ENDO-Adrenal Flashcards
Which adrenal layer secretes catecholamines (epinephrine & norepinephrine)?
medulla (inner)
richly innervated, extension of sympathetic nervous system
Which layer Secretes steroid hormones
adrenal Cortex (outer)
List the 5 steroid hormone groups based on their receptor binding sites
1] Mineralocorticoids: Aldosterone, 2] Glucocorticoids: Cortisol, 3] Androgens: Testosterone, DHEA, 4] Estrogens: Estradiol, estrone, 5] Progestins: progesterone- corpus luteum
Descibe the HPA axis
Stress -> hypothalamus -> CRH -> Anterior Pituitary -> ACTH -> adrenal glands -> cortisol
HIGH ACTH
LOW serum CORTISOL
Primary adrenal insufficiency
pituitary is pumping out lots of ACTH
adrenal gland is not responding by NOT making cortisol, problem is the adrenal
LOW ACTH
LOW serum cortisol,
Secondary adrenal insufficiency
pituitary is not responding to feedback signal of low cortisol
problem is the pituitary
PT c/o Weakness, abdominal pain, fever, confusion, N/V/D.
PE/Vitals: Low BP, dehydration; skin pigmentation
Acute (adrenal crisis) Adrenal Insufficiency
Emergency caused by cortisol insufficiency.
PT c/o Weakness, easy fatiguability, anorexia, weight loss, N/V/D. abdominal pain; MSK pains; amenorrhea,
PE/Vitals Sparse axillary hair, increased skin pigmentation (esp at creases, pressure areas, nipples),
Low BP,
small heart -quiet sounds
Chronic (Addison’s disease) Adrenal Insufficiency
Describe the causes of Primary Adrenal Insufficiency
1] Autoimmune diseases, 2] Adrenal infections and inflammation, 3] Bilateral metastases, 4] After adrenalectomy, 5] Adrenal hemorrhage or necrosis, 6] Idiopathic, 7] Drug-induced, 8] Congenital disorders
Describe the causes of Secondary Adrenal Insufficiency
1] Pituitary or hypothalamic tumor,
2] Pituitary irradiation, surgery or brain trauma,
3] Pituitary infections, inflammation, hemorrhage or necrosis,
4] Acute interruption of prolonged glucocorticoid therapy, 5] Acute adrenal crisis (shock syndromes)
PT c/o Weakness, abdominal pain, fever, confusion, N/V/D.
PE/Vitals: Low BP, dehydration; skin pigmentation
What is next step to check?
ADDison Adrenal Insufficiency -cortisol and aldosteronelow
1] CMP with high K+, low Na+, high Ca2+, high BUN,
2] CBC anemia, neutropenia with lymphocytosis, and eosinophilia (chronic),
3] Low plasma cortisol at 8:00am
4] High plasma ACTH in primary adrenal disease
PT c/o Weakness, abdominal pain, fever, confusion, N/V/D.
PE/Vitals: Low BP, dehydration; skin pigmentation
Describe the diagnositic test
secondary Adrenal Insufficiency
Cosyntropin stimulation test: Synthetic ACTH given parenterally;
draw blood 30-60 min later;
failure of serum cortisol to rise is POSTIVE FOR PRIMARY- adrenal not responding
IF give DEXA(cortisol) ACTH still stays high, then pituitary
What is treatment for Adrenal Insufficiency
1] Replace cortisol with hydrocortisone (or other form),
2] Treat infections aggressively; stress dosing appropriate
Pt C/o poor wound healing, psych changes,
Obj-“moon face,” acne, “buffalo hump,” supraclavicular fat pads, protuberant abdomen, thin extremities
PE/Vitals
Central obesity, muscle wasting, thin skin, hirsutism, purple striae, Osteoporosis, HTN,
Cushing’s Syndrome-Due to excess corticosteriods
Massive fat redistribution
What are some reproductive dysfunction of Cushing’s Syndrome
Oligomenorrhea/amenorrhea, impotence
Describe the other dysfunctions of Cushing’s Syndrome
1] Weakness, backache, HA, polyuria, polydipsia, 2] HTN, osteoporosis, bone AVN, nephrolithiasis, 3] Decreased concentration, mood lability or psychosis
What would you order first and find for the next stepss of Cushing’s Syndrome
#1] Late evening salivary cortisol level, 2] 24 hour urine for free cortisol, 3] Low-dose dexamethasone suppression test
4] CMP-Impaired glucose tolerance and insulin resistance, hyperglycemia; hypokalemia (normal sodium)
5]CBC Leukocytosis, lymphocytopenia
What are the requirements for diagnosis of Cushing’s Syndrome?
1] Cortisol levels should be checked at least twice,
2] At least two of these tests should be abnormal
What is the next step once hypercortisolism is confirmed
What would findings suggest?
plasma ACTH is ordered to find the cause
low ACTH; high serum cortisol,
high cortisol shuts off ACTH production from pituitary, so cause is adrenal tumor
If after dexa test, cortisol is till high, ACTH is high then…What is condition?
Cushing’s disease ***
high serum cortisol, high ACTH; high cortisol does not shut off ACTH
pituitary, caused by benign pituitary adenoma
What is the next step in management if the patient has Cushing’s disease?
Refer to endocrinology for CRH stimulation test to determine if cause is hypothalamus or pituitary,
What are the classic signs and sx of Primary Hyperaldosteronism
PE/Labs:HTN (Resistant HTN primary reason to consider this dx),
hypokalemia
Elevated plasma and urine aldosterone
low plasma renin level- NOT kidneys affectin Aldo
Pt-Polyuria, polydipsia, muscular weakness
What are the most common subtypes of Primary Hyperaldosteronism? What test to confirm?
1] aldosterone-producing adenoma and
2] bilateral idiopathic hyperaldosteronism
Adrenal CT scan
Describe the treatment of Primary Hyperaldosteronism
adrenalectomy
Pt c/o Attacks of HA, perspiration, palpitations, tachycardia, anxiety,
Vital- HTN
Pheochromocytoma
Tumor in adrenal medulla; rare cause of HTN
Describe the HTN in Pheochromocytoma
may be sustained, resistant to therapy or paroxysmal, esp in relation to stress
Pt c/o Attacks of HA, perspiration, palpitations, tachycardia, anxiety,
Vital- HTN
What is the work up?
Pheochromocytoma
URine- elevated catecholamines or metanephrines;
CBC-plasma fractionated free metanephrines most sensitive but many false positives
What is next step in management if catecholamines or metanephrines positive?
Refer to Endocrinology
Followed by imaging of adrenals (CT or MRI)
treatment of Pheochromocytoma
surgical resection of tumor
When should you refer to an endocrinologist?
1] If positive, refer to Endocrinology,
2] If you’re not sure, refer to Endocrinology,
3] Treatment and follow up will be done by the Endocrinologist
