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Clin Med II Final > Adrenal Gland Disorders > Flashcards

Adrenal Gland Disorders Flashcards

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1
Q

Adrenal gland hormones

A

glucocorticoids (cortisol)
mineralocorticoids (aldosterone)
androgens (DHEA)

catecholamines (EPI, NE)

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2
Q

Zones of the adrenal gland

A

glomerfulosa (aldosterone)
fasciculata (cortisol)
reticularis (androgens)
medulla (catecholamines, SS, substance P)

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3
Q

Regulation of aldosterone secretion

A

ATII

Potassium concentrations

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4
Q

Crotisol

A

fasciculata
increase blood glucose; metabolic effects

Regulation: ACTH, CRH

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5
Q

Androgens

A

reticularis
concerted to T, DHT, Estradiol

Regulation: ACTH, CRH

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6
Q

Catecholamines

A

medulla
increase BP, respiration, HR; constrict blood flow to GI tract

Regulation: preganglionic sympathetic neurons

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7
Q

Cortisol feedback

A

negative feedback to hypothalamus and anterior pituitary

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8
Q

Cortisol functions

A 
stimulate gluconeogenesis, increase blood glucose
decrease glucose uptake
promote anti-inflammatory effects
reduce bone formation
increase proteolysis in muscle
maintains normal BP
decrease intestinal and renal calcium absorption, decreasing plasma calcium
inhibits collagen formation
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9
Q

Cortisol release

A

released during night; peaks right when you wake up

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10
Q

Cushing syndrome

A

result of prolonged exposure to excess cortisol* and androgens

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11
Q

Features of cushing syndrome

A

reprod: mentrual irregularities (oligo or amenorrhea), hirsuitism, acne, increased libido

Derm: easy bruising, STRIAE, HYPERPIGMENTATION

Metabolic: glucose intolerance/hyperglycemia, CENTRAL OBESITY (moon face, buffalo hump)

CV: increased CV risk, HTN, increase VTE risk

Bone/MSK: Osteoporosis, proximal muscle wasting, weakness

Neuropsych: emotional lability, depression, anxiety

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12
Q

Cause of cushing

A

meds (prednisone)
tumor (pituitary adenoma)

ACTH dependent (80%): cushings disease = pituitary hypersecretion of ACTH; ectopic secretion of ACTH by non-pituitary tumor – ACTH and cortisol HIgh (F>M)

ACTH independent: latrogenic or factitious Cushing syndrome (adminitration of excessive cortisol); adenoma/carcinoma; pheochromocytomaa - High Cortisol, low ACTH

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13
Q

Dx of cushings

A

exclude exogenous glucocorticoids!

24-hour urinary free cortisol excretion***- gold standard
Late-night salivary cortisol
low-dose dexamethasone suppression tests

More:
MRI- r/o pituitary tumor
CXR - r/o lung mass as source of ACTH-secreting tumor
Pelvic U/S: r/o ovarian mass
CT abdomen: r/o adrenal tumor
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14
Q

Low-dose dexamethasone suppression test

A

1 mg oral dexamethasone administered at 11pm
serum cortisol levels measured at 8 am next morning
Elevated cortisol >5 mcg/dL = ABNORMAL***

if abnormal- highly suspicious for non-suppressible cortisol production from ACTH- indep etiology (adenoma/carcinoma)

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15
Q

Management of cushing

A

exogenous- taper to lowest dose
Pituitary adenoma - transsphenoidal resection
Adrenal tumor- adrenalectomy
adrenal hyperplasia - inoperable tumor, other malignacy -medical tx

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16
Q

Drugs for cushigns

A

Ketoconazole*** 1st line
Metyrapone (if keto ineffective this is added)
Mitotane- used to achieve “medical adrenalectolmy”

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17
Q

Aldosterone functions

A 
increase BP*
increase ECF
increase tubular reabsorption of sodium
promote excretion of potassium*
water retention
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18
Q

Conn’s syndrome aka

A

Primary hyperaldostronism

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19
Q

Etiology of conn’s syndrome

A

Bilateral idiopathic adrenal hyperplasia (60%)

unilateral aldosterone-producing adenoma (APA) (30%)

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20
Q

Clinical features of conn’s

A 
hypertension
hypokalemia
muscle weakness
paresthesias
h/a
polyuria
polydipsia
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21
Q

when to consider testing for conn’s

Study These Flashcards
A 
HTN + hypokalemia
resistant HTN
adrenal incidentaloma + HTN
HTN <30 yo
Severe HTN (>150 or >100)
considering secondary HTN
22
Q

Dx of Conn’s

Study These Flashcards
A

Morning blood sample (PAC; PRA or PRC)
- PAC >10 + decrease PRA or PRC –> hypokalemia + PAC >20 = Conn’s; if no, do 24 hour urine, fludrocortison suppression testing OR saline suppression testin

  • PAC <10 or PRA >1= surgically curable Conn’s is UNLIKELY

CT- r/o adrenal adenoma

23
Q

Management of Conn’s

Study These Flashcards
A

unilateral adenoma: surgical removal
Bilateral hyperplasia: mineralocorticoid receptor antagonist (SPIRONOLACTONE*** 1ST LINE) + other anti-hypertensives; monitor serum potassium, Cr, and BP frequently in first 4-6 weeks of therapy

24
Q

Primary adrenal insufficiency aka

25
What is addison's?
decreased synthesis of ALL adrenocortical hormones dec. cortisol: hypoglycemia, weight loss, mm. weakness dec. aldosterone: hyperkalemia, hypotension, metabolic acidosis, salt craving* Decreased androgens: (in females) decreased libido and pubic/axillary hair Increased ACTH: hyperpigmentation
26
Secondary adrenocortical insufficiency
failure of corticotrophs to secrete ACTH
27
Tertiary adrenocortical insufficiency
insufficient CRH from hypothalamus
28
2ndary and tertiary adrenal insufficiency
aldosterone is normal and no hyperpigmentation; sx related to cortisol and androgen deficiency
29
Etiology of Addison's
``` autoimmune destruction of adrenal cortex (most common) surgical (adrenalectomy) infection: TB, histo, cocci, HIV Hemorrhage or infarct metastases/malignancy ```
30
Etiology of secondary and tertiary AI
abrupt cessation of exogenous steroid (most common cause of secondary AI) - supresses HPA axis Pituitary disease endogenous steroid-producing tumor drugs that reduce corticosteroids (phenytoin, opiates, ketoconazole, rifampin)
31
Drugs which reduce corticosteroids
``` (oral pills reduce kindly) Opiates phenytoin rifampin ketoconazole ```
32
Adrenal crisis
``` fever syncope convulsions hypoglycemic hyponatremic severe vomiting and diarrhea ```
33
Dx of AI
serum AM cortisol** Cosyntropin (ACTH) stimulation test** ACTH, renin, aldosterone Anti-adrenal antibodies CMP, CBC screen for other endocrine disorders: TSH, prolactin, FSH, LH
34
Cosyntropin stimulation test
evaluates ability of adrenal gland to respond to ACTH Procedure: - draw baseline cortisol - administer bolus of cosyntropin (synthetic ACTH) IV or IM - draw cortisol @ 30 min and 60 min post administration ABNORMAL: cortisol fails to increase by 7mg/dL above baseline, OR to >18 (ADDISON"S)
35
Managmenet of AI
short-acting glucocorticoids (hydrocortisone BID to TID) Long-acting glucocorticoids (dexamethasone, prednisone) if non-compliant w/ short-acting Mineralcorticoid (fludrocortison) Consider oral DHEA in women
36
Mineralcorticoid drug
fludrocortisone
37
Long-acting glucocorticoids
dexamethasone | prednisone
38
Short-acting glucocorticoids
hydrocortisone (BID to TID)
39
What is pheochromocytoma?
catecholamine-secreting tumors that arise in chromaffin cells of the adrenal medulla- RARE
40
Presentation of pheochromocytoma
episodic HA tachycardia sweating paroxysmal HTN
41
Epidemiology of pheochromocytoma
sporadic or familial (MEN2) Most are benign peak incidence: 40-50 yo
42
Paragangliomas
catecholamine-secreting rumor from extra-adrenal location
43
When to suspect pheochromocytoma?
``` paroxysmal "attacks' refractory HTN or <20 YO abdominal mass family hx incidentally discovered adrenal mass MEN2, NF1 ```
44
Dx of pheochromocytoma
thyroid function test plasma/urine catecholamines plasma EPI and NE plasma metanephrines*** (drawn after 30 min supine) 24-hour urine catecholamines, metanephrines and CMA*** Clonidine suppression test** radiologic after biochemical dx made: - CT of abdomen w/o contrast*** - MRI - PET - MIBG scan - OctreoScan
45
When do you do MIBG
CT/MRI shows adrenal mass >10cm | paraganglioma
46
Management of pheochromocytoma
Chemical sympathectomy until surgery- ALPHA-BLOCKER (phenoxybenzamine) and BETA-BLOCKER (propranolol) Surgery** is definitive
47
Drugs for pheochromocytoma
Phenoxybenzamine (alpha blocker) | Propranolol (beta-blocker)
48
Adrenal Incidentaloma
mall lesion *greater than 1 cm in diameter*, serendipitously discovered by radiologic exam; 4% prevalence questions: is it functioning? is it malignant?
49
Dx of adrenal incidentaloma
r/o pheochromocytoma and subclinical cushing's syndrome if hypertensive: r/o hyperaldosteronism If there is known malignancy elsewhere: bx (do not bx if biochemical evidence of pheo or if widespread metastatic disease)
50
management of adrenal incidentaloma
if workout negative and likely benign and <2cm: repeat imaging in 6 months and repeat dexamethasone suppression test every year x 4 years if workup negative, benign but >2cm: consider surgical resection

Clin Med II Final (6 decks)

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