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Y3(M) - Endocrinology > Adrenal Pathology > Flashcards

Adrenal Pathology Flashcards

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1
Q

What is the venous drainage of the left adrenal gland?

A

Left adrenal vein -> left renal vein -> IVC

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2
Q

What is the venous drainage of the right adrenal gland?

A

Right adrenal vein -> IVC

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3
Q

What are the 3 regions of the adrenal cortex?

A

Zona Glomerulosa
Zona Fasiculata
Zona Reticularis

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4
Q

What types of substances does the Zona Glomerulosa produce?

A

Mineralocorticoids like Aldosterone

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5
Q

What types of substances does the Zona Fasiculata produce?

A

Glucocorticoids like cortisol

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6
Q

What types of substances does the Zona Reticularis produce?

A

Sex hormones like DHEA and androstenedione

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7
Q

What controls mineralocorticoid production like aldosterone from the zona glomerulosa?

A

RAAS system producing Renin

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8
Q

What controls glucocorticoid production like cortisol from the zona fasiculata?

A

ACTH control from the anterior pituitary gland

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9
Q

What controls sex hormone production like DHEA and Androstenedione from the zona reticularis?

A

ACTH by the anterior pituitary gland

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10
Q

What are the 2 types of adrenal insufficiency?

A

Primary adrenal insufficiency
Secondary adrenal insufficiency

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11
Q

What is primary adrenal insufficiency?

A

Where there are issues with the adrenal glands themselves

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12
Q

What is secondary adrenal insufficiency?

A

Where there is an issue with the pituitary gland producing ACTH

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13
Q

What is the most common cause of primary adrenal insufficiency?

A

Addisons disease (autoimmune)

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14
Q

What are some causes of primary adrenal insufficiency?

A

Addisons (autoimmune)
Infiltration (sarcoidosis, Amyloidosis)
Infection (TB,HIV)
Infarction
Congenital
Iatrogenic

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15
Q

What are some congenital causes of primary adrenal insufficiency?

A

Congenital Adrenal Hyperplasia (CAH)
Triple A syndrome

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16
Q

What is the pathophysiology of congenital adrenal hyperplasia?

A

Deficiency of 21-hydroxylase enzyme

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17
Q

What is an iatrogenic cause of primary adrenal insufficiency?

A

Bilateral Adrenalectomy

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18
Q

What is the most common cause of secondary adrenal insufficiency?

A

AXIS SUPPRESSION VIA EXOGENOUS CORTICOSTEROIDS

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19
Q

With primary adrenal insufficiency, what hormones are affected/reduced?

A

All corticosteroid hormones :
-aldosterone
-cortisol
-DHEA and androgenestione

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20
Q

What hormones are reduced in secondary adrenal insufficiency?

A

Cortisol
DHEA and androgenestione

ALDOSTERONE IS FINE SINCE CONTROLLED BY RAAS SYSTEM BUT CORTISOL AND SEX HORMONES LOW SINCE RELY ON ACTH FROM PITUITARY

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21
Q

What is an alternate name for primary adrenal insufficiency?

A

Addisons disease

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22
Q

How does primary adrenal insufficiency/addisons disease present?

A

Hyperpigmentation
Anorexia
Weight loss
Tiredness
Weakness
Dizziness
Postural hypotension
Reduced libido/pubic hair
Vomiting

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23
Q

Why does primary adrenal insufficiency cause hyperpigmentation of the skin?

A

Pituitary produces lots of ACTH to try and increase corticosteroid hormone levels of glucocorticoids and sex hormones

By product of producing ACTH is MSH (melanocytes stimulating hormone)

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24
Q

How does secondary adrenal insufficiency present?

A

Almost identical to primary BUT NO HYPERPIGMENTATION

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25
Why is there no skin hyperpigmentation with secondary adrenal insufficiency?
Secondary adrenal insufficiency caused by pituitary not producing enough ACTH leading to under active adrenal glands Low ACTH means low levels of MSH
26
What investigations would you request if you think a patient might have adrenal insufficiency?
FBC U+Es 9am cortisol Short SynACTHen test (stimulation test) ACTH levels Adrenal cortex and 21-hydroxylase autoimmune antibodies CT / MRI adrenals not always needed or MRI pituitary
27
What electrolyte abnormalities can be seen with adrenal insufficiency?
HYPONATRAEMIA (most common) Hyperkalaemia Hypoglycaemia Hypercalcaemia Elevated creatinine and urea (Dehydration)
28
Once adrenal insufficiency has been identified via a low 9am cortisol and a significant short SynACTHen test, how do you determine primary or secondary adrenal insufficiency?
Measure serum ACTH levels If ACTH levels high = Primary adrenal insufficiency If ACTH levels low = Secondary adrenal insufficiency
29
How is adrenal insufficiency managed?
Glucocorticoid replacement = Hydrocortisone BD or TDS (20-30mg per day so dose spilt with larger dose being in the morning) Mineralocorticoid replacement = fludrocortisone (50-300mg daily) Sick day rules, STEROID CARD/WRIST BAND and emergency pack
30
What are the sick day rules?
Patient taking any corticosteroids must double the dose of their steroids when they are ill Emergency IM hydrocortisone can be given if needed
31
What is an adrenal or Addisonian crisis?
An acute presentation of a severe adrenal insufficiency caused by life threatening low levels of corticosteroids
32
How can a patient present with an adrenal/addisonian crisis?
Hypotension / vascular collapse Reduced consciousness Hypoglycaemia Abdominal pain Tachycardia Hyponatraemia + Hyperkalaemia
33
When a patient has acutely deteriorated, when would you suspect an adrenal crisis/addisonian crisis?
Cortisol suspected low when: -resistant to fluid resuscitation -resistant metabolic acidosis
34
How do you diagnose an adrenal / addisonian crisis?
Cortisol levels Plasma ACTH Blood gas Short SynACTHen
35
What is the immediate emergency management of an adrenal/addisonian crisis?
100mg IV bolus hydrocortisone Then continous IV infusion of 200mg Hydrocortisone over 24hrs OR 6hrs doses of 50mg Hydrocortisone Fluid resuscitation + dextrose if. Hypoglycaemic Treat underlying causes ?calcium gluconate if hyperkalaemia
36
What causes an adrenal/addisonian crisis?
Infections Sepsis Major stress like surgery
37
What are the 2 types of Hyperaldosteronism?
Primary Hyperaldosteronism Secondary Hyperaldosteronism
38
What is primary Hyperaldosteronism?
When the adrenal glands are producing too much aldosterone without being stimulated by renin
39
What is secondary Hyperaldosteronism?
When there are very high levels of renin in the body leading to high levels of aldosterone being produced
40
What is the function of aldosterone?
Inc sodium reabsorption in kidneys Inc potassium loss in kidneys Inc hydrogen secretion from collecting duct
41
How does the RAAS lead to the production of aldosterone?
Juxtaglomerular cells make renin Renin converts Angiotensinogen to Angiotensin I, ACE converts Angiotensin I to angiotensin II which leads to prodcution of aldosterone
42
How does a patient with Hyperaldosteronism present?
Resistant HTN Hypokalaemia Alkalosis (excess H+ secretion)
43
What is resistant hypertension?
On 3 or more anti-HTN medications without the HTN resolving
44
What are the causes of primary Hyperaldosteronism?
Bilateral adrenal hyperplasia Conns syndrome (adenoma making aldosterone)
45
What are some causes of secondary Hyperaldosteronism?
Renal tubular acidosis Heart. Failure Renal artery stenosis Liver cirrhosis and ascites
46
What is essential HTN?
HTN that runs int he family and the cause isn’t known
47
What is secondary HTN?
HTN with a known cause
48
What are some causes of secondary HTN?
Renal artery stenosis Glomerulonephritis Conns syndrome Cushings Hyperparathyroidism
49
What investigations would you do for a primary Hyperaldosteronism?
U+Es (low sodium and high potassium) ABG or VBG (Alkalosis) Aldosterone to Renin Ratio CT/MRI adrenals Venous sampling Saline infusion and fludrocortisone suppression test
50
How can you differentiate between primary and secondary Hyperaldosteronism?
ALDOSTERONE TO RENIN RATIO
51
What would the aldosterone to renin ratio be for a patient with primary Hyperaldosteronism?
High aldosterone to renin ratio Low renin High aldosterone
52
What would the aldosterone to renin ratio be for a patient with secondary Hyperaldosteronism?
Normal/low aldosterone to renin ratio High renin High aldosterone
53
What is the management for Hyperaldosteronism?
Treat underlying cause. Laparoscopic Adrenalectomy Mineralocorticoid receptor antagonists like Spironolactone (bilateral adrenal hyperplasia) GRA treated with low dose dexamethasone
54
What is adrenal Cushing’s syndrome?
Too much cortisol made by the adrenals independant to ACTH
55
What are the 2 main causes of adrenal Cushing’s syndrome?
Adrenal adenoma Adrenal carcinoma
56
How does adrenal Cushing’s syndrome present?
Weight gain Plethoric moon shaped face Buffalo hump Purple striae Central adiposity Proximal limb muscle wastage
57
What are the signs of adrenal Cushing’s syndrome?
HTN T2DM Osteoporosis Recurrent infections Dyslipidaemia Anxeity Depression
58
What investigations need to be done to diagnose adrenal Cushing’s syndrome?
Any 2 abnormal from: -midnight cortisol -urine cortisol -salivary cortisol -low dexamethasone suppression test -high dose dexamethasone suppression test ACTH levels Venous sampling CT adrenals
59
How do you treat an adrenal Cushing’s caused by an adrenal adenoma?
Unilateral Adrenalectomy + Steroid cover
60
What is the management for adrenal Cushing’s caused by bilateral adrenal hyperplasia?
MDT meeting Either medical management or bilateral Adrenalectomy with steroid replacement
61
What medication can be given to treat adrenal Cushing’s?
Metyrapone
62
What is Phaeochromocytoma?
Neuroendocrine tumour originating from the adrenal medulla producing Catecholamines like adrenaline and noradrenaline
63
What cells normally produce Catecholamines like adrenaline?
Chromaffin cells
64
What genetic conditions are associated with Phaeochromocytoma?
MEN2 Neurofibromatosis 1 VHL (Von hippel Lindau)
65
How does a patient with Phaeochromocytoma present?
Resistant HTN Palpitations Headaches Sweating Anxiety Flushing Tremor Tachycardia
66
What are some complications of Phaeochromocytoma?
HF Cardiomyopathy Pulmonary oedema
67
What can precipitate and episode of Phaeochromocytoma?
Stress Exercise Pressure on the abdomen Surgery Drugs (anaesthetics, B blockers, contrast)
68
How should you investigate a Phaeochromocytoma?
24hr urine Catecholamines/metanephrines Plasma free metanephrines CT/MRI Screening for associated. Conditions (MEN, VHL, NF1)
69
How do you manage a Phaeochromocytoma?
Alpha blockers first = phenoxybenzamine or doxazosin Beta blockers after settled on alpha blockers Then surgical resection once stable

Y3(M) - Endocrinology (9 decks)

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