02b: Adrenal HT

Question 1

Adrenal mechanisms for HT can be caused by excess:

Answer 1

1. Glucocorticoids (ZF)
2. Mineralocorticoids (ZG)
3. Catecholamines (medulla)

Question 2

90% of all congenital adrenal hyperplasia is due to (X) deficiency. Is HT a symptom?

Answer 2

X = 21-a hydroxylase

No (but other enzyme deficiencies causing CAH do have HT)

Question 3

List the causes of primary aldosteronism. Star the most common. Double-star the severe causes.

Answer 3

1. Bilateral hyperplasia*
2. Adrenal adenoma/carcinoma**
3. Glucocorticoid-remediable

Question 4

Pt with treatment-resistant BP makes you suspicious for (X), especially if (Y) serum levels are (low/high).

Answer 4

X = hyperaldosteronism
Y = K
Low

Question 5

Screening for hyperaldosteronism via which test/lab?

Answer 5

Plasma aldo:renin ratio (aka aldo:PRA ratio)

Question 6

Aldo:PRA ratio cutoff greater than (X) as well as plasma (Y) greater than 10 suggests diagnosis of…

Answer 6

X = 30
Y = aldosterone
Hyperaldosteronism

Question 7

List the guidelines for screening with aldo:PRA ratio

Answer 7

1. BP over 150/100 despite 3 BP meds
2. Low K
3. Adrenal incidentaloma

Question 8

Pt has high serum aldosterone and a high aldo:PRA ratio. What’s the next step?

Answer 8

Confirm diagnosis of hyperaldosteronism by V-loading maneuver (oral salt loading, saline infusion); normal response is to lower aldosterone

Question 9

Hyperaldosteronism: (X) is the most reliable test to distinguish unilateral adenoma from bilateral hyperplasia

Answer 9

Venous aldosterone and cortisol samples from adrenal veins

Question 10

Hyperaldosteronism from adenoma: what’s the Rx?

Answer 10

Surg (often curative) and maybe medical therapy (K-sparing diuretics)

Question 11

Hyperaldosteronism from bilateral hyperplasia: what’s the Rx?

Answer 11

1. K sparing diuretics
2. Ca channel blockers
3. ACEi

Question 12

T/F: Pheochromocytomas make up only 1% of hypertensive cases

Answer 12

True

Question 13

Patient has spike in BP during surgery. What should he/she be screened for?

Answer 13

Pheo

Question 14

T/F: FHx of Pheo is reason to screen patient

Answer 14

True

Question 15

Which familial syndromes put patient at risk for Pheo?

Answer 15

1. Familial Pheo
2. MEN-2
3. Neurofibromatosis
4. VHL syndrome

Question 16

Diagnostic tests for Pheo. Star the one with the highest sensitivity and double-star the one with highest specificity.

Answer 16

1. Plasma metanephrines*
2. Urine metanephrine/normetanephrines
3. Urine VMA**

Question 17

T/F: Pheo screening is limited by certain requirements due to too many false positives.

Answer 17

True

Question 18

T/F: Pheochromocytoma is limited to adrenal medulla.

Answer 18

False - 90% are located there, but can appear at other sites

Question 19

The “Rule of 10’s” applies to which disease?

Answer 19

Pheo

10% are extra-adrenal
10% are familial
10% are bilateral
10% are malignant

Question 20

Pheo Rx:

Answer 20

1. Surg

2. Med (pre-op/palliative)

Question 21

Medical Rx for Pheo includes:

Answer 21

1. Alpha-blocker
2. Ca channel blocker
3. Beta-blocker (ONLY after alpha-blocker)

Question 22

Patient has been diagnosed with unilateral adrenal pheochromocytoma. First step for Rx is:

Answer 22

Pre-op prep with alpha blockers (10-14 days before surg) to prevent severe BP changes during/after surg

Question 23

Incidentalomas are seen in (X)% of CTs and MRIs. (Y)% make some hormone and (Z)% are malignant.

Answer 23

X = 2-4
Y = Z = 10

Question 24

You discover an adrenal incidentaloma on patient’s abdominal CT. If this is a functioning mass, what is it most likely to be secreting?

Answer 24

Cortisol

less likely: pheo, aldosteronoma

Question 25

T/F: About 52% of adrenal masses are metastases.

Answer 25

False - only 2%! | 52% are cortical adenomas

Question 26

T/F: Adrenal incidentaloma has low CT density, making you less concerned about malignancy.

Answer 26

True - low CT density = benign (lipid-rich)

Question 27

T/F: About 25% of adrenal masses over 6 cm in diameter end up being cancer.

Answer 27

True

Question 28

CT washout: measure (X) before and after (Y).

Answer 28

``` X = CT density (of mass) Y = i.v. contrast administered ```

Question 29

Adrenal incidentaloma has CT density over 10 HU, so you do CT washout. What results would point toward an adenoma?

Answer 29

Fast washout (a more rapid rise then decline in CT density after contrast administration, compared to pheo/malignant mass)