ADRENALS

Question 1

Arterial supply adrenals

Answer 1

branches of:

• inferior phrenic artery
• aorta
• renal arteries

Question 2

Venous drainage of adrenals

Answer 2

left: to left renal vein
right: to IVC

Question 3

MCC primary adrenal insuff worldwide

Answer 3

TB

Question 4

MCC primary adrenal insuff in developed world

Answer 4

autoimmune

Question 5

10% of pheochromocytoma

Answer 5

• extra-adrenal (will only secrete NE bc lack enzyme PNMT)
• bilateral
• children
• familial (MEN 2A/B)
• malignant

Question 6

Dx pheochromocytoma

Answer 6

1. plasma metanephrine (high sensitivity, low specificity)
2. if pos -> 24hr urine
3. CT abdomen (localize)
4. iodine IMBG (best localization study)

Question 7

Extra-adrenal pheo MC found at…?

Answer 7

aortobifurcation (organ of Zuckerkandl)

Question 8

Mgmt adrenal-cortisol carcinoma (ACC)

Answer 8

OPEN adrenalectomy (do not want to risk tumor spillage)

Question 9

MCC Cushing syndrome

Answer 9

ACTH secreting pituitary tumor

Question 10

3 main causes of Cushing syndrome

Answer 10

1. ACTH secreting pituitary tumor
2. Ectopic ACTH secreting tumor (SCLC)
3. Cortisol-producing adrenal tumors (adenoma)

Question 11

Dx Cushing syndrome

Answer 11

1. 24-hr urinary cortisol
2. low dose dexamethasone
3. high dose dexamethasone
4. imaging

Question 12

Mgmt unresectable adrenal-cortisol carcinoma

Answer 12

mitotane (adjuvant); cytotoxic to adrenal cells

Question 13

Pre-op prep pheo

Answer 13

1. phenoxybenzamine (non-selective, irreversible a-blocker) - know in Tx range when mild orthostatic + dry nasal mucosa
2. BB
3. lap adrenalectomy
4. keep hypervolemic periop (bc will lose sympathetic tone post-op)

Question 14

Not likely to have HPA axis suppression w/ Tx of steroids of…?

Answer 14

<20mg taken for <3 weeks

Question 15

Pheo tumor cells arise from what kind of cells?

Answer 15

adrenomedullary chromaffin cells

Question 16

Medications that may cause falsely elevated plasma/urine metanphrines

Answer 16

• TCA
• acetaminophen
• labetalol
• cocaine

Question 17

Mgmt bilateral adrenal hyperplasia causing hyperaldo sxs?

Answer 17

mineralocorticoid receptor antagonists (cannot do bilateral lap adrenalectomy)

Question 18

Dx Graves disease

Answer 18

• clinical + lab can confirm dx
• if no clinical, then may do radioactive iodine uptake scan (diffuse)
• if scan unavailable or C/I (pregnancy, lactation), then may measure TRAb levels (thyrotropic-R Ab)

Question 19

When would you check thyroglobulin level in pt w/ sxs hyperthyroid?

Answer 19

if suspect factitious ingestion of thyroid hormone - thyroglobulin level low (suppressed in setting of exogenous ingestion)

Question 20

Nelson syndrome 2/2 to…? Mgmt?

Answer 20

2/2 failed pituitary resection for Cushing disease -> residual tumor with increased ACTH levels
Mgmt: bilateral adrenalectomy

Question 21

Which adrenal incidentalomas should be resected?

Answer 21

• any functional incidentalomas
• > 4cm nonfunctional
• <4cm but w/ suspicious criteria

Question 22

Biochemical tests that should be performed for incidentaloma

Answer 22

• 24-hr urine metanephrines
• free cortisol levels
• late evening salivary cortisol
• aldo:renin ratio

Question 23

Best test for dx acute and chronic adrenal insuff

Answer 23

rapid adrenocorticotropic hormone stimulation test

Question 24

T-stage adrenocortical carcinoma

Answer 24

T1 = <5cm, no invasion
T2 = >5cm, no invasion
T3 = invasion to fat
T5 = organ invasion

Question 25

Surveillance of nonfunctional adrenal incidentalomas

Answer 25

• repeat imaging 6, 12, and 24-mo
• q1y hormonal testing for 4yrs
• if >1cm or becomes functional -> adrenalectomy

Question 26

Rank of steroids in order of ascending potency

Answer 26

hydrocortisone < prednisone < methylprednisolone < dexamethasone

Question 27

Two forms of 21-hydroxylase def

Answer 27

patial: presents in adolescence/adult, virilization only
complete: presents at birth as virilization, hypoNa, hyperK, hyperpigmentation