la endo Flashcards
cortisol,
In response to low serum cortisol or stress…
the hypothalamus secretes corticotropin releasing factor (CRF)
In response to CRF…
the pituitary releases adrenocorticotropic hormone (ACTH) and melanocyte releasing hormone
In response to ACTH …
the adrenal glands secrete cortisol
In response to elevated cortisol levels…
the hypothalamus decreases production of CRF
Cortisol is produced by the ___ in a reaction to ___. Its main functions are to suppress ___ and increase available ___ by increasing ___ levels and promoting the breakdown of __ and ___. It also regulates ___
Cortisol is produced by the adrenal glands in a reaction to stress. Its main functions are to suppress the immune response and increase available energy by increasing** blood sugar** levels and promoting the breakdown of fat and protein. It also regulates electrolytes.
Cushing’s syndrome = ____ cortisol production
Addison’s disease = ___ cortisol production
Cushing’s syndrome = excessive cortisol production
Addison’s disease = low cortisol production
Cushing’s disease
Pituitary …
gender
Cushing’s disease
- Pituitary adenoma with hypersecretion of ACTH stimulating cortisol production in the adrenals.
- Women have a three times greater chance of having this than men.
Cushing’s syndrome
3 causes
- Adrenal tumor producing an increase in cortisol
- Ectopic production of ACTH – most commonly a small cell lung cancer
- Long term use of corticosteroids usually in treatment of another disease
cushing’s disease vs syndrome
syndrome is caused by an outside source (outside)
disease is caused by an inside source (pituitary)
most specific signs of cushings
moon facies, (acanthosis nigrans) pigmented striae more than 1 cm wide(thigh, breast, abdomen), buffalo hump, truncal obesity, hirsutism
moon facies, (acanthosis nigrans) pigmented striae more than 1 cm wide(thigh, breast, abdomen), buffalo hump, truncal obesity, hirsutism
cushings syndrome
cushings skin symptoms
poor wound healing
atrophy
acanthosis nigrans
thin extremities
cushings disease
-glucose, K++, cortisol
hyperglycemia
Hypokalemia
Cortisol is elevated
hyperglycemia
Hypokalemia
Cortisol is elevated
cushings disease
ACTH (cushings)
elevated
low
ACTH
elevated – pituitary or ectopic adenoma
low – adrenal cortex problem
cushings disease
MRI or
CT
MRI for pituitary tumor
CT for adrenalcortical or other tumors
For Cushing’s disease (pituitary adenoma) tx
transsphenoidal resection
1-metyrapone and ketoconazole
2-Parenteral octreotide
Cushings
– may suppress hypercortisolism.
-may suppress ACTH
what may suppress ACTH
Parenteral octreotide
Often patients treated for Cushing’s syndrome will go into ___ withdrawal, …
cortisol withdrawal, Addison’s disease, and require hydrocortisone or prednisone.
adrenal cortex releases what 3 things
androgen/sex hormones, aldosterone, cortisol
aldosterone 3 functions
- regulates BP
- retains Na
- secretes K+
cortisol functions (3)
- increase blood glucose
- breaks down fats/proteins/carbs
- regulates electrolytes
prognosis of cushings after succesful excision of a benign adrenal adenoma
95% chance of a 5 year survival
% of recurrence over 10 years with cushings
15-20%
what % of addison’s is secondary to autoimmune issues
- other 4 causes
80% Other causes include TB, genetic disorders, removal of adrenals, trauma(hemorrhaging)
addison’s secondary causes are …
pituitary based
calicification of adrenal glands
TB
precipated by infection, trauma, surgery, stress, SUDDEN cessation of corticosteroid medications
adrenal crisis
nonspecific GI symptoms, hypoglycemia, weakness, myalgias, fatigue, lethargy, salt craving, mild hyponatremia
secondary adrenocortical insufficiency
Sparse axillary and pubic hair
Hyperpigmentation of skin especially of creases or pressure areas (waistband/bra line)
Hypotension typically systolic under 110
Salt craving
AMENORRHEA
addison’s
addison’s symptoms
Sparse axillary and pubic hair
Hyperpigmentation of skin especially of creases or pressure areas (waistband/bra line)
Hypotension typically systolic under 110 mmhg
AMENORRHEA
Salt craving
addison’s
- menstuation
- hair
- reflexes
- BP
- amenorrhea
- sparse axillary and pubic hair
- delayed DTR
- low BP
hyperpigmentation in addison’s
only in primary disease when ACTH is elevated
hypotension, acute abd or low back pain, vomiting, diarrhea, dehydration, altered mental status
addisonian crisis; can be fatal if untreated
Cosyntropin stimulation test or ACTH stimulation test
cosyntropin test is diagnostic; ACTH is injected and the plasma cortisol is then monitored for a reaction.
- a serum cortisol rise of more than 18 after adminstration of cosyntropin is nml; anything less is suspicious
imaging of addison’s
Chest x-ray for TB
Abdominal CT – small adrenal glands in an autoimmune disease
diagnostic (addison’s)
- early plasma cortisol and ACTH
low cortisol(under 3) and elevated ACTH(over 200)
DHEA level of 1,000
-produced where
- anything higher excludes Addison’s
- adrenal gland
addison’s tx
- Replacement with oral hydrocortisone 1st line. Dexmethasone.
Fludrocortisone
Has sodium retaining properties and is the treatment for Addison’s.
addison’s length of steroids
These are given for life and should be monitored by clinical symptoms as well as blood tests to assure proper dosing throughout the patient’s lifespan
addison’s tx for improved well being, increased muscle mass, reversal of femoral neck bone loss
DHEA; monitor for androgenic effects
addisonian crisis tx
IV saline, glucose, glucocorticoids and tx of underlying disease
high fever
low blood pressure
confusion or coma
hypoglycemia
adrenal crisis
give IV saline, glucose, glucocorticoids
primary and secondary addison’s differences
primary: assoc with increased skin pigmentation, decreased glucocorticoids and decreased mineralcorticoids
secondary: ONLY assoc with decreased glucocorticoids and DOES NOT have skin pigmentation or hyperkalemia
- cortisol
- aldosterone
- DHEA
- ACTH
Most common etio for Addisons
autoimmune, think Hashimotos or DM type 1
autoimmune, Hashimotos or DM type 1
think Addisons
sudden d/c of exogenous steroid
secondary adrenal insufficiency
and/or Addisonian crisis
“Stress Hormone”
cortisol
in treating a pt with chronic adrenal insufficiency, they must be given IV glucocorticoids and _______ before and after surgical procedures
IV isotonic fluids
inc ACTH: Cushing disease;
dec ACTH; Cushing disease
acanthosis nigricans: Cushing’s
chronic renal insuff
cushing
tx for cushing disease
transspenoidal resection
24 hr urinary free cortisol,
nighttime salivary cortisol,
low dose overnight dexmathasone suppression test
most specific?
24 test.
order 2 of these tests for cushings disease
hyperglycemia, leukocytosis, hypokalemia, metabolic alkalosis
Cushings disease
hyponatremia, hyperkalemia, hypoglycemia
Chr. adrenal insufficieny
hyponatremia is SIADH
chronic hyponatremia tx
1) rate
2) unresponsive to fluid restriction
3) euvolemic or hypervolemic hyponatremia
1) over 72 hr duration with <8 mEq/L/day
2) demeclocycline
3) vasopressin antagonists(conivaptan)
SIADH
DI on left
SIADH on right
chronic hyponatremia tx
1) rate
2) unresponsive to fluid restriction
3) euvolemic or hypervolemic hyponatremia
1) over 72 hr duration with <8 mEq/L/day
2) demeclocycline
3) vasopressin antagonists(conivaptan)
labs in volume depletion
hemocrit and serum albumin increased
urinary sodium decreases
urea increases (secondary to urine stasis in nephron) but little change in serum Cr
primary hyperaldosteronism
Most common cause of primary hyperaldosteronism
adrenal hyperplasia: hyperfunctioning adrenal releasing lots of aldosterone
describe secondary hyperaldosteronism
increase RAAS activity, increase renin and this leads to increase in aldosterone
HTN, HYPOkalemia, metabolic alkalosis
triad of hyperaldosteronism
Primary _____ is a cause of secondary HTN
hyperaldosteronism
polyuria, fatigue, prox muscle weakness, decreased DTR, hypomagnesemia, constipation
hypokalemia
pt develops HTN at extreme age, not controlled on 3 meds
primary hyperaldosteronism
what test to dx hyperaldosteronism
renin and aldosterone levels.
both high: secondary
aldosterone high and renin low: primary. maybe do a adrenal supp test
hypo on left. hyper on right
do labs later.
hyperthyroidism
hyperthyroidism definitive tx
radioactive thyroid ablation or total thyroidectomy
- give levothyroxine (oral T4) and steroids
avoid aspirin!
Iv fluids, propanolol, PPU and IV glucocorticoids.
increased aldosterone and decreased renin
primary hyperaldosteronism
MC etio of primary hyperaldosteronism
bilateral adrenal hyperplasia
increased aldosterone and renin
secondary hyperaldosteronism
Conn syndrome
aldosteronoma
findings with hyperaldosteronism
secondary HTN
hypernatremia
hypokalemia
metabolic alkalosis
secondary HTN
hypernatremia
hypokalemia
metabolic alkalosis
hyperaldosteronism
aldosterone function?
excretes K+ and H+, holds onto Na; interacts with angiotensin 11
testing for hyperaldosteronism
get both renin and aldosterone levels
nml ratio: secondary cause (pituitary)
If aldosterone high and renin low: primary (renal cortex)
aldosterone is part of which zona layer
glomerulosa (outer layer)
cortisol is part of which zona layer
fasciculata (middle layer)
cortisol functions
increases blood glucose, osteoclasts, increases BP, helps fight infections
decrease in ADH does what to fluid
what about increase
decrease causes excretion of fluid, diluted urine, and more water excreted (polyuria)
increase causes more retention of fluid, diluted blood, and more water retained.
zona reticularis is which layer and secretes what
inner layer, DHEA/androgens
secondary hyperaldosterone
hypothyroidism
hashimotos d/s
most common thyroid cancer
2nd
papillary
follicular
thyroid cancer for age > 65
anaplastic
thyroid cancer slow growing. distant mets more common than local.
follicular
thyroid cancer. 90% sporatic. local cervical mets early. distant mets later
medullary.
papillary is local mets(cervical(
thyroid cancer increased calcitonin
10% associated with MEN
medullary
thyroid cancer r/f iodine deficiency
follicular
thyroid cancer
painless
rock hard mass
papillary painless
anaplastic hard
thyroid cancer. hx of radiation of neck/head. FH
papillary
thyroid cancer. TSH and T3 and T4 nml. Do FNA
papillary
thyroid cancer. hematologic spread; lung, liver, brain, bone
follicular
most sensitive thyroid nodule dx test
ultrasound
test for thyroid nodule > 1.5 cm with nml TSH
FNA
if FNA indeterminate for thyroid nodule
radioactive iodine uptake
hyperparathyroidism
hyperparathyroidism
hypoparathyroidism
vitamin d defiency
hypo left
hyper right
dawn left
somogi right
dawn left
somogi right
