Adrenal glands disorders

Question 1

Describe the gross anatomy and blood supply of the adrenal glands

Answer 1

retroperitoneal
sit on kidneys
right = pyramidal
left = semilunar
right = has own artery from aorta and has own vein that drains into renal vein
left = has a division of the renal artery and own vein that drains into renal vein

Question 2

Describe the microscopic appearance of the adrenal glands

Answer 2

layers from outer to inner

capsule
zona glomerulosa
zona fasciculata
zona reticularis
medulla

Question 3

What does the zona glomerulosa layer of the adrenal gland produce?

Answer 3

mineralocorticoid (aldosterone)

Question 4

What does the zona fasciculata layer of the adrenal gland produce?

Answer 4

glucocorticoid (cortisol)

Question 5

What does the zona reticularis layer of the adrenal gland produce?

Answer 5

sex hormones (adrenal androgens)

Question 6

What does the medulla of the adrenal gland produce?

Answer 6

catecholamine (adrenaline, noradrenaline, dopamine)

Question 7

What causes high catecholamines?

Answer 7

pheochromocytoma

Question 8

What causes low cortisol?

Answer 8

adrenal failure

primary:
- Addison’s
- adrenalectomy
- infections
- congenital adrenal hyperplasia

pituitary
exogenous steroid

Question 9

What causes high cortisol?

Answer 9

Cushing’s syndrome
- adrenal (benign + ca)
- pituitary
- ectopic ACTH

Question 10

What causes low aldosterone?

Answer 10

adrenal failure
- Addison’s
- adrenalectomy
- infections
- congenital adrenal hyperplasia

Question 11

What causes high aldosterone?

Answer 11

Conn’s syndrome

Question 12

Rules of endocrine tests

Answer 12

check hormone level in question if possible
provocation tests:
- suppression test for hormone excess
- stimulation test for hormone deficiency

minimise other interferences:
- diurnal variation
- postural changes
- SNS Stimulation
- medications

Question 13

What is an addisonian crisis in simple terms?

Answer 13

can’t produce cortisol in response to stress as they taker steroids so when a stressful event happens they are then cortisol deficient and their body cannot deal with the stress

needs steroids urgently

Question 14

Symptoms of an Addisonian crisis

Answer 14

sudden penetrating pain in lower back, abdomen or legs
severe vomiting + diarrhoea, followed by dehydration
low blood pressure + shock
loss of consciousness

Question 15

Addisonian crisis management

Answer 15

is suspected:
- take blood and send for later: cortisol, ACTH and adrenal antibody measurement

• 2-3L 0.9% saline and/or colloid to restore BP
• 10% glucose if hypoglycaemic
• hydrocortisone 100 mcg IV
• antibiotics if signs of infection

make diagnosis with 250 micrograms synacthen test

Question 16

Addison’s disease symptoms/signs

Answer 16

cortisol deficiency

progressive weakness, fatigability

GI disturbance

hyperpigmentation (as ACTH also stimulates melanocytes)

decreased mineralocorticoid activity - hyperkalaemia, hyponatraemia, volume depletion, hypotension

Question 17

Hypoadrenalism causes

Answer 17

primary chronic hypofunction (rare)
autoimmune adrenalitis (Addison’s)
autoimmune polyendocrine syndrome (APS 1 + 2)
TB
AIDS
metastatic cancer

Question 18

What can cause massive adrenal haemorrhage?

Answer 18

neonates
anticoagulant therapy
DIC post-surgery
Waterhouse-Friderichsen syndrome

Question 19

Hyperaldosteronism treatment (Conn’s)

Answer 19

spironolactone (lowers aldosterone, lowers BP, potassium-sparing)

Question 20

Blood results in Conn’s

Answer 20

hypokalaemia
hypernatraemia
low renin
high aldosterone
aldosterone-renin ratio high

Question 21

What investigation can be used to work out which adrenal gland is causing hyperaldosteronism?

Answer 21

selective adrenal vein sampling
measures cortisol and aldosterone in adrenal veins

Question 22

Another name for Conn’s syndrome

Answer 22

primary hyperaldosteronism

Question 23

What is a phaeochromocytoma?

Answer 23

tumour of the chromaffin cells that secrete unregulated and excessive amounts of catecholamines

Question 24

What will most patients with phaeochromocytoma also have?

Answer 24

hypertension (often above 180 systolic)

Question 25

Phaeochromocytoma symptoms

Answer 25

anxiety
sweating
headache
tremor
palpitations
hypertension
tachycardia

Question 26

What are some conditions phaeochromocytoma can resemble?

Answer 26

abdominal catastrophe
anxiety
aortic dissection
cerebral infarct/haemorrhage
cocaine
diabetes
malignant hyperthermia
migraine headache
myocardial infarction
pulmonary oedema

Question 27

What is MEN?

Answer 27

multiple endocrine neoplasia
if one neoplasia detected patients should be screened regularly for others that also occur in that syndrome

Question 28

What condition is a mucosal neuroma seen in?

Answer 28

MEN-2B

Question 29

Phaeochromocytoma diagnosis

Answer 29

catecholamines - urine or plasma
find the tumour - CT, MRI

Question 30

Management of phaeochromocytoma

Answer 30

medical therapy:
- important for pre-op preparation
- alpha blocker - phenocybenzamine - to lower BP
- beta blocker if BP still not low enough (aim for 130 systolic)

surgery
other: MIBG therapy (radioactive iodine)

avoid some medication to prevent pheo crisis eg metoclopramide