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Y3M - Diabetes & Endocrinology > Adrenal Glands > Flashcards

Adrenal Glands Flashcards

1
Q

Major glucocorticoid.

A

Cortisol

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2
Q

Cortisol reduces CRH and ACTH, but what else?

A

Vasopressin

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3
Q

When is cortisol the highest?

A

08-09 in morning

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4
Q

When is cortisol the lowest?

A

At midnight

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5
Q

What is cortisol bound to?

A

Cortisol binding globulin (CBG; 80-90%)

Albumin (5-10%)

Only small proportion exists in the free biologically active state.

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6
Q

What do current cortisol immunoassays measure?

A

Total (bound and free)

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7
Q

Why might cortisol immunoassays measure be increased without affecting biologically active free levels?

A

Conditions that stimulate CBG levels such as oestrogen therapy may increase measured cortisol levels without actually affecting biologically active free levels.

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8
Q

What are adrenal androgens mainly controlled by?

A

ACTH

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9
Q

In which parts of the population are adrenal androgens important?

A

More important in adult owmen and in both sexes pre-pubertally.

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10
Q

Why are adrenal androgens not as important in adult men?

A

They rely mainly on testicular poroduction of androgens.

DHEA and DHEA-S and androstenedione are converted to the more potent testosterone and dihydrotestosterone in peripheral tissues.

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11
Q

Major mineralcorticoid.

A

Aldosterone

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12
Q

What is aldosterone regulated by?

A

RAAS (renin)

Low circulating blood volume

Hyponatraemia

Hyperkalaemia

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13
Q

Explain how renin regulates aldosterone levels.

A

Angiotensin II stimulates aldosterone release upon binding to the angiotensin receptor.

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14
Q

Secretions of the adrenal medulla.

A

Adrenaline

Noradrenaline

Dopamine

Metabolites such as metanephrines, nor-metanephrines and 3-methoxytyramine.

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15
Q

Other name for primary adrenal insufficiency.

A

Addisons disease.

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16
Q

Pathology of addisons.

A

Destruction of the adrenal gland or genetic defects in steroid synthesis.

Affects all three zones of the adrenal cortex.

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17
Q

Clinical features of Addisons.

A

Fatigue

Weakness

Anorexia

Weight loss

Nausea

Abdominal pain

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18
Q

Clinical features of Addisons related to mineralcorticoid deficiency.

A

Dizziness

Postural hypotension

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19
Q

Clinical features of Addisons related to glucocorticoid deficiency.

A

Hypoglycaemia

Hyperpigmentation (ACTH excess)

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20
Q

Clinical features of Addisons related to androgen deficiency.

A

Reduced libido and loss of axillary and pubic hair in women.

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21
Q

What is Addisonian crisis and how is it treated?

A

A medical emergency treated urgently with IV fluids and hydrocortisone.

Take bloods for cortisol and ACTH, U&Es (may have elevated K+)
Check ECG and give calcium gluconate if needed.

Give IV hydrocortisone 100mg stat
IV fluid bolus 500ml 0.9% saline to support BP, repeat if necessary.

Monitor blood glucose (hypoglycaemia can happen)

Blood, urine, sputum for culture and abx if concern about infection.

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22
Q

Continuing treatment of Addisonian crisis.

A

Glucose IV if hypo

Give IV fluids

Continue hydrocortisone 100mg/8H IV or IM

Change to oral steroids after 72h if patient’s condition is good.

Fludrocortisone may well be needed if the cause is adrenal disease.

Search and treat for underlying cause.

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23
Q

Most common cause of primary adrenal failure in the UK.

A

Autoimmunity.

Supported by detection of positive adrenal autoantibodies.

24
Q

Other less common causes of primary adrenal failure.

A

Infection

Infiltrative processes.

Should be considered if antibody testing is negative.

25
Q

Biochemical hallmarks of primary adrenal insufficiency.

A

Hyponatraemia

Hyperkalaemia

Raised urea

Hypoglycaemia

Mild anaemia

26
Q

Confirmatory tests of primary adrenal failure.

A

Low 9 am cortisol with simultaneously raised ACTH concentration.

Usually a SynACTHen test is needed for confirmation as well.

27
Q

Management of primary adrenal failure.

A

Lifelong glucocorticoids and mineralcorticoid replacement therapy.

Hydrocortisone is more common to give than low dose prednisolone.

28
Q

What is mineralcorticoid replacement given as?

A

Fludrocortisone

29
Q

Instructions given to patients at times of illness of primary adrenal failure.

A

Double their glucocorticoid dose and continue on a double dose until their illness has resolved.

30
Q

When else might glucocorticoids need to be administered IV or IM in primary adrenal failure?

A

During surgery or in cases of prolonged vomiting or diarrhoea.

31
Q

What should patients with primary adrenal failure also be provided? In terms of precautions.

A

Steroid emergency card

Encouraged to wear medical alert jewellery.

Emergency contact details for their endocrine team.

32
Q

Causes of secondary adrenal insufficiency.

A

ACTH deficiency

Any cause of hypopituitarism.

33
Q

Management of secondary adrenal insufficiency compared to primary.

A

Hydrocortisone and dose adjustment is the same.

However fludrocortisone is not required. This is because aldosterone levels are still normal.

34
Q

What are the risks of cessation of long-term steroids in secondary adrenal insufficiency?

A

Long-term steroids commonly cause ACTH suppression which means if you quit suddenly with the steroids it can lead to adrenal crisis.

Patients must be instructed not to stop their steroid treatment abruptly.

35
Q

What should patients with secondary adrenal insufficiency have in sense of precautions?

A

Steroid card

Education about steroid supplementation at times of illness similar to primary insufficiency.

36
Q

What is a phaeochromocytoma?

A

Catecholamine-secreting tumour in adrenal medulla.

37
Q

What is a paraganglioma?

A

Extra-adrenal chromaffin tissue secreting catecholamines.

38
Q

How common are catecholamine tumours?

A

Occur in about 0.1% of patients with hypertension.

39
Q

A familial/genetic basis of catecholamine secreting tumour is recognised in up to 30% of patients.

Especially when?

A

Bilateral tumours

Extra-adrenal tumours

Malignant tumours

40
Q

How common are paragangliomas?

A

10% of all catecholamine-secreting tumours.

41
Q

Clinical features of phaeo/para.

A

Headache

Sweating

Pallor

Palpitations

Anxiety

Panic attacks

Hypertension

42
Q

If left untreated what might happen in phaeo/para?

A

Hypertensive crisis

Encephalopathy

Hyperglycaemia

Pulmonary oedema

Cardiac arrhythmias

Ultimately death

43
Q

Initial investigations of phaeo/para.

A

Elevated catecholamines or their metabolites (metanephrines).

Radiological localisation of the tumour.

44
Q

What is the most common screening test for phaeo/para?

A

24 hour urinary catecholamines and plasma metanephrines.

45
Q

What is the intial imaging test of choice?

A

CT or MRI.

46
Q

Next imaging after CT and MRI if tumour cannot be localised?

A

Whole-body MRI.

47
Q

Next step if whole-body MRI cannot localise it?

A

123 I-meta-iodobenzylguanidine (MIBG) scans which may locate tumours not seen on MRI.

Can also be useful preoperatively to exclude multiple tumours or metastases.

48
Q

What other imaging can be used?

A

PET scans

49
Q

What testing might be done if a patient is of young age, or in those with multifocal, malignant or extra-adrenal disease?

A

Genetic testing

50
Q

What should be carried out if there is identification of predisposing mutation?

A

Annual screening for new or recurrent disease.

51
Q

Management of phaeo/para.

A

Definitive treatment is surgical excision performed either laparoscopically or open procedure.

52
Q

What do all patients with confirmed phaeochromocytoma or paraganglioma need at diagnosis?

A

Alpha +/- beta blockade.

53
Q

Explain how alpha +/- beta blockades are carried out.

A

Alpha-blockade should be done before beta-blockade.

54
Q

Why is alpha-blockade done first?

A

To avoid unopposed alpha-adrenergic stimulation and risk of hypertensive crisis.

55
Q

When are beta blockades given then?

A

To control reflex tachycardia.

56
Q

What alpha-blockade is used most commonly in phaeo?

A

Most commonly phenoxybenzamine but may be doxazosin.

57
Q

Treatment of Addison’s.

A

Replace steroids 15-25mg hydrocortisone daily in 2-3 doses.
E.g. 10mg on waking, 5mg lunch time.
Avoid giving late in the day because it can cause insomnia.

Mineralocorticoids to correct postural hypotension such as fludrocortisone PO from 50-200 mcg daily.

Add 5-10mg hydrocortisone to daily intake before strenuous exercise.
Double steroids in febrile illness, injury or stress.

Follow-up yearly.

Y3M - Diabetes & Endocrinology (17 decks)

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