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Summer FDTN Exam 2 > Adrenals > Flashcards

Adrenals Flashcards

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1
Q

Describe the HPA (hypothalamic pituitary axis)

A

Primary organ: target organ
Secondary: Pituitary
Tertiary: hypothalamus

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2
Q

What are the hormones of the adrenals

A

zona Glomerulosa: Mineralocorticoids (Aldosterone)
zona Fasciculata: Glucocorticoids (cortisol)
zona Reticularis: Adrenal androgens (DHEA)
Medulla: catecholamines (epi/NE)

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3
Q

What does aldosterone do

A

controls body fluid volume!
Increase reabsorption of Na and H2O
Increase excretion of K+ and H+

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4
Q

Describe cortisol secretion

A

Pulsatile, diurnal under control of ACTH

Secreted mainly in the morning, around 8-9AM

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5
Q

What stimulates the hypothalamus to release CRH (then ACTH then cortisol)

A

Stress!
trauma, pain, hypoglycemia, hemorrhage
Mineralocorticoids mediate the long-term stress response

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6
Q

What can long term high dose glucocorticoid therapy cause

A

adrenal atrophy

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7
Q

What does primary overproduction of cortisol by the adrenals cause

A

ACTH secretion inhibition (negative feedback)

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8
Q

What are the functions of cortisol

A 
Protect against hypoglycemia 
Decrease insulin sensitivity 
Anti-inflammatory 
Suppress immune system 
Maintain vascular responsiveness to NE/Epi 
Inhibit bone formation 
Promote increase in GFR
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9
Q

How does cortisol protect against hypoglycemia

A

Gluconeogenesis in liver
Proteolysis
Lipolysis

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10
Q

How is cortisol anti-inflammatory

A

Inhibits production of inflammatory mediators; histamine, leukotrienes, prostaglandins

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11
Q

What is DHEA

A

Little significance in men

Women: major source of androgens! causes early development of pubic and axillary hair, and masculinization

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12
Q

What are the physiologic effects of the catecholamines

A 
Epi/NE
Increase rate and force of heart contraction 
Vasoconstriction  
Dilate Bronchioles 
Stimulate lipolysis in fat cells 
Increase metabolic rate 
Pupil dilation 
Inhibit "non-essential" processes (GI secretions)
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13
Q

In other words, Epi/NE mediate

A

Short term stress response

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14
Q

What are the principles of endocrine testing

A

Hypofunction: do a stimulation test
Hyperfunction: do a suppression test

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15
Q

What are the possible results of a serum total cortisol

A

> 10: unlikely to have adrenal insufficiency
3-10: inconclusive
<3: very likely to have adrenal insufficiency

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16
Q

How do you preform a 24 hour urinary free cortisol test

A

Discard first morning void
Collect for next 24 hours (including void at end of 24 hours)
record last voiding time
Keep urine cool during collection (high temp alters results)
If urine is lost, start over the next day

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17
Q

What does a 24 hour urinary free cortisol test measure

A

quantity of free cortisol collected

Ideal for suspected hypercortisolism

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18
Q

What is the purpose of a Plasma ACTH test

A

Differentiate primary, secondary, and tertiary source of cortisol imbalance
-You collect it with a serum cortisol, as it has the same diurnal variation

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19
Q

What does the ACTH stimulation test assess

A

The source of adrenal insufficiency (cortisol deficiency)

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20
Q

How do you preform an ACTH stimulation test

A

Get baseline plasma cortisol level
Give 250 mg IV short acting Cosyntropin (synthetic ACTH)
Measure plasma cortisol at 30 and 60 min

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21
Q

What are the possible results of an ACTH stimulation test

A

Cortisol level doubles: normal adrenal fxn

Cortisol level subnormal: Adrenal Insufficiency

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22
Q

What is the Dexamethasone suppression test

A

Get baseline plasma cortisol
Give 1mg DXM (synthetic steroid) PO at 11PM
Measure plasma cortisol at 8AM

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23
Q

What are the possible results of the dexamethasone suppression test

A

Cortisol level no change: excess cortisol production (steroid can’t even suppress it)
Cortisol level suppressed: normal adrenal fxn

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24
Q

Prolonged exposure to elevated cortisol results in

A

Cushing’s Syndrome!

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25
What are the MCC of Cushing's syndrome
Exogenous: chronic excess corticosteroids Endo: Pituitary adenoma (cushing's disease)- W:M 10:1 (endo can also be 2/2 adrenal hyperplasia, sdrenocortical tumor, neuroendocrine tumor, small cell lung cancer, and ovarian cancer)
26
What are the physical manifestations of Cushing's Syndrome
HTN central obesity (moon face, buffalo hump) Insulin resistance (overt DM) Purple striae >1cm wide easy bruising androgen excess (hirsutism, acne, irreg menses) severe fatigue and proximal muscle weakness osteoporosis impaired wound healing infections psych- depression, paranoia
27
If you have clinical suspicion for Cushing's syndrome, how can you test for it and what will your results be
24 hour free urine cortisol: high midnight salivary cortisol level: high on 2 separate nights DXM suppression: no change in cortisol level Plasma ACTH: <20 is an adrenal tumor- >80 at 8am is a pituitary adenoma (ACTH dependent)
28
How do you manage Cushing's syndrome
If 2/2 pituitary tumor: get an MRI If 2/2 ectopic ACTH secreting tumor: get CXR to r/o lung mass, and pelvic u/s to r/o ovarian mass If 2/2 pituitary tumor: is there a palpable abd mass? get CT abdomen If 2/2 exog steroids: taper to lowest possible therapeutic dose
29
What are treatments for Cushing's syndrome
Pituitary adenoma: Transspheniodal resection Adrenal tumor: adrenalectomy Adrenal hyperplasia: meds Ectopic ACTH syndrome: target source of ectopic production
30
Medical management of Cushing's Syndrome includes
``` Adrenolytic agents (Mitotane): permanently destroys adrenocortical cells! medical adrenalectomy Adrenal enzyme inhibitors ```
31
What are the adrenal enzyme inhibitors used in Cushing's syndrome
Ketoconazole: antifungal, cortisol reduction in higher doses (ADE liver toxic!!) Metyrapone: inhibits cortisol synthesis, mostly a combo drug
32
What can cause Primary adrenal insufficiency
MC in USA: Addison's disease (AI cortical destruction) causing mineral/glucocorticoid deficiency MC in world: Tuberculosis -Also: congenital enzyme deficiencies, infection, surgery (adrenalectomy)
33
What can cause Secondary adrenal insufficiency
Insufficient ACTH secretion | Long term exogenous steroid= HPA suppression= abrupt med withdrawal= Addison's crisis
34
What causes tertiary adrenal insufficiency
insufficient CRH secretion
35
Clinical manifestations of adrenal insufficiency are
Insidious onset, non-specific Sx: weakness, fatigue, anorexia, weight loss *Hyperpigmentation (creases, pressure areas, and nipples) Hypotension Hypoglycemia Salt cravings GI complaints
36
What drives hyperpigmentation
ACTH
37
Clinical manifestations of Addison's Crisis (2ndry insuff) are
``` Extremely low cortisol Sudden onset Hypotension acute abd/back pain vomiting diarrhea dehydration AMS electrolyte abnormalities ```
38
What initial diagnostic studies should you get for adrenal insufficiency, and what are results
CMP: hyperkalemia, hypercalcemia, hyponatremia CBC: Eosinophilia
39
If initial CBC and CMP are suspicious, what other labs can you get
Anti-adrenal antibodies, indicating AI if primary insufficiency (Addison's) AM plasma cortisol: abn low Plasma ACTH: if high, primary. if low, second/tertiary ACTH stimulation test: cortisol level does not change
40
Review of what to do if you suspect Addison's disease
Get a CBC, CMP | Get a plasma ACTH, plasma cortisol, and ACTH stimulation test
41
When would you need a radiograph of the adrenals
CT: For secondary causes, to eval possible infection or malignancy; Not needed for primary adrenal insufficiency MRI: pituitary if secondary insufficiency (hypothalamus or pituitary)
42
How do you treat Adrenal insufficiency
Primary: Glucocorticoids (hydrocortisone) AND mineralocorticoids (fludrocortisone) replacement 1/3: Glucocorticoids only (hydrocortisone)
43
What changes can be made to adrenal insufficiency meds
Increase dose in stressful times Give DHEA to women Taper long term steroids to prevent 2/3 adrenal insuff
44
How do you treat an adrenal crisis
IV steroics Correct electrolytes (Volume resuscitation) 50% dextrose to correct hypoglycemia when stable, look for the underlying cause
45
What is Conn's syndrome
Primary hyperaldosteronism MCC adrenocortical adenoma also 2/2 cortical hyperplasia
46
How does primary hyperaldosteronism present
``` HTN Hypokalemia Muscular weakness Paresthesias Paresthesias HA Polyuria and Polydipsia ```
47
What should the work up for primary hyperaldosteronism include
Elevated plasma and urine aldosterone low plasma renin (RAAS) CT scan of adrenals to eval adrenal adenoma
48
How do you manage primary hyperaldosteronism
Surgically remove adenoma | Spironalactone, anti-HTN
49
What is a pheochromocytoma
Tumor arising from chromaffin cells in adrenals, MC in medulla; Secretes catecholamines (epi/NE) 10% are malignant
50
What are the clinical manifestations of a pheochromocytoma
Paroxysmal Palpitations (tachycardia) HA Episodic sweating Paroxysmal/sustained HTN (very high, 200/100 levels)
51
When I say "refractory hypertension" you say...
PHEOCHROMOCYTOMA!
52
What is a Pheochromocytoma attack
+/- displacement of abd contents (lift, bend) Lasts 30-40 min Increases in frequency and severity over time
53
Other Sx of pheochromocytoma include
``` pallor nausea tremor fatigue anxiety epigastric pain hypertensive retinopathy (from prolonged HTN) ```
54
When should you suspect a pheochromocytoma
``` Classic paroxsymal attacks Refractory HTN, HTN <20 y/o Idiopathic DCM Abdominal mass Fhx Adrenal mass MEN2 Neurofibromatosis ```
55
How do you diagnose a pheochromocytoma
1st*Metanephrine 24 hour urine screen (catecholamine metabolite) Clonidine suppression MRI abdomen and pelvis MIBG (radio-isotope) to ID extra-renal tumors
56
What does Clonidine usually do to catecholamines
It causes them to decrease | If you have a pheochromocytoma, they do not decrease
57
How do you treat pheochromocytomas
Give alpha blocker (phenoxybenzamine) to control BP Give beta blocker (propanolol) to control HR Surgical resection
58
What is an adrenal incidentaloma
Mass >1cm discovered incidentally by radiographs (abd CT) MC in obese, hypertensive, diabetic patients Most are non-functional
59
What must you ask yourself when you find an adrenal mass
Is it malignant (<4cm, lipid rich, rapid contrast wash out) | Is it functioning
60
How do you work up an adrenal incidenteloma
Get a plasma cortisol, serum ACTH, serum DHEA, and plasma aldosterone - Do they have Sx of cushing's? (if yes, get 24 hr urine free cortisol) (if no, do DXM suppression) - Are you susp of pheo? (24 hr metanephrine, catecholamines)
61
When would you order a fine needle aspiration/biopsy
If you have a known primary malignancy elsewhere and are evaluating an adrenal incidenteloma
62
When DON'T you need a FNA
If you have evidence of a pheo (dont want to release the contents) Known widespread mets
63
How do you treat an adrenal incidenteloma
If pheo/carcinoma: Surgery If underlying dz: pharm intervention If benign in imaging:>2cm resect, <2cm repeat imaging at 6, 12, and 24 mo; test DXM suppression q4 years

Summer FDTN Exam 2 (11 decks)

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