, phenytoin

33
Q

Hallmark TETRAD of adr insuff (KNOW!)

A

Weakness/fatigues (worse with stress)
Wgt LOSS/ anorexia (+/- with N,V, abd pain, hypoglycemia t retain H20) - ORTHOSTATIC
ALso:
salt craving, syncope, loss of pubic hair and amenorrhea

34
Q

4 work ups for adren insuff

A

1) ACTH vx Cortisol test
2) CoSynTropin Stim Test - comfirmatory dx like 24 hr urine, get baseline cortisol, Give bolus of ACTH, measure cort at 30 and 60 min: if fail to increase by >18 = abnormal
2)Metyrapone Stim Test: don’t need to dc steroids, stnd is 3 day:
do 24 hr urine baseline, then take metyrapon and collect 24 hr urine on day 2 and 3
measures: creat and 17-OHCS in urine, also measure serium cort and ACTH 4 hrs after last dose
4) check SALIVA cort level in AM (the slide says 9 pm??)

35
Q

Other labs to order in adrenal insuff and why

A

CMP - bc decreased Aldo = low Na, HyperK, HyperCalcemia
CBC bc anemia of chronic dz (normochromin, normocytic)
ABs bc most common cause of AI is Addisons (autoimmune)
TSH, PRL, FSH LH - bc could have pit dysfx: pituitary is not secreting ACTH (low cortisol), TSH (hypothyroid), FSH/LH (menstrual irreg), Prolactin (what sx are PRL deficiency?)

36
Q

How do you manage Pheo

A 
IV Nitro to tx HTN crisis
alpha blocker (phenoxybenzamine) poss followed by beta blocker (propranolol): to stabilize pt till definitive therapy 
Surgery/Excision - definitive tx
(always refer to endo and surgery)
37
Q

WHat is Pheo

A

Tumor on Adrenal gland that produces catecholamines (Epi, NE):
HA, Sweat, Palpitations for 30-40 min (panic like or hyperthyroid-like)
Acute HTN crisis (use IV nitro) (refractory HTN)
NEVER USE FNA (Fine needle aspiration)
worse when bend over or palpate abdomen

38
Q

When is IV nitro used

A

for Pheo in acute HTN crisis

39
Q

When do you NEVER use FNA?

A

in Pheo

40
Q

What causes elevated Epi and NE (cats)

A

Pheo- cats-producing adrenal tumor

41
Q

What is the first test to run when suspect Pheo

A

Thyroid panel to see if hyperthyroid bc sx are similar: palpitations, sweating, HTN, and HA (no HA in thyroid)
-also do plasma EPi and NE and 24 hr urine for cats and metanephrines (urine better than plasma)
Pt has to be supine for 30 min with needle inside

42
Q

WHich drugs could cause False positive for Pheo and why

A 
W/D of clonidine (Alpha 2 agonist decreases SNS (Epi and NE) so sudden WD will sky rocket Epi and NE
Beta blockers
Alcohol
Tylenol
Tricyclics
43
Q

What is the test used for definitive Dx of Pheo?

A

Clonidine suppression test:
if you have normal Epi and NE levels, then clonidine should suppress it 3 hrs after admin (bc alpha 2 blocks SNS)
if you have abnormally high Epi and NE, then they will not still be high!

44
Q

what is special ab clonidine test?

A

must stop all hypotensive meds for 24 hrs and fast overnight
then take baseline BP and pulse
draw labs at 3 hr intervals with BP and pulse

45
Q

Would you do and MRI or CT on PHeo

A

yes because want to remove tumor

46
Q

Adrenal Incidentaloma

A

Mass lesion > 1 cm discovered by incident: abdominal (most non-functioning)
is it malignant? -> U/S , CT
is it functioning? -> secretes (if on adrenals -> will have high cortisol)

47
Q

Work up for indicentalomas

A

1) EVERYONE: check plasma cortisol, ACTH (pituitary or adrenal?), DHEA (adrenal androgens), adlosterone (Conn syndrome - hyperAldo, secreted by pituitary?)
2) if have sx of cushings (central obesity, buffalo hump, HTN stretch marks) - do a 24 hr urine for free cortisol
if no sx of cushings - do an overnight Dexamethasone suppression test (screening for cushings)
3) if suspect Pheo (high Epi, NE):
- first do Hx and physical: HA, palpitations, sweating acute HTN for 30-40 min
- 24 hr urine cats and metanephrines
- serum metanephrines

48
Q

when to NOT use fine needle biopsy

A

when have biochemical proof of Pheo
known widespread mets

Do use: when known primary malignancy elsewhere

49
Q

Based on work up findings

A

if pheo or CA - surgery
pharma for underlying dx
if benign appearance of imaging:
>2 cm -> consider resectin
repeat imaging in 6 months (CT usu better or MRI)
REPEAT DEXAMETH SUPPR test each year for 4 years

50
Q

What must one always r/o with adrenal insuff?

A

TB!!!!
(lung, breast CA and vascular dz may impair adrenocortical function -screen with CXR and mammogram if in high risk category)

51
Q

When to do radiographic studies

A

not when it’s autoimmune
CT can ID infection, hemorrhage, CA
MRI - 2ndary adrenal insuff (low ACTH and low Cortisol)

52
Q

TX of Adr insuff

A

1) Glucocorticoid replacement:
hydrocortisone, prednisone, dexamethasone
2) Mineralocorticoid replacement (for primary adren ins)”
Fludrocortisone
3)Adrenal androgen replacement if needed:
DHEA

53
Q

What must you always tell a pt with adr insuf

A

ALways increase your glucocorticoids whe highly stressful events

54
Q

what is the gold standard for Adrenal Insuf DX?

A

Cosyntropin stimulation test

55
Q

what is conn synderome

A

HyperAldosteroism

56
Q

HyperAldo (Conn) is due to

A

adrenocortical adenoma (70%) or cortical hyperplasia (30%) - similar to ACTH independent cushings syndrome

57
Q

HyperAldo sx

A

???High Aldo= HIgh Na, low K, HTN -> low RENIN
Sx:
HTN, hypoK, paresthesia, HA, polyuria and polidypsia (like DM - misdx?) why polyuria???

58
Q

Tx of Conn/HyperAldo

A

surgery

spironolactone and antiHTN (to supress till surgery only?)

59
Q

Dx work up for HyperAldo:

A

High plasma and urine Aldo
Low plasma RENIN
CT adrenals to eval for adenoma

Clin Med II Liza (6 decks)

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