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Endocrine > The Adrenal Gland - Clinical > Flashcards

The Adrenal Gland - Clinical Flashcards

1
Q

Describe the hypothalamo-pituitary adrenal axis

A

CRH (corticotrophin releasing hormone) is produced by the anterior pituitary and stimulates ACTH (adrenocorticotrophic hormone) production

ACTH stimulates cortisol production in the adrenal cortex

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2
Q

What things can cause Addison’s disease?

A 
Immune destruction 
Invasion 
Infiltration 
Infection
Infarction
Iatrogenic
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3
Q

What is Addison’s disease?

A

Primary adrenal insufficiency

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4
Q

What is the commonest cause of Addison’s?

A

Autoimmune destruction leading to lymphocytic infiltration of the cortex

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5
Q

What conditions are associated with autoimmune Addison’s?

A

Thyroid disease
T1DM
Premature ovarian failure

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6
Q

What antibodies are found in 70% of Addison’s patients?

A

Antibodies to 21-OHase

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7
Q

What symptoms are associated with addisons?

A 
Weakness, fatigue, anorexia, wt loss
Skin pigmentation or vitiligo
Hypotension 
Unexplained vomiting/diarrhoea
Salt craving 
Postural symptoms
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8
Q

What things may point towards adrenal failure as a diagnosis?

A

Unexplained hypoglycaemia
Other endocrine features, e.g. hypothyroidism, body hair loss, amenorrhoea
Previous depression, wt loss

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9
Q

What tests should you do in suspected adrenal insufficiency?

A

UE, glucose, FBC
Random cortisol
Synacthen test and basal ACTH

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10
Q

If a patient is really unwell with suspected adrenal insufficiency what tests should you do?

A

Treat with steroids first and do test later

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11
Q

What random cortisol is definitely not Addison’s?

A

> 700nmol/l

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12
Q

What random cortisol may be Addison’s?

A

<700nmol/l

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13
Q

How do you carry out a short synacthen test?

A

Take blood for cortisol and ACTH
Give 250microg tetracosactrin IM
Half an hour later take cortisol level
Half an hour after than take another cortisol level

If congenital adrenal hyperplasia suspected can analyse bloods for 17-OH progesterone to exclude 17-hydroxylase deficiency

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14
Q

When should a short synacthen be done?

A

0900h

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15
Q

What would you expect as a normal response to the short synacthen test?

A

Stimulated plasma cortisol >550nmol/l

Failure to meet this indicates adrenal insufficiency

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16
Q

How can you distinguish between secondary and primary adrenocortical insufficiency?

A

If ACTH supressed - 2ndary

If ACTH elevated - primary

17
Q

What medication is given to treat Addison’s?

A 
Glucocorticoids:
Hydrocortisone 20-30mg 
or
Prednisolone 7.5mg 
or
Dexamethasone 0.75mg

Given in divided doses to mimic natural diurnal variation

Mineralocorticoids:
Fludrocortisone 50-300mg

18
Q

What receptors does fludrocortisone bind to?

A

Aldosterone

19
Q

How should you adjust the dose of fludrocortisone?

A

Based on clinical status, e.g. postural BP, oedema
UE
Plasma renin level

20
Q

Certain patients when they are undergoing stress may need extra steroids - what groups of people might these be?

A

Hypoadrenal patients on replacement steroids
Patients on steroids in doses sufficient to suppress the pituitary adrenal axis (>7.5mg predn daily)
Patients who have received treatment in last 18m whose HPA may still be suppressed

21
Q

If someone with Addisons is undergoing minor short lived stress/illness what advice should you give them re. their medications?

A

Double glucocorticoid dose

22
Q

If someone with Addisons is undergoing major illness/operation what steroid replacement do they need?

A

100mg hydrocortisone IV stat
50-100mg HC IV 8hrly
As stress abates, reduce HC by 50% per day until back on usual replacement dose

23
Q

What are the 3 most important rules for patients on steroids?

A

Never miss steroid doses
Double hydrocortisone in times of illness
If severe vomiting/diarrhoea call for help without delay - likely to need IM HC

24
Q

What are endocrine causes of hypertension?

A 
Unilateral adrenal adenoma
Bilateral adrenal hyperplasia
Phaeochromocytoma
Cushing's syndrome
Acromegaly
Hyperparathyroidism
Hypothyroidism
Congenital adrenal hyperplasia
25
Q

How can cushing’s syndrome cause hypertension and heart failure?

A

Xs cortisol –> sodium retention

26
Q

What are the symptoms of cushing’s syndrome?

A 
Central obesity
HTN
Glucose intolerance
Hirsutism
Amenorrhoea or impotency 
Purple striae
Plethoric faces
Easy bruising
Osteoporosis
Personality changes
Acne
Oedema
Headache
Poor wound healing
27
Q

What are the causes of cushing’s syndrome?

A 
Pituitary tumour (cushing's disease) 
Ectopic ACTH secretion, e.g. lung cancer

Adrenal tumour

Corticosteroid therapy

28
Q

How do you screen for Cushing’s?

A

24h urinary free cortisol

1mg overnight dexamethasone suppression test taken at midnight

29
Q

What is a normal 24hr urinary free cortisol?

A

14-135nmol/24h

30
Q

What is a normal 1mg overnight dexamethasone suppression test?

A

<50nml/l but there will be no suppression in cushings

31
Q

What is the first line localisation test for hypercortisolism?

A

9am and midnight plasma ACTH and cortisol

If ACTH not supressed adrenal cause unlikely

32
Q

What other two tests can be used to localise in hypercortisolism?

A

Low and high dose dexamethasone suppression test

33
Q

Not supressed by low dose dexamethasone =

A

Cushings due to corticosteroid therapy

34
Q

Not suppressed by low dose, but supressed by high dose dexamethasone = ?

A

Cushing’s disease

35
Q

Not supressed by high or low dose dexamethasone = ?

A

Ectopic ACTH secretion likely

36
Q

In hypercorticolism, how can you differentiate between pituitary and ectopic ACTH secretion?

A

Petrosal sinus sampling of ACTH

37
Q

What imaging may be useful in localising hypercorticolism?

A

MRI Sella
CT adrenals
CT chest
Bilateral inferior petrosal sinus sampling

Endocrine (11 decks)

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