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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
Q

what is a positive test with the midnight salivary cortisol?

A

high levels
normal is 0-ish

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26
Q

common causes of ACTH independent cushings syndrome?

A

iatrogenic
adrenal adenomas
adrenal Ca
think adrenals

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27
Q

which is higher in kids ACTH independent or dependent?

A

ACTH-independent

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28
Q

what does ACTH independent mean?

A

ACTH isn’t there but cortisol is still elevated

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29
Q

what does ACTH dependent mean?

A

ACTH is normal or elevated in setting of high cortisol when it should be low when cortisol is high

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30
Q

what test should be ordered to determine if the cushing’s is upstairs or downstairs?

A

AM Plasma ACTH

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31
Q

what does plasma ACTH undetectable mean when working up cushings?

A

it is ACTH independent

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32
Q

what imaging should be done if the cushings is ACTH detectable/dependent? what are you looking for?

A

Pituitary MRI for cushing’s disease (a pituitary adenoma)

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33
Q

what imaging should be done if cushings is ACTH independent/undetectable? what are you looking for?

A

CT of adrenal glands for cortisol producing tumor

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34
Q

what does it mean if it is ACTH dependent but the MRI is negative?

A

it is an ectopic producing tumor like Oat cell CA, carcinoid tumor, medulla CA of thyroid, pheo

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35
Q

why don’t we do imaging without workup for cushings?

A

high number of incidentalomas

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36
Q

first line treatment for cushings?

A

surgery

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37
Q

treatment for cushings disease?

A

pituitary surgery (transphenoidal resection)

38
Q

treatment for cushings syndrome if d/t adrenal dx (adrenal adenoma or carcinoma)?

A

adrenalectomy

39
Q

treatment for ectopic ACTH syndrome

A

surgical resection

40
Q

tx for pituitary dz that is refractory to intervention?

A

bilateral adrenalectomy

41
Q

treatment for bigger pituitary tumors or hormonal hyperfunction not responsive to surgery?

A

XRT

42
Q

name the three meds for treating cushings

A

ketoconazole
mitoane
metyrapone

43
Q

another name for conns syndrome

A

primary aldosteronism

44
Q

which condition is associated with increased aldosterone and decreased renin?

A

primary aldosteronism

45
Q

what 3 things cause release of aldosterone?

A

decrease in vascular volume
sympathetic stimulation of renin secretion
elevated serum K+ directly acts on zona glomeruosa to stimulate aldosterone synthesis

46
Q

one physiologic effect of excess aldosterone?

A

hypokalemic alkalosis

47
Q

sx of primary aldosteronism

A

HTN, Hypokalemia, alkalosis, hypernatremia
palpitations, polyuria, glucose intolerance, HA, muscle weakness

48
Q

which medication should you stop if someone has primary aldosteronism?

A

ACE inhibitors
they can falsely elevate renin activity

49
Q

4 causes of primary aldosteronism

A
  1. Aldosterone producing adrenal adenoma (APA)
  2. Idiopathic aldosteronism (zona glomerulosa hyperplasia)
  3. Primary adrenal hyperplasia
  4. Adrenal carcinoma
50
Q

3 steps of diagnosing primary aldosteronism

A
  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
Q

what 2 meds must be discontinued for 6 wks before getting plasma aldosterone/renin ratio?

A

spironolactone
eplerone

52
Q

why should you replace K+ if its low?

A

if it is low, it will inhibit aldosterone

53
Q

what is the positive level with aldosterone/renin ratio?

A

> 30
aldosteronism is likely

54
Q

if someone has primary aldosteronism and you did a suppression test, what should you expect?

A

NOT suppressible

55
Q

what two suppression tests can you do when working up primary aldosteronism?

A

IV normal saline ( + if >10)
oral salt loading (>14)

56
Q

expected renin levels with primary aldosteronism

A

it will be low! if it is normal then it’s not it!

57
Q

what class of meds can cause false positives when checking renin and aldosterone levels?

A

beta blockers

58
Q

what class of meds can cause false negatives when checking renin and aldosterone levels?

A

ACE-inhibitors
ARBs
Calcium channel blockers

59
Q

tx for primary aldosteronism

A
  1. surgery– for APA and adrenal CA
  2. Meds for bilateral adrenal hyperplasia to decrease HTN and Increase K+
60
Q

which two meds are given for bilateral adrenal hyperplasia

A

spironolactone
eplerenone

61
Q

what is a pheochromocytoma

A

catecholamine secreting tumor from adrenal medulla

62
Q

how does Pheo typically present?

A

paroxysmal sx/spells or chronic precipitated by postural changes, exercise, increased abdominal pressure

63
Q

sx and classic triad of pheo

A

HTN!!, “PHE”
PHE= palpitations, HA, excessive sweating/diaphoresis

64
Q

how is pheo worked up

A

24 hr urine collection to measure catecholamines and metanephrines
diagnosed if >2 fold above normal/ repeat if borderline
then abdominal CT/MRI

65
Q

what is vanillymandic acid?

A

a byproduct of epi and NE

66
Q

how is pheo treated?

A

adrenalectomy + premedicate w/ alpha and beta blockers to avoid adrenal crisis

67
Q

what is an incidentaloma?

A

adrenal lesion on abdominal imaging ordered for something else

68
Q

if an incidentaloma is <4cm, what now? (3 things to r/o)

A

dexamethasone supp. test to r/o cushing
aldosterone/renin ration to r/o hyperaldosteronism
metanephrine levels to r/o pheo

69
Q

what do you do if an incidentaloma is >4cm?

A

remove it AFTER r/o pheo to avoid adrenal crisis

70
Q

what is another name for primary adrenal insufficiency?

A

addison’s disesase

71
Q

what is addison’s dz characterized by?

A

low serum cortisol

72
Q

most common cause of addison’s dz?

A

autoimmune destruction

73
Q

how is addison’s dz treated?

A

hydrocortisone and Flurocortisone

74
Q

what tests would show decreased cortisol with addisons dz

A

8AM cortisol
midnight salivary swabs
24 hr urine
ACTH stimulation test

75
Q

expected result of ACTH stimulation test in person with addisons dz

A

still low cortisol/ no increase

76
Q

which autoimmune diseases is addisons dz associated w/

A

vitiligo
T1DM
hashimotos thyroiditis
pernicious anemia
celiac sprue

77
Q

non autoimmune causes of primary adrenal insufficiency

A

adrenal hemorrhage
sepsis
trauma
infections (TB, HIV)
genetic syndromes
sarcoidosis

78
Q

sx of primary adrenal insufficiency

A

hyperpigmentation, wt loss, hypotension
salt craving!!
other sx– weakness, fatigue, postural sx

79
Q

3 lab findings with primary adrenal insufficiency

A

electrolyte disturbances
hyponatremia
hyperkalemia-acidosis

80
Q

causes of secondary adrenal insufficiency

A

pituitary lesions, metastatic breast, prostate, lung CA
pan-hypopituitarism
steroid use

81
Q

which 4 sx are seen with secondary but not primary adrenal insufficiency?

A

NO hyperpigmentation
NO hyperkalemia
NO vitiligo
ISOLATED glucocorticoid insufficiency

82
Q

how is acute adrenal insufficiency diagnosed?

A

low serum cortisol and decreased serum cortisol response is diagnostic!

83
Q

what three tests/labs are used with diagnosing adrenal insufficiency?

A

Cosyntropin stim test (aka Rapid ACH stim test)– no response
plasma ACTH levels
basal cortisol levels

84
Q

tx for secondary adrenal insufficiency

A

hydrocortisone

85
Q

hydro vs fludrocortisone

A

fludrocortisone is a fake mineralocorticoid and is used in primary but not secondary adrenal insufficiency

86
Q

what is adrenal crisis

A

crisis from patients w/ Al exposed to trauma, illness, surgery or miss a steroid

87
Q

sx of adrenal crisis

A

acute abdomen
hypotension
dehydration
circulatory shock

88
Q

clinical findings/lab findings of adrenal crisis

A

hypotension
hyperkalemia
hyponatremia
hypoglycemia

89
Q

how is adrenal crisis treated?

A

hydrocortisone 100mg IV every 8 hrs
IVF for hypotension and shock

90
Q

how to avoid adrenal crisis

A

give 100mg IV hydrocortisone before surgery and 8 hrs after in patients chronically treated with prednisone

91
Q

important SE fo glucocorticoid therapy

A

adrenal suppression!
can be asymptomatic or non-specific sx till stress happens

ENDO 2 (6 decks)

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