SOME adrenal gland stuff Flashcards
what hormones are released by glomerulosa?
mineralcorticoids
what hormones are released by fasciculata?
glucocorticoids
what hormones are released by reticularis?
androgens
also cortisol
what hormones are released by medulla?
catecholamines
what are the zones of the adrenal cortex from outer to inner?
GFRM
how do cortisol levels change throughout the day?
diurnal variation
peaks in the early AM
effects of chronic steroids on HPA axis
it can suppress it a lot and create cushing’s like symptoms
cushings syndrome vs disease
syndrome– excess glucocorticoids
disease– excess pituitary secretion of ACTH causing excess glucocorticoids
tumors that make ACTH
small cell lung carcinoma
OAT cell CA
they are associated with ACTH dependent
common iatrogenic cause of Cushing’s syndrome
glucocorticoid therapy
Symptoms of Cushing’s syndrome
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
Name the only two conditions that causes buccal and hand hyperpigmentation
primary adrenal insufficiency
ACTH- dependent Cushing’s syndrome
3 screening tests for working up Cushing’s
24 urine cortisol
Dexamethasone suppression testing
midnight salivary cortisol
what does <1.8ug aka being able to suppress cortisol indicate for the low dose suppression test?
its NOT cushings
if you do the low dose dexamethasone suppression test and cortisol levels do not get suppressed, what is this indicative for?
cushing’s syndrome
could also get elevated instead of suppressed
midnight salivary cortisol test results if person has cushings
high
steps to work up cushings
- H&P
- inquire about exogenous cortisol/steroid
- screening tests
- determine if ACTH dependent or ACTH independent
- imaging if screening is positive
is cushings DISEASE ACTH dependent or independent
it is dependednt
who should not get the 24 hr urine cortisol test?
renal dysfunction or profound stress
what level is considered diagnostic for cushings syndrome with urine cortisol?
> 300 ug
what is pseudo-cushings
when urine cortisol level is above normal but below 300ug
obesity, alcohol, depression
who should not get the dexamethasone suppression test?
women on OCP
why dont we use the dexamethasone suppression test in women who use OCPs?
the test measures total cortisol so it will cause false positives
who should not get the midnight salivary cortisol test?
people with sleep apnea or shift workers
what is a positive test with the midnight salivary cortisol?
high levels
normal is 0-ish
common causes of ACTH independent cushings syndrome?
iatrogenic
adrenal adenomas
adrenal Ca
think adrenals
which is higher in kids ACTH independent or dependent?
ACTH-independent
what does ACTH independent mean?
ACTH isn’t there but cortisol is still elevated
what does ACTH dependent mean?
ACTH is normal or elevated in setting of high cortisol when it should be low when cortisol is high
what test should be ordered to determine if the cushing’s is upstairs or downstairs?
AM Plasma ACTH
what does plasma ACTH undetectable mean when working up cushings?
it is ACTH independent
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)
what imaging should be done if cushings is ACTH independent/undetectable? what are you looking for?
CT of adrenal glands for cortisol producing tumor
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
why don’t we do imaging without workup for cushings?
high number of incidentalomas
first line treatment for cushings?
surgery
treatment for cushings disease?
pituitary surgery (transphenoidal resection)
treatment for cushings syndrome if d/t adrenal dx (adrenal adenoma or carcinoma)?
adrenalectomy
treatment for ectopic ACTH syndrome
surgical resection
tx for pituitary dz that is refractory to intervention?
bilateral adrenalectomy
treatment for bigger pituitary tumors or hormonal hyperfunction not responsive to surgery?
XRT
name the three meds for treating cushings
ketoconazole
mitoane
metyrapone
another name for conns syndrome
primary aldosteronism
which condition is associated with increased aldosterone and decreased renin?
primary aldosteronism
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
one physiologic effect of excess aldosterone?
hypokalemic alkalosis
sx of primary aldosteronism
HTN, Hypokalemia, alkalosis, hypernatremia
palpitations, polyuria, glucose intolerance, HA, muscle weakness
which medication should you stop if someone has primary aldosteronism?
ACE inhibitors
they can falsely elevate renin activity
4 causes of primary aldosteronism
- Aldosterone producing adrenal adenoma (APA)
- Idiopathic aldosteronism (zona glomerulosa hyperplasia)
- Primary adrenal hyperplasia
- Adrenal carcinoma
3 steps of diagnosing primary aldosteronism
- Plasma aldosterone/renin ratio (or 24 hr urine)
- confirm w/ suppression test
- MRI or CT to confirm (adrenal mass or hyperplasia)
what 2 meds must be discontinued for 6 wks before getting plasma aldosterone/renin ratio?
spironolactone
eplerone
why should you replace K+ if its low?
if it is low, it will inhibit aldosterone
what is the positive level with aldosterone/renin ratio?
> 30
aldosteronism is likely
if someone has primary aldosteronism and you did a suppression test, what should you expect?
NOT suppressible
what two suppression tests can you do when working up primary aldosteronism?
IV normal saline ( + if >10)
oral salt loading (>14)
expected renin levels with primary aldosteronism
it will be low! if it is normal then it’s not it!
what class of meds can cause false positives when checking renin and aldosterone levels?
beta blockers
what class of meds can cause false negatives when checking renin and aldosterone levels?
ACE-inhibitors
ARBs
Calcium channel blockers
tx for primary aldosteronism
- surgery– for APA and adrenal CA
- Meds for bilateral adrenal hyperplasia to decrease HTN and Increase K+
which two meds are given for bilateral adrenal hyperplasia
spironolactone
eplerenone
what is a pheochromocytoma
catecholamine secreting tumor from adrenal medulla
how does Pheo typically present?
paroxysmal sx/spells or chronic precipitated by postural changes, exercise, increased abdominal pressure
sx and classic triad of pheo
HTN!!, “PHE”
PHE= palpitations, HA, excessive sweating/diaphoresis
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
what is vanillymandic acid?
a byproduct of epi and NE
how is pheo treated?
adrenalectomy + premedicate w/ alpha and beta blockers to avoid adrenal crisis
what is an incidentaloma?
adrenal lesion on abdominal imaging ordered for something else
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
what do you do if an incidentaloma is >4cm?
remove it AFTER r/o pheo to avoid adrenal crisis
what is another name for primary adrenal insufficiency?
addison’s disesase
what is addison’s dz characterized by?
low serum cortisol
most common cause of addison’s dz?
autoimmune destruction
how is addison’s dz treated?
hydrocortisone and Flurocortisone
what tests would show decreased cortisol with addisons dz
8AM cortisol
midnight salivary swabs
24 hr urine
ACTH stimulation test
expected result of ACTH stimulation test in person with addisons dz
still low cortisol/ no increase
which autoimmune diseases is addisons dz associated w/
vitiligo
T1DM
hashimotos thyroiditis
pernicious anemia
celiac sprue
non autoimmune causes of primary adrenal insufficiency
adrenal hemorrhage
sepsis
trauma
infections (TB, HIV)
genetic syndromes
sarcoidosis
sx of primary adrenal insufficiency
hyperpigmentation, wt loss, hypotension
salt craving!!
other sx– weakness, fatigue, postural sx
3 lab findings with primary adrenal insufficiency
electrolyte disturbances
hyponatremia
hyperkalemia-acidosis
causes of secondary adrenal insufficiency
pituitary lesions, metastatic breast, prostate, lung CA
pan-hypopituitarism
steroid use
which 4 sx are seen with secondary but not primary adrenal insufficiency?
NO hyperpigmentation
NO hyperkalemia
NO vitiligo
ISOLATED glucocorticoid insufficiency
how is acute adrenal insufficiency diagnosed?
low serum cortisol and decreased serum cortisol response is diagnostic!
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
tx for secondary adrenal insufficiency
hydrocortisone
hydro vs fludrocortisone
fludrocortisone is a fake mineralocorticoid and is used in primary but not secondary adrenal insufficiency
what is adrenal crisis
crisis from patients w/ Al exposed to trauma, illness, surgery or miss a steroid
sx of adrenal crisis
acute abdomen
hypotension
dehydration
circulatory shock
clinical findings/lab findings of adrenal crisis
hypotension
hyperkalemia
hyponatremia
hypoglycemia
how is adrenal crisis treated?
hydrocortisone 100mg IV every 8 hrs
IVF for hypotension and shock
how to avoid adrenal crisis
give 100mg IV hydrocortisone before surgery and 8 hrs after in patients chronically treated with prednisone
important SE fo glucocorticoid therapy
adrenal suppression!
can be asymptomatic or non-specific sx till stress happens
