Patho - adrenal gland

Question 1

adrenal medulla secretes:

Answer 1

• epinephrine

- norepinephrine

Question 2

adrenal cortex secretes:

Answer 2

• mineralocorticoids

- glucocorticoids

Question 3

where is the short term stress response from?

Answer 3

• adrenal medulla

- epi and norepi

Question 4

short term stress response

Answer 4

• increase in blood glucose
• increased BP
• increased breathing rate

Question 5

where is the long term stress response from?

Answer 5

• adrenal cortex

- mineral and glucocorticoids

Question 6

long-term stress response effects of mineralocorticoids

Answer 6

• retention of Na and water by kidneys

- increased blood volume and BP

Question 7

long-term stress response effects of glucocorticoids

Answer 7

• increased blood glucose

- immune system suppression

Question 8

adrenal cortex: steroid hormone production

-flow from cholesterol to aldosterone

Answer 8

cholesterol –> progesterone – (21-hydroxylase) –> corticosterone –> aldosterone

Question 9

all end points of cholesterol from the adrenal cortex

Answer 9

• aldosterone
• cortisol
• estradiol
• DHT

*review this whole chart, he said to know it

Question 10

adrenal cortex

Answer 10

• 3 zones

- corticosteroid hormones are synthesized from cholesterol by cytochrom P450 enzymes

Question 11

zona glomerulosa

Answer 11

aldosterone causes K wasting and Na reabsorption in the distal nephron of the kidney

Question 12

zona fasciculata

Answer 12

• cortisol production under influence of ACTH from the pituitary
• circadian rhythm: high levels in morning and very little secreted at night

Question 13

zona retiucularis

Answer 13

• adrenal androgens are synthesized
• DHEA and SHEAS
• under the influence of ACTH

Question 14

what is the key in the steps that occur in the adrenal medulla?

Answer 14

tyrosine metabolism

Question 15

an increase of production of adrenal medulla catecholamines causes what?

Answer 15

pheochromocytoma

Question 16

underproduction of adrenal medulla catacholamines causes what?

Answer 16

-not many problems like an increase does b/c there are plenty of catecholamines produced by the SNS

Question 17

adrenal hormone excess =

Answer 17

cushing’s

Question 18

MC cause of Cushings

Answer 18

• taking exogenous steroids w/ glucocorticoid activity

- 5 mg/day of prednisone is unlikely to cause suppression but higher doses for 3 weeks or more can

Question 19

difference b/w cushing’s disease and cushing’s syndrome

Answer 19

• disease: overproduction of ACTH from the pituitary gland which stimulates the adrenal cortex to make corticosteroid
• syndrome: excess from any other source (exogenous steroids)

Question 20

physical findings of cushing’s

Answer 20

• centripetal obesity
• facial plethora
• supraclavicular fat pads
• wide violaceous striae
• buffalo hump

Question 21

a physical finding differentiation between cushing disease and syndrome

Answer 21

hyperpigmentation usually means it’s coming from the pituitary (cushing’s DISEASE)

Question 22

ACTH dependent vs. independent Cushing’s syndrome

Answer 22

• dependent: (aka disease) caused by pituitary adenoma; 2/3 of cases
• independent: caused by hyperplasia of the adrenal gland or adrenal adenoma

Question 23

w/u of cushing’s

Answer 23

1. clinically suspected
2. exclude exogenous glucocorticoids
3. initial testing: 24 hr. UFC; LN salivary cortisol
   - if nl, Cushing is unlikely
   - if abnl: exclude physiologic hypercortisolism
4. if physiologic is excluded, do additional testing

Question 24

important note on diagnostic testing of the pitutary/adrenal glands

Answer 24

• biochemical testing first!!

- b/c there are common findings of non-functioning adenomas in both glands

Question 25

initial cushings testing

Answer 25

- low dose dexamethasone suppression test - 24-hr urine free cortisol - late night salivary cortisol

Question 26

steps to take after cushing's has been established

Answer 26

- further testing to determine if it's ACTH dependent or independent - referral to endo

Question 27

tx for CS if caused by pituitary tumor

Answer 27

surgery

Question 28

tx for CS if caused by adrenal adenoma

Answer 28

surgery

Question 29

tx of CS if caused by hyperplasia

Answer 29

-refer to endo

Question 30

adrenal insufficiency

Answer 30

- may be d/t failure of the adrenal glands (primary) - or maybe inadequate secretion of cortisol form adrenals d/t other causes: critical illness (story of little baby) - or pituitary ACTH deficiency (secondary)

Question 31

sx of cortisol deficiency

Answer 31

- fatigue - weakness - low grade fever - weight loss - anorexia - n/v - abdominal pain - arthralgia - myalgia

Question 32

signs of cortisol deficiency

Answer 32

- hyperpigmentation | - decrease in BP

Question 33

lab finding of cortisol deficiency

Answer 33

- decreased serum cortisol - increased ACTH - decreased Na and glucose

Question 34

sx of aldosterone deficiency

Answer 34

- salt craving | - dizziness

Question 35

signs of aldosterone deficiency

Answer 35

- orthostasis | - hypotension

Question 36

lab findings of aldosterone deficiency

Answer 36

- increased PRA - increased K - decreased Na

Question 37

S/S of DHEAS deficiency

Answer 37

-reduced libido -decreased axillary or pubic hair (in women only)

Question 38

MC cause of primary adrenal failure

Answer 38

autoimmune adrenalitis | -antibodies to 21-hydroxylase

Question 39

diagnosis of primary adrenal failure

Answer 39

- based on low serum cortisol levels | - most will present w/ hypotension, hyponatremia, hyperkalemia

Question 40

lab cortisol values in primary adrenal failure

Answer 40

- early morning cortisol of <3ug/dl consistent w/ cortisol deficiency - > 15 excludes this diagnosis

Question 41

what to do if cortisol testing = 5-14 ug/dl

Answer 41

stimulation testing w/ synthetic ACTH

Question 42

how to differentiate primary vs secondary adrenal insufficiency

Answer 42

measure 8am plasma ACTH

Question 43

potential effects of primary adrenal insufficiency

Answer 43

Fatal!! this is why you have to pay attention of mineralocorticoid and glucocorticoid effect and strength of drugs

Question 44

steroid drug strengths

Answer 44

- hydrocortisone: 1 - prednisone: 4 - prednisolone: 4 - methylprednisolone: 5 - triamcinolone: 5 - dexamethasone: 25 - bethamethasone: 25 - cortivazol: 50

Question 45

adrenal crisis

Answer 45

- adrenal fxn during critical illness: - pts who have been on cortisol replacement tx may need emergent dose of hydrocortisone when they become ill - pts who have been on steroids daily (COPD, arthitis, etc) will need a stress dose when acutely ill b/c they pituitary is suppressed

Question 46

primary aldosteronism

Answer 46

- autonomous secretion of aldosterone - usually adrenal adenoma - in 10% of pts w/ HTN

Question 47

how do pts w/ primary aldosteronism usually present?

Answer 47

with hypokalemia and metabolic alkalosis

Question 48

what to do when primary aldosteronism has been established

Answer 48

- CT to determine if there is an adenoma, hyperplasia, or carcinoma - renal vein renin then localize the source

Question 49

tx of primary aldosteronism

Answer 49

- mineralocorticoid antagonsits (spironolactone) | - surgery

Question 50

pheochromocytom

Answer 50

- tumor of the adrenal medulla secreting catecholamines (epi, norepi, dopamine) - most cause intermittent or sustained HTN - 1/3 occur w/ MEN-2

Question 51

best screening test for pheo

Answer 51

plasma free metanephrine