FN: Adrenal Insufficiency

Question 1

Primary Adrenal insufficiency

Answer 1

Addison’s

Question 2

Addisons disease

Answer 2

Destruction of adrenal cortex –> glucocorticoid and mineralcorticoid deficiency

Question 3

Causes of Addisins

Answer 3

1. Autoimmune destruction: 80% in the UK
2. TB: commonest worldwide
3. Metastasis: lung, breast, kidneys
4. Haemorrhage: waterhouse-Friedrichson
5. Congenital

Question 4

Symptoms of adrenal insufficiency

Answer 4

1. Wt. loss + anorexia
2. n/v, abdo pain, diarrhoea/constipation
3. Lethargy, depression
4. Hyperpigmentation: buccal mucosa, palmer creases
5. Postura hypotension –> dizziness, faints
6. Hypoglycaemia
7. Vitiligo
8. Addisonian crisis

Question 5

Investigations

Answer 5

Bloods
Differential
Other

Question 6

Bloods show

Answer 6

Hyponatraemia/ Hyperkalaemia
REduce glucose
Reduced Caclium
Anaemia

Question 7

Differential by using which tests

Answer 7

Short synACTHen test

Question 8

SynACTH test

Answer 8

Cortisol before and after tetracosactide
Exclude Addison’s if raised cortisol

if 9am ACTH (usually low)

Question 9

Other investigations

Answer 9

1. 21-hydroxylase Abs: _ve in 80% of AI disease
2. Plasma renin and aldosterone
3. CXR: evidence of TB
4. AXR: adrenal calcification

Question 10

Treatment

Answer 10

1. Replace
2. Advice
3. Follow up

Question 11

Repace

Answer 11

Hydrocortisone

Fludrocortison

Question 12

Advice

Answer 12

1. Dont stop steroids suddenly
2. Increase steroids during intercurrent illness, injury
3. Wear a medic-alert bracelet

Question 13

Secondary adrenal insufficiency

Answer 13

i.e. hypothalamus or pituitary failure

Question 14

Causes of secondary adrenal insufficiency

Answer 14

1. Chronic steroid use –> supression of HPA axis
2. Pituitary apoplexy/Sheehans
3. Pituitary microadenoma

Question 15

Features of secondary adrenal insufficiency

Answer 15

1. Normal mineralcorticoid production

2. No pigmentation (ACTH drop)

Question 16

Features of secondary adrenal insufficiency

Answer 16

1. Normal mineralcorticoid production

2. No pigmentation (ACTH drop)

Question 17

Addisonian crisis presentation

Answer 17

Shocked: raised HR, postural drop, confused
Hypoglycaemia
Usually known addisons or chronic steroid use

Question 18

Addisonian crisis precipitants

Answer 18

Infection
Trauma
Surgery
Stopping long-term steroids

Question 19

Addisonian crisis management

Answer 19

1. Bloods: cortisol, ACTH, U+E, culture
2. Check CBG: glucose may be needed
3. Hydrocortisone 100mg IV 6hrly
4. IV crystalloid
5. Septic screen
6. Treat underlying cause