Adrenal Glands Flashcards
Where are the adrenal glands found?
On top of the kidneys
What do the adrenal glands produce?
Glucocorticoids - cortisol (carb, lipid and protein metabolism)
Mineralocorticoids (sodium and potassium balance)
Androgens (sex hormones - converted into testosterone peripherally)
What controls androgen and corticosteroid release?
Corticotropin-releasing factor from hypothalamus
Stimulates ACTH production from pituitary
This acts on adrenal cortex
What is Cushing’s syndrome?
Clinical state from excess glucocorticoids
Loss of normal feedback mechanisms from hypothalamo-pituitary-adrenal axis
Loss of circadian rhythm of cortisol secretion
What is main cause of Cushing’s syndrome?
Oral steroids
How do you initially confirm the diagnosis of Cushing’s syndrome?
Raised plasma cortisol
Tests for investigating Cushing’s syndrome?
Overnight dexamethasone suppression test - give 1mg at night and 8am cortisol should be suppressed - no suppression in cushing’s syndrome
48hour dexamethasone suppression test - give 0.5mg every 6 hours for 2 days - measure cortisol at 0 and 48 hours - won’t be suppressed in cushing’s syndrome
48 hour high dose - give 2mg
Midnight cortisol measurement - when it is lowest normally - in cushing’s it is still high
Localisation tests in Cushing’s syndrome
If ACTH is undetectable - likely to be an adrenal tumour
If ACTH is high - could be pituitary cause or ectopic ACTH production
To distinguish - high dose test will have suppression with pituitary cause but not if from other cause
CRH test - if pituitary cause then cortisol will rise - if it is ectopic ACTH production then CRH will have no effect
Commonest cause of increased ACTH
Pituitary adenoma = Cushing’s disease
Usually a microadenoma and it causes bilateral adrenal hyperplasia
Peak age 30-50 years
Very high dose suppression test can decrease cortisol slightly
Two other causes of raised ACTH levels
1) Ectopic ACTH production - especially small cell lung carcinoma and carcinoid tumours - weight loss, hyperglycaemia and classic cushings features often absent
- even high dose suppression test won’t have an effect
2) Ectopic CRH production
- rare, some thyroid and prostate cancers
Signs of high plasma ACTH
Will get pigmentation (due to ACTH cross reacting with melanin receptors)
What can you get with very high cortisol levels
Increased mineralocorticoid activity therefore hypokalaemic metabolic alkalosis
4 ACTH-independant causes of Cushing’s syndrome
Adrenal adenoma (can get virilization)
Adrenal nodular hyperplasia
Iatrogenic - STEROIDS
Rarely - Carney Complex causing endocrine tumours
Symptoms of Cushing’s Syndrome
Weight gain Fatigue Mood change (depression, lethargy) Acne Proximal weakness Gonadal dysfunction - irregular menses, hirsutism, ED
Signs of Cushing’s syndrome
Moon face, plethoric face
Buffalo neck hump, supraclavicular pattern and central obesity
Bruises, poor healing and purple abdominal striae
Skin (thin) and muscle atrophy
Osteoporosis
High BP and glucose
Pigmentation if ACTH dependant
Treatment of Cushing’s disease
Removal pit adenoma
Can always do removal of adrenals if source un-locatable or recurrence post-op - can be Nelsons syndrome where pit enlarges following loss of negative feedback from adrenals - increased ACTH production
Metyrapone
Suppresses cortisol secretion - can be used pre-op
Cortisol also suppressed by ketoconazole
Prognosis of Cushing’s
Good if treated, vascular complications if not treated. Effects of Cushing’s often remain eg. obesity, menstrual irregularity
What is Addison’s Disease?
Primary adrenocortical insufficiency - not enough corticosteroids produced by adrenal cortex