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Adrenal glands Flashcards

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1
Q

Where are the adrenal glands located?

A

Above the kidneys

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2
Q

What are the three major layers of the adrenal gland?

A

Capsule
Adrenal cortex
Adrenal medulla

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3
Q

What are the three zones of the adrenal cortex (list from out to in).

A

Zona glomerulosa
Zona fasciculata
Zona Reticularis

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4
Q

What does the zona glomerulosa produce?

A

Mineralocorticoids such as aldosterone

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5
Q

What does the zona fasciculata produce?

A

Glucocorticoids such as cortisol

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6
Q

What does the zona reticularis produce?

A

Adrenal androgens such as testosterone

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7
Q

What is the precursor for all products of the adrenal cortex?

A

Cholesterol

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8
Q

How does cholesterol proceed through the metabolism?

A

Straight down to aldosterone
Diverted off to cortisol precursors
Cortisol precursors to cortisol or androgen precursors
Androgen precursors to androgens

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9
Q

How is cortisol and androgen release regulated?

A

By ACTH release from the anterior pit

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10
Q

What is the negative feedback for cortisol release?

A

Cortisol inhibits hypothalamus and ant pit

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11
Q

What effects does cortisol have on circulation and renal efficiency?

A

Increase CO and BP

Increase renal blood flow and GFR

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12
Q

What effects does cortisol have on metabolism?

A

Increase blood sugar
Increase lipolysis and central redistribution
Increase proteolysis

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13
Q

What effects does cortisol have on the CNS?

A

Mood lability
Euphoria/psychosis
Decrease libido

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14
Q

What effects does cortisol have of bone and connective tissue?

A

Increase osteoporosis
Decrease serum Ca
Decrease collagen formation
Decrease wound healing

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15
Q

WHat effects does cortisol have on the immune system?

A

Decrease cap dilation
Decrease leukocyte migration
Decrease macrophage activity
Decrease inflammatory cytokine production

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16
Q

What are the clinical uses of cortisol?

A

Suppress inflammation
Suppress immune system
Replacement therapy

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17
Q

How much cortisol is used in replacement therapy?

A

Enough to restore normal levels

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18
Q

How much cortisol is used in suppression therapy?

A

> 10x dose used in replacement

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19
Q

How should you give steroids?

A

PO if well

IV/IM if unwell

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20
Q

How is aldosterone release regulated?

A

RAAS

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21
Q

Describe RAAS

A

Drop in BP stim renin release
Renin converts angiotensinogen to angiotensin I
ACE converts angiotensin I to angiotensin II
Angiotensin II stim aldosterone release

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22
Q

What effect does aldosterone have?

A

Increases Na retention in kidneys therefore increasing BP

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23
Q

What are the two broad categories of adrenal dysfunction?

A

Hypo and hyper production

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24
Q

What two areas of the adrenal gland are affected by adrenal insufficiencies?

A

Cortex and medulla

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25
What are some common causes for primary adrenal insufficiencies?
``` Infection- TB/HIV Autoimmune Tumours Haemorrhage- Waterhouse-Friderichsen syndrome Genetic defects ```
26
What two forms of adrenal insufficiency affect the adrenal cortex?
Primary | Secondary
27
What is an adrenal insufficiency of the adrenal MC producing area of the adrenal gland called?
Addison's disease
28
What is the most common cause of Addison's disease?
Autoimmune destruction
29
What other autoimmune diseases is Addison's disease linked with?
T1DM | Autoimmune thyroiditis
30
How does Addison's disease present?
``` Anorexia/weight loss Fatigue DIzziness Low BP Abdo pain Vomiting Diarrhoea Skin pigmentation (due to elevated ACTH levels) ```
31
How do you treat Addison's disease?
Fludrocortisone- if suspect Addison's treat as such until proven otherwise.
32
How does adrenal insufficiency tend to present?
``` Anorexia/weight loss Fatigue DIzziness Low BP Abdo pain Vomiting Diarrhoea Skin pigmentation (due to elevated ACTH levels) ```
33
What blood chemistry would you see in Addison's disease?
``` Low Na High K Hypotension Raised renin Low aldosterone ```
34
What blood chemistry would you see in adrenal insufficiency?
``` Low Na High K Hypotension Hypoglycemia Raised renin Low aldosterone Raised ACTH levels ```
35
How do you diagnose Addison's disease/adrenal insufficiency?
Synacthen test
36
How do you do a synacthen test?
Give ACTH and check cortisol levels at: 0, 30, 60 and 90 mins. Baseline should be >250nmol/l. Should rise to >550nmol/l
37
Give a genetic cause of adrenal insufficiency
Congenital adrenal hyperplasia (CAH)
38
What are some causes of secondary causes of adrenal insufficiency?
Excessive exogenous steroid | Pit problems resulting in lack of ACTH
39
What is the most common cause of secondary adrenal insufficiency?
Exogenous steroids
40
How does secondary adrenal insufficiency present?
``` Weight loss/ Anorexia Fatigue Dizziness Abdo pain Vomiting Diarrhoea ```
41
How do you treat secondary adrenal insufficiency?
Treat underlying cause | Hydrocortisone
42
How should you administer hydrocortisone?
Large does in morning Small does at lunch Nothing after as will cause sleep problems
43
What is an excess of cortisol called?
Cushing's syndrome
44
What can cause Cushing's syndrome?
Pit adenoma- Cushing's disease (too much ACTH) Ectopic ACTH/CRH production Adrenal adenoma/carcinoma Nodular hyperplasia Iatrogenic- too much exogenous steroid atrophying adrenal glands.
45
How can Cushing's present?
``` Interscapular fat pad Thin skin/ bruising Proximal muscle wasting/thin arms and legs Central obesity Moon face Striae- dark colour/purple ```
46
What signs can you get in Cushing's?
``` Hypertension Osteoporosis- rare in obesity Hyperglycemia Poor wound healing Infections Eye problems ```
47
How do you diagnose Cushing's?
Overnight dexamethasone suppression test Low dose dexamethasone suppression test Urine free cortisol test
48
How do you do an overnight dexamethasone suppression test?
1mg dexa at midnight and cortisol test at 8am | <50 is normal and >100 is abnormal
49
What is the best test for diagnosis Cushing's?
Low dose dexa suppression test
50
How do you do a low dose dexa suppression test?
0.5mg dexa every 6 hours | <40 is normal
51
What is a normal result in a urine free cortisol test?
<250
52
How do you differentiate between primary and secondary Cushing's?
Primary ACTH<1 Secondary pit origine <300 Secondary ectopic origine >300
53
How do you treat Cushing's?
Treat underlying cause Metyrapone Ketoconazole
54
What is Cushing's disease?
Pit adenoma producing too much ACTH leading to Cushing's syndrome
55
What two forms of hyperaldosteronism can you have?
Primary/Conn's syndrome | Secondary
56
What causes secondary hyperaldosteronism?
Decrease blood flow to the kidneys increasing aldosterone release.
57
What causes primary hyperaldosteronism?
Adenoma or hyperplasia of adrenal glands. | Remember not all nodules are significant!!!
58
What is primary hyperaldosteronism?
Autonomous production of aldosterone
59
What is another term for primary hyperaldosteronism?
Conn's syndrome
60
How does primary hyperaldosteronism present?
Hypertension Hyperkalemia Alkalosis Raised BP
61
How do you diagnose hyperaldosteronism?
Confirm aldosterone excess by doing: | Ratio of plasma aldosterone and renin. If ratio raised diagnose subtype
62
How do you diagnose the subtype of hyperaldosteronism?
CT imaging | Adrenal vein sampling (use cortisol as a control)
63
How do you treat primary hyperaldosteronism?
Remove underlying cause (only in the young) | Spironolactone
64
What causes Congenital Adrenal Hyperplasia?
The loss of an enzyme in the metabolism of cholesterol to steroids
65
What is the most commonly lost enzyme in CAH?
12alpha hydroxylase
66
What does the loss of 12alpha hydroxylase do?
Inability to produce aldosterone or cortisol so direct metabolites down testosterone route
67
What are some symptoms of CAH?
Addison's style symptoms Early puberty in males Ambiguous female genitalia Poor weight gain
68
How do you diagnose CAH?
Genetic testing | Synacthen test but look for 17-OH progesterone
69
How do you treat CAH?
Give GC and MC replacement | Correct physical abnormalities
70
Is the loss of the adrenal medulla much of a problem?
No as catecholamines (adrenaline etc) are made elsewhere too.
71
What is a major cause of adrenal medulla overaction?
Phaeochromocytoma
72
What is pheochromocytoma?
Tumour derived from chromaffin cells in the adrenal medulla
73
What is another name for the pheochromocytoma?
10% tumour
74
What is a common triad of symptoms in pheochromocytoma?
Hypertension- labile or postural Paroxysmal (fast on/off) sweating Headaches
75
What are some of the symptoms of pheochromocytoma?
``` Hypertension- labile or postural Paroxysmal (fast on/off) sweating Headaches Pallor Tachycardia Hyperglycemia Low K Lactic acidosis ```
76
How do you diagnose pheochromocytoma?
24h urine catecholamines | Plasma catecholamines at time of symptoms
77
What do you have to do once you've diagnosed pheochromocytoma?
ID the source- MRI or MIBG (radio uptake) to do this
78
How do you ID where a pheochromocytoma is?
MRI or MIBG (radio uptake)
79
How do you treat pheochromocytoma?
Treat underlying cause Alpha and beta blockers Always give alpha first
80
What is pheochromocytoma often associated with?
MEN2 VHL Succinate dehydrogenase B and D mutations Neurofibromatosis
81
What is an extra adrenal gland source of excessive catecholamine production?
Extra adrenal paraganglioma
82
Where can extra adrenal paragangliomas be found?
Anywhere in the sympathetic chain
83
In panhypopituitarism what is the most important hormone to replace?
Cortisol
84
Why does ACTH not tend to be measured directly?
Needs to be sent to lab on ice and processed ASAP
85
What time of day and how often should cortisol replacement be given?
Large dose in morning Smaller dose at lunch Nothing in evening or won't sleep
86
What do you need to monitor when taking fludrocortisone and why?
Blood chemistry and BP to check not retaining too much salt
87
What is an Addisonian crisis?
Symptomatic Addison's- especially with low BP
88
How do you treat an Addisonian crisis?
Fluid and hydrocortisone
89
Why can you use hydrocortisone to treat and Addisonian crisis?
Because GC have a degree of efficacy at MCR.
90
What should you do to their medication if a patient receiving cortisol replacement therapy is ill?
Minor illness- double dose and keep doubled for 24hrs after illness Major illness- Double dose and wean off after
91
How do you treat Conn's disease?
Spironolactone
92
What is Conn's disease?
Primary hyperaldosteronism
93
How does Conn's disease present?
Raised BP and Na | Low K
94
What does Metyrapone do?
Block GC production
95
What two kind of steroids can the adrenal gland produce?
Glucocorticoids | Mineralocorticoids
96
How do GCs work?
Bind to nuclear receptors which can then form a dimer with the help of +Glucocorticoid Recognition Element or bind to nGRE remain as a monomer
97
Are GC monomers and dimers active?
Monomer inactive | Dimer active
98
Are GCs restricted to acting on just their own receptors?
No, they can act on MCR too
99
What negative effects can activation of the GCR have?
Increase feeding | Increase alcohol cravings
100
What negative effects can actions of the GC on the MCR have?
Skin atrophy and poor wound healing
101
How can you mitigate GCR effects on alcohol cravings?
By giving the morning after pill
102
What does a solid mass in the adrenal gland suggest?
Metastasis- lung met most common

Endocrine (23 decks)

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