- Mineralocorticoids - Adrenal Androgen (sex steroids) - CAtecholamines

ENDO BLOCK (ADRENAL) Flashcards by Aserah Blank

Hormone produces in Zona Glomerulosa

Aldosterone

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Hormone produces in Adrenal Medulla

Chromaffin cells: Epinephrine, Norepi

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Hormones produced in Zona FAsciculata

Glucocorticoids

- Adrenal adrogens

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Common precursor of all steroid hormones derived from the adrenal cortex

Cholesterol

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Increase NA reabsorption and K and H excretion as well as regulated by renin-angiotensin system

Aldosterone

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Adrenal Hormones

Mineralocorticoids
Adrenal Androgen (sex steroids)
CAtecholamines

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Examples of Mineralocorticoids

Aldosterone
11-deoxycorticosterone (DOC)
Cortisol

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Major adrenal glucocorticoid

Cortisol

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Examples of Catecholamines

Epinephrine
Norepinephrine
Dopamine

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Examples of Adrenal androgen

Dehydroepiandrosterone (DHEA) / Dehydroepiandrosterone sulfate (DHEAS)
Androstenedione
testosterone and estrogen

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There is autonomous aldosterone secretion which leads to suppresion of renin secretion. Solitary functioning adrenal adenoma (70%), idiopathic bilateral hyperplasia (30%), associated w/ hypokalemia

Primary Hyperaldosteronism

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Typically presents with hypertension: long standing, moderate to severe, may be difficult to control despite multiple drug therapy, headaches, polydisia, polyuria, nocturia, muscle weakness and fatigue (hypokalemia)

Primary Hyperaldosteronism

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Must be suspected in any hypertensive patient who present with hypokalemia.

Lab Studies: spontaneous hypokalemia (K<3.2mmol/L)
hypokalemia on diuretic therapy (K<3mmol/L)
Radiologic Studies: CT scan with 0.5cm cuts
MRI scans
scintigraphy with 121I-6B-iodomethyl noriodocholesterol (NP-59)

Hyperaldosteronism

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Treatment:

CT Scan/ MRI -> Bilaterally abnormal or normal adrenals -> (1)Selective venous catheterization for aldosterone and cortisol, (2) NP-59 scan -> Unilateral increased aldosterone =?

Adrenalectomy

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Treatment

CT Scan/ MRI -> Bilaterally abnormal or normal adrenals -> (1)Selective venous catheterization for aldosterone and cortisol, (2) NP-59 scan -> Bilateral hyperfunction or failure to localize =?

Medical management

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Treatment

CT Scan/ MRI -> Unilateral adrenal tumor (0.5-2cm in diameter) =?

Adrenalectomy

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Treatment for Primary Hyperaldosteronism

Preoperative control of hypertension and adequate potassium supplementation (keep K>3.5mmol/L)
generally treated with spironolactone, amiloride, nifedipine or captopril
unilateral tumors producing aldosterone are best managed by

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Percentage of success in Adrenalectomy in treating Primary Hyperaldosteronism
Hypokalemia= ?
Correcting hypertension= ?

Hypokalemia= 90%

Correcting hypertension= 70%

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Complex of symptoms and signs resulting from hypersecretion of cortisol regardless of etiology.

Leads to peculiar fat deposition, amenorrhea, impotence, hirsutism, purple striae, hypertension, diabetes

Cushing’s Sydrome

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Refers to a pituitary tumor, usually an adenoma, w/c leads to bilateral adrenal hyperplasia and hypercortisolism

Cushing’s Disease

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Features of Cushing’s Syndrome

Weight gain (buffalo humps, supraclavicular fat pads)
hirsutism, plethora, purple striae, ecchymosis
hypertension
fatigue, osteopenia
emotional lability, psychosis, depression
diabetic, hyperlipidemia
polyuria, renal stones
impotence, decreased libido, menstrual irregularities

There is progressive truncal obesity which is the most common sign and symptoms.

Cushing’s Syndrome

Radiologic studies used to diagnose Cushing’s Syndrome

CT SCAN/ MRI (identify adrenal tumor 95% sensitivity)

elevated glucocoticoid levels that are not suppressible by exogenous hormone adminstration
loss of diurnal variation
overnight low-dose dexamethasone suppression test (N: <3ug/dl)
plasma ACTH levels (N: 10-100 pg/ml)

Cushing’s Syndrome

Treatment of Cushing's Syndrome - Laparoscopic adrenalectomy= ? - Open adrenalectomy= ? - Transphenoidal excision of pituitary adenoma= ? - Pituitary irradiation=?

- Laparoscopic adrenalectomy= px with adrenal adenomas - Open adrenalectomy= px w/ large tumor (>6cm) / suspected to be adrenocortical cancers - Transphenoidal excision of pituitary adenoma= Cushing's DIsease - Pituitary irradiation= persistent/ recurrent disease after surgery

Adrenal adenomas or carcinomas that secret adrenal androgens leads to what _______ in sex steroids excess

Virilizing syndrome

Women in this disorder develop hirsutism, amenorrhea, infertility, increased muscle mass, deepend voice, temporal baldness

Sex steroid excess

Diagnostic test for Sex Steroid Excess

DHEA (measured in plasma and urine as 17-ketosteroids)

Treatment for Sex Steroids Excess

Adrenalectomy

Group of disorders that result from deficiencies or complete absence of enzymes involved in adrenal steroidogenesis

Congenital adreenal hyperplasia (CAH)

Deficiency of this CAH is the most common that leads to virilization

21-hydroxylase (CYP21A2)

Second most common CAH that leads to hypertension, virilization and hyperpigmentation

11B-hydroxylase deficiency

The most severe form fo CAH, caused by cholesterol desmolase dificiency which result in fatal salt-wasting syndrome in female patients

Congenital adrenal lipoid hyperplasia

Diagnostic test for CAH

karyotype analysis and measurement of plasma and urinary steroids

Tx for CAH

-traditionally managed medically with Cortisol and mineralocorticoid replacement - - recently, bilateral laparoscopic adrenalectomy has been proposed as an alternative treatment

Rare tumors with prevalence rate from 0.3 - -.95% and often called the "10 percent tumor": 10% bilateral, 10% malignant, 10% occur in pediatric px, 10% are extra-adrenal and 10% are familial. It also occurs in families with MEN2A and MEN2B

Pheochromocytomas

Signs and symptoms of Pheochromocytomas

- classic triad (headache, palpitations & diaphoresis) - non specific: anxiety, tremulousness, paresthesia, flushing, chest pain, shortness of breath, abdominal pain, nausea & vomiting - most common clinical sign is hypertension

Biochemical studies used in pheochromocytomas

- diagnosed by testing 24-hour urine samples for catecholamines and their metabolites - determining plasma metanerphrine levels - urinary metanerphines are 98% sensitive and 98% specific

Radiologic studies for pheochromocytomas

- CT scans w/out contrast - MRI scan (pregnant women) - 121I-radiolabeled MIBG_ localizing pheochromocytomas es. in ectopic positions

Medical management is aimed chiefly at BP control and volume repletion preoperatively. Adrenalectomy is tx of choice usually performed via an open anterior approach to faciliate detection of bilateral tumor, extra-adrenal lesions or metastatic lesions

Treatment for Pheochromocytomas

Tumor in this disorder tends to be multiple and bilateral

Hereditary pheochormocytoma

Is rercommended in the absence of obvious lesions in the contralateral adrenal gland

Unilateral adrenalectomy

Px with tumors in both adrenal gland, this surgery may preserve adrenocortical function and avoid the morbidity of bilateral total adrenalectomy

Cortical-sparing subtotal adrenalectomy

DIsorder that 12-29% of pheochromocytomas are malignant and are associated w/ decreased survuval. There's no definitive histologic criteria defining this and malignancy is diagnosed when there is evidence of invasion into the surrounding structures or distant metastasis

Malignant Pheochromocytoma

In general, soft tissue lesions of malignant pheochromocytomas are treated with what if feasible

resection

Can be used for unresectable lesions or symptomatic skeletal metastases

External-beam radiation

MAybe useful in px with diffuse disease showing uptake on a diagnotic scan in Malignant Pheochromocytoma

Therapeutic 131I-MIBG Irradation

Cause: Primary Adrenal Insufficiency= Secondary Adrenal INsufficiency=

Primary Adrenal Insufficiency= resulting from adrenal disease Secondary Adrenal INsufficiency= due to deficiency of ACTH

Treatment fo Adrenal Insufficiency

- treatment must be inititiated based on clinical suspicion alone, even before test results are obtained or the patient is unlikely to survive - volume resuscitation with at least 2 to 3L of a 0.9% saline solution or 5% dextrose in saline solution - dexamethasone (4mg) should be administered IV - once patient has stabilized, infection should be sought, identified and treated

Diagnostic Studies: Characteristic lab findings: Diagnosed by ACTH Srimulation test: Peak cortisol levels:

Characteristic lab findings: hyponatremia, hyperkalemia, eosinophilia, mild azotemia and fasting or reactive hypoglycemia Diagnosed by ACTH Srimulation test: ACTH (250μg) is infused IV and cortisol levels are measured at 0, 30 and 60 mins. Peak cortisol levels: <20µg/dL suggest adrenal insufficiency

Subtle symptoms: fatigue, salt craving, weight loss, nausea, vomiting and abdominal pain

Chronic Adrenal Insufficiency

Suspected in stressed patients with any of relevant risk and may mimic sepsis, M.I., or pulmonary embulos and presents with fever, weakness, confusion, N&V, lethargy abdominal pain or severe hypotension

Acute Adrenal Insufficiency