12 - Adrenal Disorders

Question 1

Describe the adrenal glands

Answer 1

• Tiny glands that sit on top of kidneys

- They make epi, norepi, aldosterone and cortisol

Question 2

What do epi and norepi do?

Answer 2

• Epinephrine – flight or fight. Increases HR, BP, dilates pupils, redirects blood to muscles
• Norepinephrine – Increases BP

Question 3

What does cortisol do?

Answer 3

Regulates BP, cardiac function, immune system, mood, insulin metabolism

Question 4

What does aldosterone do?

Answer 4

• Increase blood pressure
• Controls water and sodium balance (water retention with low BP)
• Helps kidneys keep sodium or get rid of potassium

Question 5

What is secreted from the medulla of the adrenal gland?

Answer 5

Epinephrine and norepinephrine

Question 6

What problems can arise from problems form the medulla or epinephrine/norepinephrine?

Answer 6

• Pheocytocytoma

- Autonomic failure

Question 7

What is secreted from the cortex of the adrenal gland?

Answer 7

Aldosterone and cortisol

Question 8

What problems can arise from problems with the cortex/aldosterone?

Answer 8

Conn’s disease

Hypoaldosteronism

Question 9

What problems can arise from problems with the cortex/cortisol?

Answer 9

Cushing’s disease

Addison’s disease

Question 10

What is a pheochromocytoma?

Answer 10

Growth on the adrenal(s) leads to increased production of epi and NE

Question 11

Why is a pheochromocytoma called a 10% tumor?

Answer 11

Called 10% tumor, because 10% are…

• Malignant
• 2 sided
• In kids
• Familial
• Recur

Question 12

Signs and symptoms of pheochromocytoma

Answer 12

Rapid HR
High BP
Flushed
Anxiety
Pale

Need to surgically remove, radiation if malignant

Question 13

What can cause autonomic failure?

Answer 13

A lack of epinephrine/norepinephrine

Question 14

What is POTS?

Answer 14

Postural orthostatic tachycardic syndrome

• A combination of symptoms from a variety of causes (viral, cancer, adrenals, etc.)
• Patient will faint with SOB and fatigue
• Orthostatic hypotension

Question 15

How will you treat hypotension?

Answer 15

Hypotension medication

Question 16

What is Addison’s disease?

Answer 16

Failure of adrenals to make enough cortisol (sometimes aldosterone can be low too)

It is rare –> 1/100,000

Question 17

What causes Addison’s disease?

Answer 17

• Lack of adrenal function/response to ACTH

- Lack of ACTH from the pituitary to act on the adrenals

Question 18

Which cause of Addison’s disease is primary? Which is secondary?

Answer 18

Primary

• Lack of adrenal function/response
• Most common
• Mostly autoimmune

Secondary

• Pituitary dysfunction leading to a lack of ACTH
• Less common

Question 19

What signs and symptoms of Addison’s do you NEED to know?

Answer 19

• Low glucose
• Low sodium
• High potassium

** NEED TO KNOW **

Question 20

What other symptoms will you see in Addison’s?

Answer 20

• Weight loss
• Decreased appetite
• Fatigue
• Low BP
• Darkening of skin folds/membranes
• Electrolyte imbalances

Question 21

What is an Addison’s crisis?

Answer 21

Not enough cortisol for the patient when they get sick or are in a stressful situation

• This can be fatal
• Abdominal, back, leg pain
• Dehydration and hypotension
• MAJOR low glucose, low sodium and high potassium

Question 22

How do you treat an Addison’s crisis?

Answer 22

STEROIDS

You can also pretreat an Addison’s patient with steroids before stress, such as a surgical case

Question 23

How do you test for Addison’s?

Answer 23

Give synthetic ACTH

• If the cortisol level goes up, there is a problem in the pituitary gland producing ACTH
• If the cortisol level does not go up, there is a problem with the adrenal gland

Question 24

What are the signs and symptoms of Cushing’s disease?

Answer 24

• Trunk obesity
• Buffalo hump
• Hypertension
• Hyperglycemia, hypernatremia, hypokalemia
• Moon face
• Purple stretch marks
• Easy fractures
• Sex hormone dysregulation

Question 25

What will long term Cushing's lead to?

Answer 25

- Obesity - Osteoporosis - Diabetes - Muscle weakness - Skin issues

Question 26

What causes Cushing's?

Answer 26

Lots of things - Iatrogenic (we give them steroids for chronic problems so they develop Cushings) - Pituitary tumors - Ectopic tumors (islet cell, small cell, thyroid) - Adrenal problems - Familial causes

Question 27

What do we commonly use steroids for?

Answer 27

- Autoimmune - Lung - Tendonitis - GI issues Long term use can be an iatrogenic cause of Cushing's disease

Question 28

What causes an overproduction of ACTH?

Answer 28

- Over stimulation of adrenals, leading to too much cortisol - Pituitary tumors (adenomas) – called Cushing’s Disease. If large enough, can over-secrete other hormones (prolactin) - Ectopic ACTH from hormone secreting tumors (almost always lung cancers)

Question 29

How do you diagnose Cushing's?

Answer 29

- 24 hour urine – measure amount of cortisol made over 24 hours - Once you determine that this is high, chase down the source

Question 30

What do you do if cortisol is high?

Answer 30

Dexamethasone suppression test When given steroids, body should adjust and decrease its own production – sees if the brain is responding and shutting down ACTH (remember control center is in the brain)

Question 31

How do you treat Cushing's?

Answer 31

- If they are on steroids, taper off the steroids - If they have a pituitary adenoma. surgery and maybe radiation - If they have ectopic production, remove tumor - If there is an adrenal lesion, surgically remove Possibly treat with a new medicaiton - Signifor, which reuces cortisol in Cushing's disease

Question 32

What do you give to a Cushing's disease patient when they have a stressful event?

Answer 32

Like Addisons, Cushings may require stress dosing of steroids during illnesses, prior to surgery, etc... Seems contradicting, but this is what works

Question 33

What is Conn's disease?

Answer 33

Hyperaldosteronism Overproduction of aldosterone - Benign tumor (usual) Bilateral adrenal hyperplasia Either caused by a benign tumor or bilateral adrenal hyperplasia (not sure why)

Question 34

How common is Conn's disease?

Answer 34

We used to think it was rare, but really it is not

Question 35

What can Conn's be responsible for? ***

Answer 35

Resistant hypertension Now we think 5-15% of hypertensive patients have adrenal hyperplasia or an adrenal mass and that is causing the high BP There are many problems associated with high BP

Question 36

What is the treatment for Conn's disease?

Answer 36

Treatment - Take out adrenal (if there is a mass) or - Spiranolactone (blocks aldosterone)

Question 37

What are the signs and symptoms of Conn's disease? ***

Answer 37

- Hypertension - Low potassium*** Hypertensive patient with low potassium --> NEED to consider Conn's

Question 38

What glucose issue can be present in up to 20% of Conn's disease patients? ***

Answer 38

Glucose intolerance – they have high glucose but it does not lead to diabetes

Question 39

What acid base issues may patients with Conns have? ***

Answer 39

Metabolic alkalosis

Question 40

Why will metabolic alkalosis develop? ***

Answer 40

Renal loss of hydrogen ions occurs when excess aldosterone (Conn's syndrome) increases the activity of a sodium-hydrogen exchange protein in the kidney Excess sodium increases extracellular volume and the loss of hydrogen ions creates a metabolic alkalosis. Later, the kidney responds through the aldosterone escape to excrete sodium and chloride in urine.