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Y2 Endocrine Block > Adrenals > Flashcards

Adrenals Flashcards

1
Q

what is adrenal insufficiency

A

Inadequate adrenocortical function- not producing cortisol or aldosterone

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2
Q

what is included in Primary adrenal insufficiency

A

Addison’s disease
Congenital Adrenal Hyperplasia (CAH)
Adrenal TB/malignancy

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3
Q

what is congenital adrenal hyperplasia (CAH)

A

genetic condition where there is deficiency of cortisol and aldosterone production, pretty rare

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4
Q

what is the cause of Congenital adrenal hyperplasia and what does it result in

A

Autosomal recessive
Lack of 21-hydroxylase activity

Deficiency of cortisol and aldosterone
Increased adrenal androgens

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5
Q

what is Addison’s Disease

A

Autoimmune destruction of adrenal cortex = decreased cortisol production
>90% destroyed before symptomatic

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6
Q

what other auto immune conditions is Addisons diseases associated with

A

Type 1 DM,
autoimmune thyroid disease,
pernicious anaemia,
coeliac disease

People with addisons disease, up to 60% have other autoimmune disease

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7
Q

what are the clinical features of addisons disease

A 
Anorexia, weight loss
Fatigue/lethargy
Dizziness and low BP
Abdominal pain, vomiting, diarrhoea
Skin pigmentation-  (commonly in buccal mucosa and in palmar creases)
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8
Q

how to diagnose adrenal insufficiency

A

1) ‘Suspicious biochemistry’
high Na, low K
Hypoglycaemia- very difficult to develop if not diabetic and on insulin medication

2) SHORT SYNACTHEN TEST
Measure plasma cortisol before and 30 minutes after iv ACTH injection
Normal: baseline >250nmol/L, post ACTH >480

3) Measuring ACTH levels
Should be high (causes skin pigmentation)

4) Renin/Aldosterone level
Increased renin, low aldosterone

5) Adrenal autoantibodies

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9
Q

what is the management of adrenal insufficiency

A

Hydrocortisone (synthetic equivalent) as cortisol replacement

  • If unwell, give intravenously first
  • Then 15-30mg tablets daily in divided doses
  • Try to mimic diurnal rhythm

Fludrocortisone (synthetic equivalent) as aldosterone replacement
Careful monitoring of BP and plasma potassium

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10
Q

What is included in secondary adrenal insufficiency

A

–> Due to lack of ACTH production by pituitary gland
Pituitary/hypothalamic disease Tumours
- Surgery/radiotherapy
Exogenous steroid use- Commonest cause

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11
Q

give examples of exogenous steroids that cause secondary adrenal insufficiceny

A

High dose prednisolone
Dexamethasone
Inhaled corticosteroid

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12
Q

what are the clinical features and management of secondary adrenal insufficiency

A 
Clinical features:
Anorexia, weight loss
Fatigue/lethargy
Dizziness and low BP
Abdominal pain, vomiting, diarrhoea
NO SKIN PIGMENTATION (no increased ACTH)

Management:
Hydrocortisone Treatment

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13
Q

what is Cushing’s syndrome:

A

Excess cortisol secretion

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14
Q

what are the clinical features of cushing’s syndrome

A 
Easy bruising
Facial plethora
Striae- stretch mark
Proximal myopathy- Increased abdominal fat
Thin arm and legs
Moon face
Buffalo hump
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15
Q

what are the causes of Cushings syndrome (ACTH dependent and independent)

A

ACTH dependent (excess ACTH = excess cortisol)

  • Pituitary adenoma (68%) Cushing’s Disease
  • Ectopic ACTH 12% (carcinoid/carcinoma)- lung cancer, broncho carcinoid
  • Ectopic CRH <1%

ACTH independent (adrenal problem- autonomous production of cortisol)
Adrenal adenoma
Adrenal carcinoma
Nodular hyperplasia

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16
Q

how to diagnose Cushing’s syndrome

A

1) Establish cortisol excess
- Dexamethasone suppression testing
Normally, person switches off cortisol production next day but this doesn’t occur in people with cushings’ syndrome
- 24 hour urinary free cortisol
Late night salivary cortisol- normally cortisol production would be low but if you have high cortisol production at night- Cushing’s syndrome

2) Establish source of cortisol excess
- Measure ACTH
Undetectable- carry out Adrenal CT scan

Normal/ High- carry out CRH (corticotrophin) stimulation test:

  • No change in ACTH- CT chest
  • Exaggerated rise in ACTH- pituitary MRI
17
Q

what is the management of Cushing’ syndrome

A

Surgical

  • Transphenoidal pituitary surgery
  • Laparoscopic adrenalectomy
  • Removal of ACTH source (lobectomy if in lung)

Medical (bridge to surgery or people who can’t have surgery)
Metyrapone/ketoconazole
- Inhibit cortisol production
- Short term measure

18
Q

what is Iatrogenic Cushing’s syndrome

A

Due to prolonged high dose steroid therapy
eg. asthma, rheumatoid arthritis, inflammatory bowel disease, transplants
Usually oral therapy
Can occur with high dose inhaled steroids or steroid injections

19
Q

How does adrenal suppression occur in Iatrogenic Cushing’s syndrome

A
  • Long term steroid treatment suppresses ACTH production (negative feedback to anterior pituitary)
  • Atrophy of adrenal cortex
  • -> no cortisol production
20
Q

what is the management of Iatrogenic Cushing’s syndrome

A

Gradual withdrawal of steroid therapy (weeks, months)

21
Q

what is primary aldosteronism

A
  • Commonest cause of 2ndary hypertension
    Autonomous production of aldosterone independent of its regulators (angiotensin II/potassium)
    Due to either single adrenal adenoma or bilateral adrenal nodules
22
Q

what are the clinical features of primary aldosteronism

A

Significant hypertension
Hypokalaemia (in up to 50%)
Alkalosis

23
Q

what is the diagnosis of primary aldosteronism

A

Biochemistry

  • Plasma aldosterone elevated
  • Plasma renin concentration suppressed

Suppression testing
- Intravenous saline load

Adrenal CT scan

24
Q

what is the management of primary aldosteronism

A

Surgical

  • Unilateral laparoscopic adrenalectomy
  • Only if adrenal adenoma
  • Cure of hypokalaemia
  • Cures hypertension in 30-70% cases

Medical

  • In bilateral adrenal hyperplasia
  • Use MR (mineralcorticoid) antagonists (spironolactone or eplerenone)
  • Or amiloride (blocks Na reabsorption by kidney)
25
Q

What is Phaeochromocytoma

A

Catecholamine secreting tumours of the adrenal medulla (catecholamine excess- intermittent excess so comes in surges)
- Pale sweating with palpitations

26
Q

what is the diagnosis and treatment of Phaeochromocytoma

A

Diagnosis:
Measure urinary catecholamines and metabolites
CT scan of adrenals

Management:
Adrenalectomy
Pre-operative medicines- α1 +/- β1 antagonists to block effects of catecholamine surge (block a1 first and then B1 with alpha and beta blockers)

Y2 Endocrine Block (21 decks)

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