1. Adrenal

Question 1

Congenital absent kidneys will result to what adrenal?

Answer 1

Pancak adrenals

Flat
Straight
Discoid

Question 2

Each adrenal gland gets arterial blood from these 3 arterial supplies

Answer 2

Superio - phrenic
middl - aorta
inferior - renal artery

Question 3

There are 4 zones to the adrenal, each of which makes different stuff.

Answer 3

Zona Glomerulosa
Zona Fasiculata
Zona Reticularis
Medulla

Question 4

Makes Aldosterone

Answer 4

Zona gromerulosa

Prolonged stimulation = hypertrophy

Question 5

Makes cortisol

Answer 5

Zona Fasciculata

Question 6

Makes Androgens

Answer 6

Zona Reticularis

Question 7

Makes Catecholamines

Answer 7

Medulla

Question 8

Age related trivia: The relative size of the adrenal changes as you age.
* Second Trimester:
* Third Trimester:
* Adulthood:

Answer 8

• Second Trimester: Adrenal is Half the Size of the Kidney
• Third Trimester: Adrenal is 1/3 the Size of the Kidney
• Adulthood: Adrenal is 1/13 the Size of the Kidney

Question 9

In babies, the cortex is ____
the medulla is ____

Answer 9

Normal Adrenal -
Hypoechoic Cortex,
Hyperechoic Medulla,
Hypoechoic Cortex - like an Oreo, with a creamfilling.

Question 10

If you see a Pediatric Adrenal Cases you should think about:

Answer 10

(a) normal
(b) congenital
(c) neuroblastoma
(d) hemorrhage
(e) hyperplasia

Question 11

There are three classic congenital cases

Answer 11

Pancake (Discoid)
Horseshoe
Adrenal Cyst

Question 12

This occurs when the limbs of the adrenal glands fuse in the midline, and is associated with asplenia (right isomerism)

Answer 12

Horseshoe adrenals

Remember, they can show you bilateral trilobed lungs, a horizontal midline liver, an absent spleen, malrotation, and congenital heart disease (total anomalous pulmonary venous return - most commonly) — all in association with this horseshoe adrenal gland.

Question 13

in a newborn - an adrenal cyst usually get resected because you can’t tell them apart from ?

Answer 13

Neuroblastoma

Question 14

they form in the adrenal medulla (usually), and typically look like an enlarged gland with a hyperechoic component.

Answer 14

Neuroblastoma

Question 15

This occurs most commonly in the setting of trauma or stress (neonates).

What this typically looks like on ultrasound is an enlarged gland with an anechoic component.

Answer 15

Hemorrhage

Question 16

Hemorrhage of the adrenal in the setting of M fulminant meningitis (from Neisseria Meningitidis).

Answer 16

Waterhouse-Friderichsen Syndrome

Question 17

Answer 17

Adrenal Hyperplasia

So what does “looks like a brain ” mean ? That means the surface is wrinkled, like it has gyri and sulci.

Question 18

Congenital adrenal hypertrophy is caused by

Answer 18

21-Hydroxylase Deficiency in 90% of the cases

Question 19

21-Hydroxylase Deficiency clicial manifestation

Answer 19

Genital ambiguity (girls)

Salt losing pathology (boys) - life threatening

Limb > 4 mm
loss of centrl hyperechoic stripe

Question 20

I say “Genital ambiguity”,

Answer 20

21-Hydroxylase Deficiency

Question 21

bilateral adrenal gland hyperplasia =

Answer 21

overproduction o f ACTH

Question 22

This is an overproduction ofACTH by a pituitary adenoma,

Answer 22

Cushing Disease = too much coritsol

Question 23

This is actually the most common cause of excess cortisol (75%)

Answer 23

Cushing Disease

Question 24

Cushing syndrome:

Answer 24

overproduction of ACTH by:
1. An ACTH secreting tumor - small cell tumor
2. Overproduction of ACTH via an adrenal adenoma
3. Straight up adrenal hyperplasia

+

Taking chronic high dose sterioid

Any way you end up with a fat moon face and big gross lines all over you belly counts as “syndrome.”

Question 25

classic mimic of an adrenal mass on imaging.

Answer 25

Infradiaphragmatic extralobar sequestration The ultrasound will show a heterogeneous suprarenal mass CT picture clearly showing the blood supply from the aorta (or branches o f the aorta):

Question 26

It is really hard to tell Infradiaphragmatic extralobar sequestration from an adrenal mass with out any “hints.” Examples of hints:

Answer 26

Hx of history “male neonatal with respiratory distress and cyanosis. ”

Question 27

Normal adrenal

Answer 27

Triple Stripe - Hypoechoic Cortex, - Hyperechoic Medulla - Hypoechoic Cortex - Smooth Surface

Question 28

Hyperplasia:

Answer 28

Big Longer than 20 mm Looks like a "brain" “Genital ambiguity”, = 21-OH Deficiency

Question 29

Hemorrhage:

Answer 29

Big with an anechoic (or echogenic) component Gets smaller over time Seen with “stress” or trauma

Question 30

Neuroblastoma

Answer 30

Big with an echogenic (or anechoic) component Does NOT gets smaller over time

Question 31

These things are easily the most common tumor in the adrenal gland

Answer 31

Adrenal Adenoma

Question 32

Absolute washout result of adenoma

Answer 32

Question 33

Relative washout result of adenoma

Answer 33

Question 34

what is a mimic of adenoma washout?

Answer 34

Hypervascular mets Portal venous HU values > 120 should make you think about a met.

Question 35

Answer 35

Adrenal Adenoma Signal drop out In and Out of Phase

Question 36

Real Life = Mass in Adrenal =

Answer 36

Adenoma

Question 37

If adnreal HU on PVP is > 120 =

Answer 37

MEts from RCC/HCC or pheo

Question 38

Two different tumors that smash together to look like one mass.

Answer 38

“Collision Tumors” usually one of them is an Adenoma

Question 39

Syndrome of excessive aldosterone production. This is most commonly caused by a benign adenoma (70%).

Answer 39

Conn's Syndrome

Question 40

Answer 40

Pheochromocytoma T2 bright. a heterogeneous mass with AVID ENHANCEMENT

Question 41

if they show you HU measurements > 120 on arterial or portal venous phase =

Answer 41

you can NOT call the thing an adenoma.

Question 42

Rule of 10s of pheocromocytoma

Answer 42

10% are extraadrenal (Organ of Zuckerkandl - usually at the IMA 10% are bilateral 10% are in children 10% are hereditary 10% are NOT active (no HTN)

Question 43

Associated Syndrome of Pheochromocytoma

Answer 43

First Von Hippel Lindau then think MEN Ila and Ilb

Question 44

Carney Triad

Answer 44

Extra-Adrenal Pheo GIST Pulmonary Chondroma (hamartoma). Don't confuse this with the Carney Complex (Cardiac Myxoma, and Skin Pigmentation).

Question 45

Benign tumor that contains bulk fat

Answer 45

Myelolipoma

Question 46

Answer 46

Myelolipoma > 4 cm, can bleed + retroperitoneal hemorrhage

Question 47

Adrenal calcifications are often a result of ?

Answer 47

prior trauma + infection (TB) Certain tumors (cortical carcinoma, neuroblastoma, myelolipoma) can have calcifications. Melanoma mets are known to calcify.

Question 48

Answer 48

Bilateral enlarged calcified adrenals. It’s a fat metabolism error thing that kills before the first year of life.

Question 49

Answer 49

Cortical Carcinoma LARGE (4 cm -10 cm), May be functional (Cushings) Calcify in about 20% of cases Bad news & met everywhere (direct invasion often first). not likely to be less than 5 cm + often has central necrosis.