Adrenal disorders - Cushing's

Question 1

What are 9 signs of Cushing’s syndrome?

Answer 1

MR CUSHING
(moon face,
red striae,
centripetal obesity,
urine cortisol,
skin thinning,
hypertension,
impaired wound healing,
greater bruising) + Proximal myopathy

Question 2

Causes of Cushing’s

Answer 2

• Taking too much steroid (usually prednisolone)
• pituitary dependent cushing’s disease
• Ectopic ACTH from lung cancer
• Adrenal adenoma secreting cortisol

Question 3

What are the three investigations to diagnose Cushing’s syndrome?

Answer 3

24h urine collection for free urine cortisol,
Late night cortisol levels, (should be low)
low dose dexamethasone suppression test

Question 4

Dexamethasone suppression test

Answer 4

Potent version of cortisol, in normal people this would switch off cortisol production due to negative feedback
Cushing’s will fail to suppress cortisol to 0

Question 5

What would you ask a patient you suspect has Cushing’s to perform to suggest a diagnosis?

Answer 5

Squat - will be difficult to perform due to proximal myopathy and peripheral oedema

Question 6

11BHSD action on aldosterone receptors (MR)
11 beta hydroxysteroid dehydrogenase

Answer 6

Prevents action of cortisol on MR, making inactive cortisone

Question 7

What are the three drugs given for Cushing’s syndrome and what do they target?

Answer 7

Metyrapone (11-hydroxylase inhibitor and 11BHSD),
Ketoconazole (17-hydroxylase inhibitor)
Osilidrostat (new drug)

Question 8

What are the two adverse effects of metyrapone?
Short term solution

Answer 8

Hypertension (11-deoxycorticosterone),
Hirsutism (increased tesosterone) - meTYrapone (testosterone, ypertension)

Question 9

What are the two uses for metyrapone?

Answer 9

Prior to surgery, control of radiotherapy

Question 10

What is the adverse effect of ketoconazole?

Answer 10

Liver damage from hepatotoxicity

Question 11

What are the three surgical treatments for Cushing’s?

Answer 11

Pituitary surgery (trans-sphenoidal hypophysectomy), Bilateral adrenalectomy, (in rare cases)
Unilateral adrenalectomy for an adrenal tumour

Question 12

What is Conn’s syndrome?

Answer 12

Benign adrenal cortical tumour in zona glomerulosa - aldosterone excess produced (primary hyperaldosteronism)

Question 13

What are the two effects of Conn’s syndrome?

Answer 13

Hypertension, Hypokalaemia

Question 14

Conn’s diagnosis

Answer 14

Renin-angiotensin system should be suppressed due to hypertension

Question 15

What two drugs are used to treat Conn’s syndrome?

Answer 15

Spironolactone and Epleronone

Question 16

Spironolactone action

Answer 16

Competitive antagonist of mineralocorticoid receptor
Blocks Na+ resorption and K+ excretion in the kidney tubules (potassium sparing diuretic).

Question 17

Adverse effects of Spironolactone

Answer 17

Menstrual irregularities, gynaecomastia

Question 18

What is the difference in epleronone’s action to spironolactone?

Answer 18

Less binding to androgen and progesterone receptors, better tolerated in the body

Question 19

What are phaeochromocytomas?

Answer 19

Tumours of adrenal medulla which secrete catecholamines (adrenaline and noradrenaline)

Question 20

What are some body signs of the effects of phaeochromocytomas?

Answer 20

High blood pressure,
high basal metabolic rate,
high heart rate,
high blood glucose
Pale due to vasoconstriction

Question 21

What are the clinical features of phaeochromocytomas?

Answer 21

Hypertension in young people,
with severe episodic hypertension following abdominal palpitation
can be genetic

Question 22

What are two medical emergencies that can arise from phaeochromocytomas?

Answer 22

Severe hypertension - myocardial infarction and stroke // High adrenaline - ventricular fibrillation

Question 23

What do anaesthetists need to be aware of when operating on phaeochromocytomas?

Answer 23

Anaesthesia can invoke panic - leading to temporary hypertension, which should be avoided in this case

Question 24

What are the three solutions to the htn caused by anasthesia in phaechromacytoma?

Answer 24

Alpha-blockers, followed by intravenous fluid. Beta-blockers for tachycardia

Question 25

Why do we prescribe alpha blockers

Answer 25

Alpha receptors on arteries cause vasoconstriction. Blockers prevent hypertension during surgery