Adrenal

Question 1

Blood supply to the adrenal

Answer 1

superior adrenal (inferior phrenic)
middle adrenal (aorta)
Inferior adrenal (renal artery)

Question 2

Venous drainage for the adrenal

Answer 2

Left - into left renal vein
Right - into cava

Question 3

Layers of adrenal and function

Answer 3

Cortex
-Glomerulosa (aldosterone)
-Fasiculata (glucocorticoid)
-Reticularis (androgens)
Medulla
-catecholamines

Question 4

Adrenalectomy approaches

Answer 4

Open
-Flank RP
-Anterior subcostal or chevron
-Posterior lumbodorsal
-Thoracoabadominal
Lab/robo
-Transabdominal
-Retroperitoneal

Question 5

If an adrenal mass is <__HU on noncon, no further workup needed. If not, then ____

Answer 5

10
Washout study

Question 6

Differential for Adrenal mass

Answer 6

Myelolipoma
ACC
Functional tumor
Mets

Question 7

Adrenal washout study

Answer 7

> 60% relative washout is lipid-poor adenoma
40% relative washout is lipid-poor adenoma

Question 8

Adrenal mass metabolic workup

Answer 8

BMP
Aldo – add renin if hypokalemia
Cortisol
17 ketosteroids
Metanephrines (plasma or urinary)
androgens only if ACC or virilization

Question 9

Cholesterol to pregnenolone

Answer 9

StAR and cyp11a1

Question 10

Pregnenolone to progesterone

Answer 10

3B-HSD

Question 11

Androstenedione to T

Answer 11

17B-HSD

Question 12

Progesterone to 17-OHP

Answer 12

Cyp17

Question 13

Progesterone to corticosteroids

Answer 13

Cyp21 and Cyp11

Question 14

Testosterone to estradiol

Answer 14

Aromatase

Question 15

Imaging approach to adrenal masses

Answer 15

noncon CT
>10HU –> washout CT or MRI

Question 16

Should adrenal masses be biopsied?

Answer 16

Nope

Question 17

Adrenal functional workup

Answer 17

Low dose dexamethasone suppression
BMP/HTN -> renin/aldo ratio if low K
Plasma free or 24hr urine metanephrines
DHEAS or testosterone

Question 18

Abnormal dex suppression - next steps

Answer 18

Check ACTH

Question 19

Next steps if aldo/renin ratio abnormal

Answer 19

adrenal vein sampling

Question 20

aldosterone mechanism

Answer 20

Acts at receptors in distal tubules/collecting ducts, wasting K

Question 21

Low dose dex suppression test process

Answer 21

Stop ACEI or ARB 4 weeks before test
1mg dex at 11pm, measure at 8am
>138 = cortisol hypersecretion

Question 22

When should androgens be tested for adrenal masses?

Answer 22

ACC or virilization

Question 23

Management of benign adrenal masses >4cm

Answer 23

repeat imaging, resect if growing >5mm/yr

Question 24

Causes of Cushing’s syndrome

Answer 24

ACTH dependent
-ACTH overproduction by pituitary (Cushing’s disease)
-Ectopic ACTH secretion by non-pituitary tumors
ACTH independent
-Cortisol-secreting adenoma

Question 25

Management of elevated ACTH

Answer 25

Brain MRI Petrosal vein sampling Neurosurgery consult

Question 26

Staging workup for suspected malignant adrenal mass

Answer 26

Chest imaging

Question 27

General steps for open adrenalectomy

Answer 27

Open gerota's fascia No touch technique for ACC ligate/clip adrenal arteries Ligate adrenal vein Check for bleeding Regional LND No drain Close

Question 28

Intraop complications from adrenalectomy

Answer 28

-Hypotension intraop - fluids -Tear adrenal vein - compress, obtain proximal/distal control, oversew with 4-0 prolene -Pleural leak - put red rubber inside, close, evacuate air, remove catheter

Question 29

Postop complications from adrenalectomy

Answer 29

PTX -> chest tube if large

Question 30

Management of pancreatic injury

Answer 30

-Close pancreatic capsule and place drain -Distal - can staple distal panc -Give TPN

Question 31

Management of liver injury

Answer 31

Horizontal mattress with bolster Pringle if bad bleeding Partial hepatectomy

Question 32

Management of duodenal injury

Answer 32

Repair in multiple layers with 4-0 silk Omental flap NGT

Question 33

Management of splenic injury

Answer 33

Control with hemostatics If needed, splenectomy (divide short gastrics, divide splenic artery, splenic vein)

Question 34

Management of metastatic ACC

Answer 34

Mitotane, etoposide, doxorubicin, cisplatin

Question 35

aldo/renin interpretation

Answer 35

FIRST make sure off spironolactone! High renin (low ratio) - think RAS, CHF, JG tumor aldo/renin >30 = primary hyperaldo

Question 36

If hyperaldo, next steps

Answer 36

CT scan, adrenal vein sampling

Question 37

Bilateral symmetric aldo on renal veins in hyperaldo

Answer 37

adrenal hyperplasia - start spironolactone

Question 38

Side effects of aldo receptor antagonists like spironolactone

Answer 38

gynecomastia, ED, hyperkalemia

Question 39

What stimulates aldo secretion

Answer 39

RAAS -blood loss, hyponatremia -Inhibited by ANF

Question 40

What is MIBG

Answer 40

norepi precursor - taken up by chromaffin cells - marker for tumors

Question 41

Pheo appearance on MRI

Answer 41

T2 bright

Question 42

Indications for genetic testing for adrenal mass

Answer 42

Under 50, FMHx pheo, multiple lesions, bilateral, malignant

Question 43

Mutation with highest malignant risk in pheo

Answer 43

SDHD

Question 44

Pheo prep

Answer 44

alpha blockade with phenoxybenzamine (or CCBs) THEN beta blockade THEN fluids

Question 45

Symptoms of pheo (8)

Answer 45

Headache Palpitations Sweating HTN Pallor Hyperglycemia Fatigue Anxiety

Question 45

Hereditary genetic forms pf pheo

Answer 45

Genes -RET -VHL -NF1 -SDHD -SDHB

Question 46

Syndromes associated with pheo

Answer 46

VHL NF1 MEN2A MEN2B Familial paraganglioma 1/4

Question 47

Rules of 10s for pheo

Answer 47

10% bilateral, malignant, extra-adrenal, pediatric, familial