Term
| What composes the adrenal cortex? What are there maini products? The adrenal medulla? |
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Definition
zona glomerulosa- mineralocorticoids
zona fasciculata- glucocorticoids
zona reticularis- sex steroids
medulla-catecholamines |
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Term
| Which layer of the adrenal gland still functions without the stimulation of ACTH? |
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Definition
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Term
| where is the major source of testosterone in woman derived from? |
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Definition
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Term
| what is the thickest layer of the adrenal gland? |
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Definition
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Term
| ACTH has negative feedback on what? |
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Definition
| both CRH and ACTH release |
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Term
| 95% of cortisol in the body is bound to which binding protein? |
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Definition
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Term
| ACTH is secreted in a ______ rhythm, highest during the _____ and lowest during the ______ |
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Definition
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Term
| What are the systemic effects of cortisol? |
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Definition
catabolic processes:
inhibit DNA and RNA synthesis
protein catabolism
inhibits bone formation
collagen loss, decreased fibroblast activity
increased gluconeogenesis, lipolysis, decreased peripheral glucose uptake
decreases inflammation |
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Term
| Cushing's syndrome vs cushing's disease |
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Definition
| syndrome is a state of chronince glucocorticoid excess, while disease is specifically due to an ACTH secreting pituitary tumor |
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Term
| what are the 4 ways to obtain cushing syndrome? most common? |
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Definition
cushing's disease
ectopic ACTH syndrome, due to secretory tumors
adrenal tumor
exogenous-most common |
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Term
| ectopic ACTH syndrome is typically found in what patients? |
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Definition
| small cell lung carcinoma, bronchial carcinoids |
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Term
| should you remove the adrenal glands in a cushing disease patient? |
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Definition
no, because there is still some negative feedback from the higher cortisol levels
if removed the ACTH secreting tumor in the pituitary will just grow bigger |
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Term
| what will occur to the adrenal glands in a patient that has exogenous steroid excess? |
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Definition
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Term
| What are the clinical features of cushing's syndrome? |
|
Definition
obesity
facial plethora
hirsutism (hair in woman)
menstrual irregularity
hypertension
muscle weakness
back pain
striae
acne
bruising
edema
kidney stones
diabetes
headache
osteoporosis |
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Term
| what is the screen test for cushing's syndrome? |
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Definition
overnight dexamethasone suppression test
give 1 mg dexamethasone at 11 pm an d test serum cortisol next morning, should be less that 5ug/dl
OR
24 hour urine free cortisol, should be less than 50ug/dl
false positive include obesity, depression, alcohol abuse, anticonvulsant mediation |
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Term
| how do you confirm cushing's after a positive screen? |
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Definition
| give .5 mg dexamethasone 8 doses total and get a baseline, urinary free cortisol levels tested second day and normal suppression should be greater than 70% |
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Term
| what test distinguishes from cushing's disease and other causes? |
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Definition
| high dose DST where 2mg x 8 dextramethasone is given and urinary free cortisol given 2nd day, would show some suppressibility while other causes do not suppress at all |
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Term
| what is a direct test that allows the doctor to distinguish from cushings disease and ectopic ACTH syndrome? |
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Definition
petrosal sinus sampling
in cushings the petrosal sinus sampling will have higher ACTH levels then peripheral ACTH levels |
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|
Term
Treatment for:
cushing's disease
adrenal tumors
ectopic ACTH
latrogenic |
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Definition
remove pituitary tumor
remove affected tumor, give steroids
inhibitors of cortisol synthesis
reduction of steroid dose |
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Term
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Definition
| hyperpigmentation due to enlargement of ACTH-secreting tumor after bilateral adrenalectomy |
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Term
| What is the cause of Addison's disease? |
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Definition
autoimmune is 80%
tuberculosis 20%
some rare causes such adrenal hemorrhage, fungal infections, sarcoidosis, hemochromatosis, metastatic tumor |
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Term
| what happens to ACTH levels in addison's disease? What happens to glucocorticoid levels? Mineralocorticoid levels? |
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Definition
acth elevated
gluco/mineralocorticoids are depressed |
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Term
| The autoimmune type of addison's disease often is associated with... |
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Definition
| other autoimmune problems such as type 1 diabetes, hypothyroidism, graves, primary gonadal failure |
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Term
| what are the clinical features of addison's? |
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Definition
weakness, fatigue, anorexia, weight loss
hyper pigmentation
hypotension
salt craving
depression |
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Term
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Definition
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Term
| laboratory finding in addison's disease |
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Definition
hyperkalemia
hyponatremia (cortisol deficiency)
anemia
hypoglycemia
elevated BUN/creatinine (dehydration)
hypercalcemia (cortisol increases receptors in intestines) |
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Term
| how do you diagnose addisons? |
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Definition
| give cosyntropin (ACTH analog) and measure cortisol to see if it elevates |
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Term
| what are some causes of secondary adrenal insufficiency/ |
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Definition
defect in ACTH secretion from pituitary or hypothalamic lesions
adrenocortical suppression by chronic glucocorticoid administration then removal of excess steroid
adrenocortical suppression after treatment of cushing's syndrome |
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Term
| what is the most common cause of secondary adrenal insufficiency? |
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Definition
| adrenocortical suppression by chronic glucocorticoid administration and then removing excess exogenous steroid |
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Term
| How could you distinguish between addison's (primary adrenal insufficiency) from secondary adrenal insufficiency? |
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Definition
zone glomerulosa is not ACTH dependent and is functionally intact
thus hyperkalemia would be absent
hyper pigmentation absent
glucocorticoids required for life |
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|
Term
| treatment for primary vs secondary adrenal insufficiency |
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Definition
| primary requires both glucocorticoids and mineralocorticoids, secondary only needs glucocorticoids |
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Term
| Does hydroicortisone and cortisone have mineralocorticoid activity? |
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Definition
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Term
| what are the symptoms of hyperaldosteronism? |
|
Definition
excess K excretion causing hypokalemia
na normal-elevated
excess fluid volume
hypertension
edema
metabolic alkalosis
polyuria, polydipsia
headache |
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Term
|
Definition
| primary hyperaldosteronism |
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Term
| what is the most common cause of hyperaldosteronism? other causes? |
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Definition
aldosterone-secreting adenomas
bilateral adrenal hyperplasia
adrenocortical carcinoma (rare) or adrenal enzyme defects (rare) |
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Term
| With primary hyperaldosteronism, aldosterone levels stays ____ in response to saline load. Serum renin levels are ____ and serum K levels are ____ |
|
Definition
increased
decreased, decreased |
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Term
| Does ACTH stimulate mineralocorticoid release from adrenal glands? |
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Definition
| yes, although not as much as glucocorticoids it still does stimulate release. |
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Term
| what is the treatment for aldosterone-secreting tumors? for bilateral hyperplasia? |
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Definition
1. surgical resection, remaining adrenal gland sufficient for normal function
2. spironolactone (aldosterone antagonist, with diuretic properties) given because surgery does not improve hypertension |
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Term
| renovasular hypertension is primarily due to excess _____, less so by aldosterone |
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Definition
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Term
| how can you diagnose renovascular hypertension |
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Definition
angiogram is the gold standard
renal vein renin sampling
ace inhibitor renogram, affected kidney will show an decrease in flow after ACEI (normally should increase flow) |
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Term
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Definition
neuroendocrine tumor which produces excess catecholamins
usually benign and occur in adrenal gland
can occur wherever sympathetic tissue is found (10% rule)
10% extra-adrenal, 10%malignant, 10% bilateral |
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Term
| what three molecules are responsible for the symptoms seen in pheochromocytoma? |
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Definition
| epinephrine, norepinephrine, dopamine |
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Term
| what are some of the symptoms of pheochromocytoma? |
|
Definition
headache
PALLOR (not flushing)
diaphoresis (excess sweating)
tachycardia
anxiety, fear of impending doom
tremor
fatigue
nausea/vomiting
abdominal/chest pain |
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Term
| what are some of the consequences of untreated pheochromocytoma? |
|
Definition
MI
stroke
cardiac arrhythmias
shock
renal failure
dissecting aortic aneurysm |
|
|
Term
| how can pheochromocytoma be diagnosed? |
|
Definition
24 hour collection for catecholamines, metabolites such as VMA
CT or MRI
111In-labeled octreotide imaging |
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|
Term
| what is the treatment options for pheochromocytoma? |
|
Definition
first give an alpha adrenergic to control hypertension
then give a beta blocker to control tachycardia
blockage of catecholamine synthesis can be done by alpha-methyl tyrosine
surgical is definitive treatment |
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Term
| what is an adrenal incidentaloma? what is the typical diagnoses? |
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Definition
adrenal masses found on abdominal imaging done for non-adrenal related reasons
usually an adenoma (54%) and only 11% of the time is it a pheocremocytoma |
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Term
|
Definition
nonsecretory (70%)
25% cortisol producing
6% aldosterone producing |
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