Adrenal Pathology

Question 1

What are the 3 layers of the adrenal cortex? What does each layer secrete?

Answer 1

From outside-in:

zona glomerulosa - aldosterone in response to angiotensin II
zona fasiculata - cortisol in response to ACTH
zona reticularis - androgens

Question 2

What is the effect of Addison’s on the blood?

Answer 2

Hypotension
Hyperkalaemia
Hyponatreamia
Hypoglycaemia
Metabolic acidosis

Question 3

What are 2 primary and 2 secondary causes of adrenal insufficiency?

Answer 3

Addison’s
Congenital adrenal hyperplasia

Pituitary disease
Exogenous steroid use

Question 4

What is the test for adrenal insufficiency? What is the anticipated result?

Answer 4

Short synacthen test

normally cortisol should have baseline >250 nmol/l and rise to >550 nmol/l after IM Synacthen

Question 5

What does aldosterone normally do?

Answer 5

Increases blood pressure

Causes excretion of K+ and H+

Causes resorption of Na+

Question 6

What is the treatment for adrenal insufficiency?

Answer 6

Hydrocortisone and fludrocortisone

Hydrocortisone - Split over the day, most given in the morning.

Question 7

What are the sick-day rules for treatment of adrenal insufficiency?

Answer 7

Double hydrocortisone, maintain fludrocortisone dose

Question 8

What is the management of Addisonian crisis?

Answer 8

Hydrocortisone 100 mg
Normal saline with dextrose if hypoglycaemic
Continue hydrocortisone 6 hourly until the patient is stable - no need for fludrocortisone

Question 9

What test is used in Cushing’s syndrome?

Answer 9

Overnight dexamethasone suppression test

Question 10

Cushing’s syndrome may be ACTH-dependant (pituitary adenoma, small cell cancer) or -independant (adrenal adenoma or carcinoma).

How may the the underlying be determined to be ACTH-dependant or -independant?

Answer 10

9am and midnight plasma ACTH + cortisol levels

low- and high-dose dexamethasone suppression test

Question 11

What are the 3 features of primary hyperaldosteronism?

Answer 11

Significant, resistant hypertension.
Hypokalaemia
Metabolic alkalosis

Question 12

What are the 2 potential underlying causes of primary hyperaldosteronism?

Answer 12

Conn’s syndrome (adrenal adenoma)

bilateral adrenocortical hyperplasia

Question 13

What tests may diagnose primary hyperaldosteronism?

Answer 13

Aldosteron-Renin ratio

CT and adrenal vein sampling can determine if Conn’s or bilateral hyperplasia is cause.

Question 14

How would you treat Conn’s syndrome?

Answer 14

Surgical adrenelectomy

Question 15

How would you treat bilateral adrenocortical hyperplasia?

Answer 15

Spironolactone

Question 16

What is congenital adrenal hyperplasia?

Answer 16

A congenital disease in which there may be inappropriate secretion of hormones:

In 21alpha hyroxylase deficiency subtype:
Aldosterone and cortisol may be low
Testosterone may be high

Although different subtypes exist

Question 17

What is the treatment of congenital adrenal hyperplasia?

Answer 17

Hydrocortisone and fludrocortisone

Surgical correction of ambiguous genitals

Question 18

What are the symptoms of congenital adrenal hyperplasia

Answer 18

Adrenal insufficiency (similar to Addison’s = lack of aldosterone)

• Hyponatraemia
• Hyperkalaemia
• Hypoglycaemia

Salt-loss crisis

Poor weight gain

Genital ambiguity in females

Question 19

What is the classical triad of phaeochromocytoma?

Answer 19

Hypertension, headache, sweating

Question 20

What blood abnormalities may be seen in pheochromocytoma?

Answer 20

Hyperglycaemia
Hypokalaemia
Hypercalcaemia

High haematocrit
Lactic acidosis without shock

Question 21

What test confirms pheochromocytoma?

Answer 21

24hr urinary metinephrines

Question 22

What is the treatment for phaeochromocyotoma?

Answer 22

alpha-blocker THEN beta-blocker

Surgery - aim to excise, debulk if not possible

Chemo if malignant