L05 - Adrenal Causes of Hypertension

Question 1

Layers of adrenal gland

Answer 1

Gomerulosa, Fasciculata, Reticularis

Question 2

Adrenal causes of hypertension

Answer 2

Primary Hyperaldosteronism
CONN’s syndrome
— zona glomerulosa (adenoma, hyperplasia, rare genetic causes)

Phaeochromocytoma (Phaeo)
— adrenal medulla tumour

[[Some forms of congenital adrenal hyperplasia]]

Question 3

pathway map for aldosterone secretion

Answer 3

liver produces angiotensinogen, kidney produces renin which converts to angiotensin i, then ACE converts to angiotensin ii, then aldosterone.

Question 4

Primary hyperaldosteronism

who to screen. what do they have more of

Answer 4

Hypokalaemia, resistant hypertension, younger people

have more vascular and renal pathology than essential hypertension

Question 5

Primary hyperaldosteronism

what to screen (tests)

tests for specidic aetiology

Answer 5

initial tests
supressed renin, normal/high aldosterone

confirmary tests
oral or IV Na+ suppression test

to see if its for secreting adeoma or bilateral hyperplasia:

• -Adrenal CT scan
• -Adrenal venous sampling
• ———-Is the aldo secretion unilateral?
• -Metomidate PET CT

Question 6

Primary hyperaldosteronism

treatments

Answer 6

Unilateral Adenoma

• —-Laparoscopic Adrenalectomy
• —Medical Treatment ( sometimes )

Bilateral Hyperplasia
—-Medical Treatment ( Aldosterone Antagonists) - eg Spironolactone, Eplerinone

Question 7

Adrenal medulla

what is it

what connected

what does it secrete

Answer 7

Modified Post-Ganglionic Nerve cells inervated by preganglionic nerves

symp neurones in spinal cord

tyrosine –> LDOPA–> dopamine–> NA—(cortisol)–> adrenaline

last 3 are catecholamines

Question 8

Catecholamines

what are they what are the biological effects

Answer 8

Noradrenalin (Alpha 1 & 2 )

• -Vasoconstriction
• —-Increased BP
• —-Pallor
• -Glycogenolysis

Adrenalin ( Alpha 1, Beta 1 & 2 )

• -Vasoconstriction
• -Vasodilatation in Muscle
• -Increased heart rate
• -Sweating

Question 9

Phaechromocytoma

Presentation

Answer 9

“Spells”

• • Headache, Sweating
• • Pallor, Palpitation
• • Anxiety

Hypertension

• • Permanent
• • Intermittent

Family history

Question 10

Phaeochromocytoma

genetic conditions associated, symptoms of them

Answer 10

Neurofibromatosis Type 1
( NF1 )
—neurofibromas, axillary freckling

Multiple Endocrine Neoplasia type 2
( MEN 2 )
— medullary carcinoma of thyroid gland

Von Hippel – Lindau Syndrome

• – retinal hemangioglioblastoma
• – cerebellar haemangioglioblastoma

Question 11

Phaeochromocytoma

Biochemical diagnosis

what scan can you do

Answer 11

24 hour urine

• –Normetanephrines & Metanephrines
• – 3 Methoxytyromine

Plasma

• – Noradrenalin & Adrenalin
• – Metanephrines

MIGB scan

Question 12

Phaeochromocytoma

CATCHES
what else can elevate measured catecholamines

Answer 12

Obstructive Sleep Apnoea
Amphetamine like drugs
L-DOPA
Labetalol

Urine Dopamine comes from Kidney & Nervous system NOT the Adrenal Medulla. So measure urine Methoxytyramine

Question 13

Phaeochromocytoma

management and aftercare

Answer 13

Alpha Blockers

• –Phenoxybenzamine
• –Doxazocin

Beta Blockers
—Propranolol

Laparoscopic adrenalectomy

POST ADRENALECTOMY
---Consider Genetic testing
30% are genetic ( 13 mutations so far)
---Annual Metanephrines: 24 hour urine, Plasma
---Additional treatment if Malignant