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ENDO 2 > SOME adrenal gland stuff > Flashcards

SOME adrenal gland stuff Flashcards

1
Q

what hormones are released by glomerulosa?

A

mineralcorticoids

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2
Q

what hormones are released by fasciculata?

A

glucocorticoids

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3
Q

what hormones are released by reticularis?

A

androgens
also cortisol

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4
Q

what hormones are released by medulla?

A

catecholamines

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5
Q

what are the zones of the adrenal cortex from outer to inner?

A

GFRM

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6
Q

how do cortisol levels change throughout the day?

A

diurnal variation
peaks in the early AM

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7
Q

effects of chronic steroids on HPA axis

A

it can suppress it a lot and create cushing’s like symptoms

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8
Q

cushings syndrome vs disease

A

syndrome– excess glucocorticoids
disease– excess pituitary secretion of ACTH causing excess glucocorticoids

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9
Q

tumors that make ACTH

A

small cell lung carcinoma
OAT cell CA
they are associated with ACTH dependent

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10
Q

common iatrogenic cause of Cushing’s syndrome

A

glucocorticoid therapy

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11
Q

Symptoms of Cushing’s syndrome

A

facial plethora
truncal obesity
purple striae
hirsutism
HTN
proximal muscle weakness
easy bruising
buffalo hump
moon facies
growth arrest in kids w/ progressive obesity
hyperpigmentation ONLY if excess ACTH

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12
Q

Name the only two conditions that causes buccal and hand hyperpigmentation

A

primary adrenal insufficiency
ACTH- dependent Cushing’s syndrome

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13
Q

3 screening tests for working up Cushing’s

A

24 urine cortisol
Dexamethasone suppression testing
midnight salivary cortisol

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14
Q

what does <1.8ug aka being able to suppress cortisol indicate for the low dose suppression test?

A

its NOT cushings

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15
Q

if you do the low dose dexamethasone suppression test and cortisol levels do not get suppressed, what is this indicative for?

A

cushing’s syndrome
could also get elevated instead of suppressed

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16
Q

midnight salivary cortisol test results if person has cushings

A

high

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17
Q

steps to work up cushings

A
  1. H&P
  2. inquire about exogenous cortisol/steroid
  3. screening tests
  4. determine if ACTH dependent or ACTH independent
  5. imaging if screening is positive
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18
Q

is cushings DISEASE ACTH dependent or independent

A

it is dependednt

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19
Q

who should not get the 24 hr urine cortisol test?

A

renal dysfunction or profound stress

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20
Q

what level is considered diagnostic for cushings syndrome with urine cortisol?

A

> 300 ug

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21
Q

what is pseudo-cushings

A

when urine cortisol level is above normal but below 300ug
obesity, alcohol, depression

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22
Q

who should not get the dexamethasone suppression test?

A

women on OCP

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23
Q

why dont we use the dexamethasone suppression test in women who use OCPs?

A

the test measures total cortisol so it will cause false positives

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24
Q

who should not get the midnight salivary cortisol test?

A

people with sleep apnea or shift workers

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25
what is a positive test with the midnight salivary cortisol?
high levels normal is 0-ish
26
common causes of ACTH independent cushings syndrome?
iatrogenic adrenal adenomas adrenal Ca *think adrenals*
27
which is higher in kids ACTH independent or dependent?
ACTH-independent
28
what does ACTH independent mean?
ACTH isn't there but cortisol is still elevated
29
what does ACTH dependent mean?
ACTH is normal or elevated in setting of high cortisol when it should be low when cortisol is high
30
what test should be ordered to determine if the cushing's is upstairs or downstairs?
AM Plasma ACTH
31
what does plasma ACTH undetectable mean when working up cushings?
it is ACTH independent
32
what imaging should be done if the cushings is ACTH detectable/dependent? what are you looking for?
Pituitary MRI for cushing's disease (a pituitary adenoma)
33
what imaging should be done if cushings is ACTH independent/undetectable? what are you looking for?
CT of adrenal glands for cortisol producing tumor
34
what does it mean if it is ACTH dependent but the MRI is negative?
it is an ectopic producing tumor like Oat cell CA, carcinoid tumor, medulla CA of thyroid, pheo
35
why don't we do imaging without workup for cushings?
high number of incidentalomas
36
first line treatment for cushings?
surgery
37
treatment for cushings disease?
pituitary surgery (transphenoidal resection)
38
treatment for cushings syndrome if d/t adrenal dx (adrenal adenoma or carcinoma)?
adrenalectomy
39
treatment for ectopic ACTH syndrome
surgical resection
40
tx for pituitary dz that is refractory to intervention?
bilateral adrenalectomy
41
treatment for bigger pituitary tumors or hormonal hyperfunction not responsive to surgery?
XRT
42
name the three meds for treating cushings
ketoconazole mitoane metyrapone
43
another name for conns syndrome
primary aldosteronism
44
which condition is associated with increased aldosterone and decreased renin?
primary aldosteronism
45
what 3 things cause release of aldosterone?
decrease in vascular volume sympathetic stimulation of renin secretion elevated serum K+ directly acts on zona glomeruosa to stimulate aldosterone synthesis
46
one physiologic effect of excess aldosterone?
hypokalemic alkalosis
47
sx of primary aldosteronism
HTN, Hypokalemia, alkalosis, hypernatremia palpitations, polyuria, glucose intolerance, HA, muscle weakness
48
which medication should you stop if someone has primary aldosteronism?
ACE inhibitors they can falsely elevate renin activity
49
4 causes of primary aldosteronism
1. Aldosterone producing adrenal adenoma (APA) 2. Idiopathic aldosteronism (zona glomerulosa hyperplasia) 3. Primary adrenal hyperplasia 4. Adrenal carcinoma
50
3 steps of diagnosing primary aldosteronism
1. Plasma aldosterone/renin ratio (or 24 hr urine) 2. confirm w/ suppression test 3. MRI or CT to confirm (adrenal mass or hyperplasia)
51
what 2 meds must be discontinued for 6 wks before getting plasma aldosterone/renin ratio?
spironolactone eplerone
52
why should you replace K+ if its low?
if it is low, it will inhibit aldosterone
53
what is the positive level with aldosterone/renin ratio?
>30 aldosteronism is likely
54
if someone has primary aldosteronism and you did a suppression test, what should you expect?
NOT suppressible
55
what two suppression tests can you do when working up primary aldosteronism?
IV normal saline ( + if >10) oral salt loading (>14)
56
expected renin levels with primary aldosteronism
it will be low! if it is normal then it's not it!
57
what class of meds can cause false positives when checking renin and aldosterone levels?
beta blockers
58
what class of meds can cause false negatives when checking renin and aldosterone levels?
ACE-inhibitors ARBs Calcium channel blockers
59
tx for primary aldosteronism
1. surgery-- for APA and adrenal CA 2. Meds for bilateral adrenal hyperplasia to decrease HTN and Increase K+
60
which two meds are given for bilateral adrenal hyperplasia
spironolactone eplerenone
61
what is a pheochromocytoma
catecholamine secreting tumor from adrenal medulla
62
how does Pheo typically present?
paroxysmal sx/spells or chronic precipitated by postural changes, exercise, increased abdominal pressure
63
sx and classic triad of pheo
HTN!!, "PHE" PHE= palpitations, HA, excessive sweating/diaphoresis
64
how is pheo worked up
24 hr urine collection to measure catecholamines and metanephrines diagnosed if >2 fold above normal/ repeat if borderline then abdominal CT/MRI
65
what is vanillymandic acid?
a byproduct of epi and NE
66
how is pheo treated?
adrenalectomy + premedicate w/ alpha and beta blockers to avoid adrenal crisis
67
what is an incidentaloma?
adrenal lesion on abdominal imaging ordered for something else
68
if an incidentaloma is <4cm, what now? (3 things to r/o)
dexamethasone supp. test to r/o cushing aldosterone/renin ration to r/o hyperaldosteronism metanephrine levels to r/o pheo
69
what do you do if an incidentaloma is >4cm?
remove it AFTER r/o pheo to avoid adrenal crisis
70
what is another name for primary adrenal insufficiency?
addison's disesase
71
what is addison's dz characterized by?
low serum cortisol
72
most common cause of addison's dz?
autoimmune destruction
73
how is addison's dz treated?
hydrocortisone and Flurocortisone
74
what tests would show decreased cortisol with addisons dz
8AM cortisol midnight salivary swabs 24 hr urine ACTH stimulation test
75
expected result of ACTH stimulation test in person with addisons dz
still low cortisol/ no increase
76
which autoimmune diseases is addisons dz associated w/
vitiligo T1DM hashimotos thyroiditis pernicious anemia celiac sprue
77
non autoimmune causes of primary adrenal insufficiency
adrenal hemorrhage sepsis trauma infections (TB, HIV) genetic syndromes sarcoidosis
78
sx of primary adrenal insufficiency
hyperpigmentation, wt loss, hypotension salt craving!! other sx-- weakness, fatigue, postural sx
79
3 lab findings with primary adrenal insufficiency
electrolyte disturbances hyponatremia hyperkalemia-acidosis
80
causes of secondary adrenal insufficiency
pituitary lesions, metastatic breast, prostate, lung CA pan-hypopituitarism steroid use
81
which 4 sx are seen with secondary but not primary adrenal insufficiency?
NO hyperpigmentation NO hyperkalemia NO vitiligo ISOLATED glucocorticoid insufficiency
82
how is acute adrenal insufficiency diagnosed?
low serum cortisol and decreased serum cortisol response is diagnostic!
83
what three tests/labs are used with diagnosing adrenal insufficiency?
Cosyntropin stim test (aka Rapid ACH stim test)-- no response plasma ACTH levels basal cortisol levels
84
tx for secondary adrenal insufficiency
hydrocortisone
85
hydro vs fludrocortisone
fludrocortisone is a fake mineralocorticoid and is used in primary but not secondary adrenal insufficiency
86
what is adrenal crisis
crisis from patients w/ Al exposed to trauma, illness, surgery or miss a steroid
87
sx of adrenal crisis
acute abdomen hypotension dehydration circulatory shock
88
clinical findings/lab findings of adrenal crisis
hypotension hyperkalemia hyponatremia hypoglycemia
89
how is adrenal crisis treated?
hydrocortisone 100mg IV every 8 hrs IVF for hypotension and shock
90
how to avoid adrenal crisis
give 100mg IV hydrocortisone before surgery and 8 hrs after in patients chronically treated with prednisone
91
important SE fo glucocorticoid therapy
adrenal suppression! can be asymptomatic or non-specific sx till stress happens

ENDO 2 (6 decks)

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