Adrenal Insufficiceny Flashcards
What is adrenal insufficiency?
clinical manifestation of hypocortisolism and hypoaldosteronism
What is primary adrenal insufficiency?
adrenal pathology
What is secondary adrenal insufficiency?
pituitary / hypothalamic insufficiency
What are the causes for adrenal insufficiency?
- TB (most common worldwide)
- AI destruction (most common in the UK)
- Meningococcal septicaemia (Waterhouse-Friderichsen syndrome)
- Pituitary tumours, radiation or infiltration
What is the presentation of primary adrenal insufficiency?
- Lethargy
- Anorexia
- N+V
- Weight loss
- Salt craving
- Pigmented skin
- Hyponatraemia
- Hyperkalaemia
What is the presentation of secondary adrenal insufficiency?
- Lethargy
- Anorexia
- N+V
- Weight loss
- Salt craving
What is the presentation of an adrenal crisis?
- Collapse
- Shock
- Hypotension
- Pyrexia
What is Waterhouse-Friderichsen syndrome?
adrenal haemorrhage induced by meningitis
Why is there hyperpigmentation in primary adrenal insufficiency?
due to the lack of negative feedback on ACTH which drives high levels of the hormone.
How is ACTH produced?
from the cleavage of POMC (MSH is a byproduct of this too)
Why is there no hyperpigmentation in secondary adrenal insufficiency?
there is a pituitary dependent reduction in ACTH – this means less MSH so no hyperpigmentation
What bloods are done for adrenal insuff?
- FBC, U+Es (Na and K)
- Glucose
- 9am serum cortisol <500 nmol/L
What is the diagnostic test for adrenal insufficiency?
Short synACTHen test
What other investigations may be done for adrenal insuff?
- Investigations for TB
- Adrenal imaging
- Pituitary imaging
What is the process of the the short synACTHen test?
- 250 ug IM synthetic ACTH
- Check cortisol at 30 and 60mins
- Cortisol <550nM = diagnostic
What is the management of adrenal insuff?
- Homrone replacement
- sick day rules
- management of underlying cause if app
What hormone replacement is used?
- Life long hydrocortisone +/- fludrocortisone
2. Consider DHEA replacement (androgens) in certain cases - to be decided by specialists
What is fludrocortisone used?
an aldosterone agonist and so would only be needed if the cause is primary
What is the acute management of adrenal insuf?
- Hormone replacement
- Resus
- Rehydration
- Continued maangement
What hormone replacement is used acutely?
- 100mg hydrocortisone IV / IM
- 200mg HC /24h continuous infusion OR
- 50mg every 6hours IV or IM
What is the resusitation process?
- 500ml fluid bolus of 0.9% NaCl over 15mins
2. Replace any deficits
What rehydration is used acutely?
3-4L 0.9% NaCl in 24hours
What continued management for adrenal insuff?
refer to endo for advice and LT management including sick day rules etc
