Chem Path: Adrenal disease

Question 1

Explain the microanatomy of the adrenals

Answer 1

From the outside:

• Capsule
• Glomerulosa making mineralocortocids
• Fasiculata making glucocorticoids
• Reticularis making sex steroids
• Medulla making adrenaline

Question 2

What about the vasculature of the adrenals

Answer 2

Only 1 central vein but many arteries

Question 3

Is cortisol a gluco or mineralocorticoid

Answer 3

Glucocortocid

Question 4

How do the left and right adrenal veins drain

Answer 4

Left drains into left renal vein

Right drains into IVC directly

Question 5

What is addison’s disease and how does it present?

Answer 5

Deficiency of aldosterone (low Na and high K) and glucocorticoid (Hypoglycaemia)

Question 6

Addison’s + hypothyroidism is called what?

Answer 6

Schmidt’s syndrome / PGAI Type 2

Question 7

How to test for Addison’s?

Answer 7

Synacthen test

Question 8

How is it synacthen test done?

Answer 8

Measure cortisol and ACTH before injecting 250micro grams syActh my IM and see if cortisol rises

Question 9

What do you use low dose dexa supp test for?

Answer 9

Cushings

Question 10

What do you use glucose tolerance test for?

Answer 10

T2DM and 5 x GTT for acromegaly

Question 11

What can cause Addison’s?

Answer 11

Autoimmune and TB

Question 12

What are the 3 differentials for adrenal masses and how do they present?

Answer 12

Medulla - Phaechromocytoma - Excess adrenaline
Fasciculata - Cushings - Excess cortisol
Glomerulosa - Conns - Excess aldosterone

All present with hypertension and low K and high Na (less so for phaeo)

Question 13

What can you see in the urine for people with adrenal masses?

Answer 13

Urinary catecholamines

Question 14

What can phaeo cause?

Answer 14

Severe hypertension, cardiac arrhythmias and death

Question 15

How to treat phaeo?

Answer 15

Alpha blockade

Remove tumour

Question 16

How do you alpha blockade a patient for phaeo?

Answer 16

Phenoxybenzamine

Question 17

What are some genetic associations with phaeo?

Answer 17

MEN 2, NF 1, VHL

Question 18

How does Conns present

Answer 18

High Na, low K, hypertensive, raised aldosterone, low renin

Question 19

What can cause Cushings syndrome

Answer 19

It is basically excess cortisol

Can be due to:

• Adrenal tumour
• Pituitary tumour producing ACTH
• Ectopic tumour producing ACTH
• Oral steroids

Question 20

How do you test for Cushings

Answer 20

9 am cortisol
12 midnight cortisol
Dexa suppression test. - You are supposed to switch off ACTH and cortisol

Question 21

How do you do a dexa test?

Answer 21

Measure ACTH and cortisol at the start
Give 0.5mg dexa every 6 to 48 hours
Cortisol should fall to <50nM

Question 22

What is the difference between cushings syndrome and disease?

Answer 22

Syndrome - can be multiple causes

Disease - Pituitary DEPENDANT

Question 23

How does Cushings present?

Answer 23

Hypertension, bruising, low K, high Na

Question 24

What is pseudo-Cushings?

Answer 24

Obese people can present with high cortisol

Question 25

How do you determine the cause of Cushings syndrome after dexa test

Answer 25

Pituitary sampling