Endocrine Part 1

Question 1

Chronic Adrenocortical Insufficiency is a disorder in which

Answer 1

the adrenal gland does not produce enough hormones

Question 2

Secondary adrenocortical insufficiency is when the

Answer 2

pituitary fails to secrete ACTH

Question 3

Causes of secondary adrenocortical insufficiency

Answer 3

• Exogenous glucocorticoid use (MCC)

- Hypopituitarism

Question 4

On the other hand, primary adrenal insufficiency is

Answer 4

Adrenal gland destruction, so a lack of cortisol AND aldosterone

Question 5

True or False: In secondary adrenal insufficiency, there is a lack of cortisol only. The aldosterone is intact because of the renin angiotensin aldosterone system?

Answer 5

True!

Question 6

Causes of primary adrenal insufficiency

Answer 6

• Autoimmune (MC)
• Infection (TB, HIV)
• Vascular
• Medications (Ketoconazole, Rifampin, Phenytoin)

Question 7

Symptoms of adrenocortical insufficiency (lack of cortisol)

Answer 7

• Weakness, myalgias, fatigue
• Nonspecific GI symptoms
• Abnormal menstruation
• Mild hyponatremia, salt craving
• Hypotension

Question 8

Symptoms in Primary (Addison’s Disease) due to lack of sex hormones and aldosterone

Answer 8

• Hyperpigmentation (increased ACTH stimulates melanocytes)
• Orthostatic Hypotension
• Loss of libido, amenorrhea, and loss of pubic hair in women

Question 9

What do the labs show in Primary Adrenocortical insufficiency?

Answer 9

• Elevated ACTH

- Hyperkalemia, Metabolic Acidosis

Question 10

What do the labs show for secondary adrenocortical insufficiency

Answer 10

• Decreased ACTH

- Hypoglycemia

Question 11

What is the screening test for adrenal insufficiency?

Answer 11

• High dose ACTH stimulation test

- -This test is positive if insufficient or absent rise in serum cortisol ( < 18) after ACTH administration

Question 12

Treatment for adrenal insufficiency

Answer 12

• Glucocorticoid replacement (Hydrocortisone)

- Mineralocorticoid replacement (Fludricortisone) ONLY in Addison’s

Question 13

What are some patient education tips if they have adrenal insufficiency?

Answer 13

• Patients must be treated with IV glucocorticoids and IV isotonic fluids before and after surgery
• During illness/stress/surgery, oral dosing needs to be adjusted to triple the dose
• Everyone should carry a medical alert tag and injectable form of cortisol

Question 14

Explain the pathophysiology of Adrenal (Addisonian) Crisis

Answer 14

-Triggered by a stressful event (trauma, illness, surgery) and usually the response is to increase cortisol by three-fold. Patients with this are unable to do so to meet the demand.

Question 15

Etiologies of Addisonian Crisis

Answer 15

• Abrupt withdrawal of glucocorticoids (without tapering)

- Bilateral adrenal infarction

Question 16

Symptoms of Addisonian Crisis

Answer 16

• Shock is the primary manifestation
• Hypotension
• Hypovolemia

Question 17

What do labs show for Addisonian Crisis

Answer 17

• Hyponatremia
• Hyperkalemia
• Hypoglycemia

Question 18

Treatment for Addisonian Crisis

Answer 18

-Isotonic fluids (normal saline or D5N5) + IV hydrocortisone or Dexamethasone

Question 19

Cushing’s Syndrome is signs and symptoms related to

Answer 19

Cortisol excess

Question 20

What are the four main causes of Cushing’s Disease

Answer 20

• Long-term high-dose glucocorticoid therapy (MC exogenous cause)
• Pituitary gland ACTH overproduction (MC endogenous cause)
• Adrenal tumor (Adenoma)
• Ectopic ACTH producing tumor (Small cell lung cancer)

Question 21

Symptoms of Cushing’s Disease

Answer 21

• Weight gain, proximal muscle weakness
• Central obesity
• Moon facies
• buffalo hump
• Supraclavicular fat pads
• Thin extremities
• Striae
• Acanthosis Nigricans
• Hypertension

Question 22

What are the screening test options for Cushing’s?

Answer 22

• 24 hour urinary free cortisol (most specific)
• Nightime salivary cortisol
• Low dose overnight Dexamethasone suppression test

Question 23

To differentiate Cushing’s from other causes, what is the diagnostic that is done?

Answer 23

Baseline ACTH + High-dose dexamethasone suppression test

suppression of cortisol with high dose

Question 24

Treatment for Cushing’s

Answer 24

• Corticosteroid use: gradual taper

- Cushing Disease: Transsphenoidal Resection