Endocrinology 3 - Adrenal Insufficiency

Question 1

differentiate adrenal insufficiency and adrenal disease

Answer 1

insufficiency = adrenal glands not producing enough steroid hormones

disease = specifically where the adrenal gland has been damaged

Question 2

define primary // secondary // tertiary adrenal insuff

Answer 2

1 - adrenal failure (usually autoimmune cause)
2 - pituitary damage + lack of ACTH
3 - inadequate CRH (usually from sudden withdrawal of long term steroids)

Question 3

5 symptoms and 2 signs of adrenal insufficiency

Answer 3

fatigue
reduced libido 
nausea
abdo pain 
cramps 

bronzing of skin
hypotension, particularly postural

Question 4

7 investigations with adrenal insufficiency

Answer 4

U+Es (high potassium, low sodium)
early morning cortisol (8-9am)
short synacthen test 
ACTH levels 
adrenal autoantibodies 
CT/MRI adrenals 
MRI pituitary

Question 5

what autoantibodies x2 may be involved in adrenal insufficiency

Answer 5

vs adrenal cortex

vs 21-hydroxylase

Question 6

short synacthen test

Answer 6

in morning
measure baseline, 30, 60 mins

suggestive of adrenal insufficiency if fails to double cortisol levels in this time

Question 7

treating adrenal insufficiency

Answer 7

titrate hydrocortisone and fludrocortisone to symptomatic relief

need steroid card and emergency bracelet /ID

double dose if acutely ill

Question 8

addisonian / adrenal crisis signs x 4

Answer 8

reduced GCS /coma
hypotension
low sugar, low sodium, high potassium
very unwell!!!

Question 9

cause of adrenal crisis

Answer 9

first presentation of disease or acute trigger with PMH (e.g. infection, trauma)

Question 10

treating adrenal crisis x5

Answer 10

intensive monitoring 
IV steroids (100mg hydrocortisone, then repeated 6 hourly)
IV fluids
correct hypoglycaemia
careful U+E and fluid balance monitoring