Adrenal + Parathyroid Dz Lecture Flashcards by Cassidy Ruocco

Secretion localized to outer layer of adrenal cortex

regulated by renin secretion by kidneys

Aldosterone

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Major glucocorticoid secreted by middle/inner adrenal cortex

secretion regulated by ACTH (from pituitary)

Cortisol

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Androgens > estrogens

testosterone, androstenedione, DHEA, estradiol

..secreted from which layer of adrenal cortex?

sex hormones are secreted from inner adrenal cortex

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Inhibits insulin secretion
Increases hepatic gluconeogenesis
Decreases protein stores
Dampens defense mechanisms
Inhibits production or action of inflammation
Lowers serum calcium

Cortisol

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Secreted in response to:

Stress
Trauma
Infection

Cortisol

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Plays a major role in supporting normal circulatory function and hemodynamic stability in respons to stress

Normal daily secretion= 15-25 mgs

weak mineralcorticoid effect

Cortisol

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Results from excessive systemic corticosteroids

Cushings syndrome/disease

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Can be caused by….

endogenous over production (ie tumor secreting cortisol or ACTH)
exogenous glucocorticoid administration (steroid drugs for other condition)

Cushings syndrome/disease

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MC cause of Cushings?

Pts treated with high dose corticosteroids for some other condition (ie lupus, asthma, etc)

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Causes:

Adrenal tumor (adenoma or carcinoma) which secretes excess cortisol
Neoplasms secreting ectopic ACTH (ie small cell lung cancer)
Unknown ectopic ACTH production

Cushings syndrome

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Pituitary adenoma secreting excessive ACTH

Cushings disease

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Central obesity:

moon facies
abdominal protuberance
buffalo hump
supraclavicular fat

Cushings

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Catabolic effects:

Thin skin with easy bruising
Striae
Thin extremities
Muscle wasting
Acne
Hirsutism
Impaired healing

Cushings

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Glucose intolerance/DM, HTN:

Oligomenorrhea
Amenorrhea
Impotence
Weakness
HAs
Increased thirst
Polyuria
(high glucose levels)

Cushings

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Osteopenia and osteoporosis:

Decreased bone protein

Cushings

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Too much cortisol?

Too little cortisol?

Too much= Cushings

Too little= Addisons disease

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Labs: hyperglycemia, glycosuria, leukocytosis

*elevated cortisol levels with loss of diurnal pattern

Cushings

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Diagnostic testing that can be done in Cushings?

Dexamethasone suppression test

(Dexamethasone is a steroid that mimics cortisol..should exert negative feedback on ACTH production)

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Increased morbidity of…

Diabetes
HTN
Osteoporosis
Infections
Compression/pathologic fractures

Complications of untreated Cushings

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Transphenoidal resection of the pituitary cures what percentage of Cushings?

75-90%

post op Rx Cortisol often needed

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CORTISOL excess= ?

ACTH excess= ?

CORTISOL excess= Cushings syndrome

ACTH excess= Cushings disease

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“stones, bones, groans, moans” is referring to having too much….

Calcium! (which can occur with hyperparathyroidism)

stones= renal loss of Ca and PO4, causing kidney **stones**
bones= bone loss, so **bone** pain
**groans**= increased GI absorption and abominal cramps
**moans**= irritability, psychosis, depression

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Obesity is centripetal
Extremities appear wasted

Fat deposition…buffalo hump, moon facies, supraclavicular pads

Cushings

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MOST SPECIFIC SIGNS=

proximal muscle weakness
pigmented striae over 1 cm wide

Cushings

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May present with HA, backache Oligomenorrhea, amenorrhea Disorders of calcium metabolism may cause: **Osteoporosis, vertebral fractures Hypercalciuria, kidney stones Possible avascular necrosis**

Cushings

Impaired wound healing Acne Easy bruising Superficial infections

Cushings

Prolonged administration of synthetic, exogenous glucocorticoids in **supra**physiologic doses **(2-40x normal)** **this leads to chronic ACTH suppression**

MC cause of Cushings

Prednisone is ___ x's cortisol potency

4x!

Developing exogenous Cushings is dependent on...

Dose Duration Timing of administration

Chronic suppression of adrenal gland is important if/when glucocorticoids are discontinued ..why?

MUST taper!

Risk factors: Taking exogenous corticosteroids with suppression of hypothalamic pituitary adrenal axis Can occur if corticosteroids are tapered/stopped too quickly

Adrenal insufficiency

Autoimmune adrenal insufficiency

Addisons disease

Autoimmune destruction of adrenal cortex that can develop over time, resulting in **chronic cortisol, aldosterone and adrenal androgen deficiency**

Addisons disease

Decreased cortisol Decreased aldosterone Decreased adrenal androgens

Addisons disease

S/S: Weakness, fatigue, weight loss, myalgias, arthralgias N/V/D, abdominal pain, anxiety, irritability **low BP, orthostasis, hyperpigmented skin** (including knuckles, palmar creases, elbows, knees, nipples, nail beds, decreased axillary and pubic hair)

Addisons disease

Labs: Neutropenia, lymphocytosis, eosinophilia, **low AM cortisol levels**, hypoNa **Abdominal CT may show small non-calcified adrenals**

Addisons disease

Cosyntropic (synthetic ACTH) stimulation test ..used to measure _____ \_\_\_\_\_\_

adrenal reserve | (**diagnostic in adrenal insufficiency**)

Cosyntropin 250 given Serum cortsiol obtained 30-60 mins later ..what happens in a normal/healthy individual?

Cortisol rises at least 20

If pt is on hydrocortisone, how long do they need to hold the medication for before a Cosyntropin test?

8 hours

Tx= Hydrocortisone 15-20 mg in AM 5-10 mg in PM

Adrenal insufficiency

During what times do you need to increase maintence dose of hydocortisone in adrenal insufficiency patients?

During times of stress! ..to avoid acute adrenal insufficiency/crises | (Infection, trauma, surgery, MI)

Must **TAPER** steroid dose before they are D/Cd to allow what to recover?

Adrenal pituitary axis | (can take weeks or longer)

What must you consider if a pt has **hypotension/shock unresponsive to IV fluids and pressors**

Acute adrenal insufficiency | (**this is a medical emergency!**)

Tx= Rapid isotonic fluids IV hydrocortisone Tx underlying stress Oral hydrocortisone when stable

Tx for acute adrenal insufficiency

Rare cause of secodary HTN **Tumor of adrenal medulla** ## Footnote **increases amounts of epinepherine and norepinepherine into circulation**

Pheochromocytoma

HTN with HA, sweating, palpitations Dx: 24 hr urine for catecholamines and metanephrines Tx: removal of tumor. post-op alpha and beta blockers

Pheochromocytoma

Maintains Ca homeostasis **increases osteoclastic activity** in bone, resulting in delivery of Ca and PO4 into circulation **increases renal tubular reabsorption of Ca** **increases PO4 excretion in urine increases absorption of Ca from GI tract** (thru synthesis of 1,25 dihydroxycholecalciferol, a vitamin D metabolite)

PTH

osteoclastic activity maintains..

Ca levels

**\_\_\_%** **total body Ca in solution:** 50% ionized 40% protein bound 10% complexed with anions

Hallmark is low ionized Ca MC post thyroidectomy **may develop with chronic Mg deficiency**

HYPOparathyroidism

Acute s/s: Muscle cramps, irritable, carpopedal spasm, tetany, seizures, parasthesias of hands and feet

HYPOparathyroidism

Chronic s/s: lethargy, personality changes, decreased cognitive fxn, cataracts

HYPOparathyroidism

Chvosteks and Trousseau's sign dry, thin nails hyperactive reflexes

HYPOparathyroidism

Labs: **decreased** serum total and ionized calcium **increased** PO4 **low** urine Ca **decreased** PTH levels

HYPOparathyroidism

Important to also check what levels in hypoparathyroidism?

Magnesium

ECG: prolonged QT interval and arrhytmias

Hypoparathyroidism

Acute tx: IV calcium gluconate Chronic: oral calcium, calcitrol, Mg supplment

Hypoparathyroidism

Hypersecretion of PTH, usually a parathyroid adenoma ## Footnote **Hallmark= elevated serum total and ionized calcium**

HYPERparathyroidism

Increased excretion of Ca and PO4 by kidney, which overwhelms tubular Ca absorptive capacity ..leading to?

HYPERcalciuria

Chronic hyperparathyroidism can do what to bones?

**increases bone resorption (**process by which osteoclasts break down bone**)**

Process by which osteoclasts break down bone Seen in chronic hyperparathyroidism

Bone resorption

Diffuse demineralization Osteopenia Osteoporosis Pathologic fractures

seen in HYPERparathyroidism (if there is severe bone resorption)

Often asymptomatic, found incidentally Can cause...bone pain, arthralgias **hypercalcemia/hypercalciuria can result in nephrogenic diabetes insipidus (decreased sensitivity to ADH) with polyuria and polydipsea**

Hyperparathyroidism

Hypercalcemia/hypercalciuria can result in...

diabetes insipidus (decreased sensitivity to ADH)

Anorexia Lethargy Fatigue Weakness Pancreatitis Altered MS Nausea Constipation Increased BP

Can result with very high calcium levels

**elevated** serum Ca (over 10.5) **elevated** ionized Ca **decreased** PO4 **elevated** Ca in 24hr urine **elevated** alk-phos (bone dz) PTH assay via RIA

Labs of hyperparathyroidism

Pathologic fractures Urinary stones, obstruction, UTIs Renal failure CNS changes PUD Pancreatitis

Complications of hyperparathyroidism

What must you rule out if you get a high Ca level?

Malignancy! (also..if you get 1 high Ca, must repeat)

Bisphosphonates (inhibit bone resorption) Parathyroidectomy

Tx for hyperparathyroidism

**SYMPTOMATIC** with bone disease or kidney stone **ASYMPTOMATIC** with: significant hypercalciuria cortical bone density greater than 2 SDs below norm age under 50 Ca over 1.0 above upper limit norm pregnant (2nd trimester)

Indications for parathyroidectomy

Elevated calcium with low PTH indicates a secondary disorder, such as...

Malignancy

Adrenal + Parathyroid Dz Lecture Flashcards

(71 cards)