Chapter 21 Adrenal

Front 1

List the arterial supply to the adrenal glands

Back 1

Superior adrenal - inferior phrenic artery
Middle adrenal - aorta
Inferior adrenal - renal artery

Front 2

List the venous drainage of the adrenal glands

Back 2

Left adrenal vein goes to left renal vein
Right adrenal vein goes to inferior vena cava

Front 3

When is sx indicated for ASYMPTOMATIC ADRENAL MASS

Back 3

Surgery is indicated if mass has ominous characteristics (nonhomogenous) or is
>4-6 cm, functioning, or enlarging

Front 4

What are the Common metastases to the adrenals?

Back 4

Lung CA (# 1), breast CA, melanoma, renal CA
Cancer history with asymptomatic adrenal mass - need biopsy

Front 5

ADRENAL CORTEX
What hormone is produced by
Glomerulosa

Back 5

Aldosterone

Front 6

ADRENAL CORTEX
What hormone is produced by
Fasciculata

Back 6

Glucocorticoids

Front 7

ADRENAL CORTEX
What hormone is produced by
Reticularis

Back 7

Androgens/ estrogens

Front 8

is released from the anterior pituitary gland and causes the release of cortisol

Back 8

ACTH

Front 9

ADRENAL CORTEX
All zones have ________ hydroxylase

Back 9

21 - and 11 -beta hydroxylase

Front 10

stimulates renal sodium resorption and secretion of potassium, hydrogen ion , and ammonia

Back 10

Aldosterone

Front 11

What stimulates Aldosterone secretion?

Back 11

Angiotensin II
Hyperkalemia
and to some extent ACTH

Front 12

Excess estrogens and androgens by adrenals is _______ until proven otherwise

Back 12

Cancer

Front 13

Congenital adrenal hyperplasia (enzyme defect in cortisol synthesis)
most common; precocious puberty in males, virilization in females
increase in17-0H progesterone leads to increase production of testosterone
salt wasting (decrease in sodium and increase in potassium) and causes hypotension

Back 13

21 -Hydroxylase deficiency (90%)
• Tx: cortisol, genitoplasty

Front 14

Congenital adrenal hyperplasia (enzyme defect in cortisol synthesis)
precocious puberty in males, virilization in females
Increase 11 - Deoxycortisone
Is salt saving (deoxycortisone acts as a mineralocorticoid) and causes hypertension

Back 14

11 - Hydroxylase deficiency
• Tx: cortisol, genitoplasty

Front 15

Congenital adrenal hyperplasia (enzyme defect in cortisol synthesis)
ambiguous genitalia in males at birth; salt saving

Back 15

17-Hydroxylase deficiency

Front 16

Symptoms: HTN 2/2 sodium retention with out edema; hypokalemia; also have weakness, polydipsia, and polyuria

Back 16

Hyperaldosteronism (Conn's syndrome)

Front 17

Low renin - # 1 cause
adenoma (80%-90%)
hyperplasia (10%- 20% ), ovarian tumors (rare), cancer (rare)

Back 17

Primary disease Hyperaldosteronism (Conn's syndrome)

Front 18

(high renin) - more common
CHF, renal artery stenosis, liver failure, pregnancy, diuretics, Bartter's syndrome (renin secreting tumor)

Back 18

Secondary disease Hyperaldosteronism (Conn's syndrome)

Front 19

Dx for primary hyperaldosteronism

Back 19

Urine aldosterone after salt load best (will stay high)
decreased serum K, increased urine K,
increased serum Na,
metabolic alkalosis
• Plasma renin activity will be low
• Aldosterone: renin ratio > 20

Front 20

Tx for Hyperaldosteronism (Conn's syndrome) 2/2 hyperplasia

Back 20

Medical therapy first with hyperplasia using spironolactone, calcium channel blockers, and potassium

Front 21

Tx: adenoma cuasing Hyperaldosteronism (Conn's syndrome)

Back 21

resection has good results with adrenalectomy

Front 22

Localizing studies for Hyperaldosteronism (Conn's syndrome

Back 22

MRI, NP- 59 scintigraphy (shows hyperfunctioning adrenal tissue; differentiates adenoma from hyperplasia; 90% accurate)

Front 23

#1 cause - withdrawal of exogenous steroids
#1 primary disease - autoimmune disease

Back 23

Hypocortisolism (adrenal insufficiency, Addison's disease)
Decreased cortisol and aldosterone

Front 24

Dx of Hypocortisolism (adrenal insufficiency, Addison's disease)
Decreased cortisol and aldosterone

Back 24

Dx: decreased serum Na , increased serum K,
ACTH stimulation test

Front 25

sx hypotension, fever, lethargy, abdominal pain,
decreased glucose, decreased mental status, nausea and vomiting, increased K

Back 25

Acute adrenal insufficiency

Front 26

most common cause Hypercortisolism (Cushing's syndrome)

Back 26

iatrogenic

Front 27

#1 noniatrogenic cause of Cushing's syndrome

Back 27

Pituitary adenoma (Cushing's disease)

Front 28

Most sensative test for dx Hypercortisolism (Cushing's syndrome)

Back 28

24hr Urine cortisol (most sensitive test)

Front 29

Bimodal distribution (before age 5 and in the 5th decade); more common in females
• 5O% are functioning tumors - cortisol, aldosterone, sex steroids
precocious puberty in boys, virilization in females
Sx abdominal pain, weight loss, weakness
• 80% have advanced disease at the time of diagnosis
• Tx: radical adrenalectomy; mitotane for residual or recurrent disease
• 20% 5-year survival rate

Back 29

Adrenocortical carcinoma

Front 30

What structure?
From ectoderm neural crest cells
• Catecholamine production tyrosine> dopa> dopamine> norepinephrine> epinephrine

Back 30

ADRENAL MEDULLA

Front 31

What is the rate- limiting step in catecholamine production?

Back 31

tyrosine > dopa
Tyrosine hydroxylase

Front 32

enzyme that converts norepinephrine> epinephrine
(requires methylation)
• Enzyme is found only in adrenal medulla (exclusive producers of epinephrine)

Back 32

PNMT

Front 33

converts:
norepinephrine >
normetanephrine,
epinephrine > metanephrine,
VMA produced from these

Back 33

MAO monoamine oxidase

Front 34

Usually slow growing; arise from sympathetic ganglia or ectopic neural crest cells
R side predominance
• "Extra"adrenal tumors more likely malignant
• Sx: HTN (frequently episodic), HA, diaphoresis, palpitations
• Dx: urine metanephrines and VMA - breakdown products of epi and norepinephrine

Back 34

Pheochromocytoma
chromaffin cells

Front 35

Most sensitive test for Pheochromocytoma

Back 35

VMA in urine most sensitive

Front 36

#2 noniatrogenic cause of Cushing's syndrome

Back 36

small cell lung CA
Cortisol is not suppressed with either low- or high-dose dexamethasone
suppression test
Tx: resection of primary if possible; medical suppression or bilateral adrenalectomy for inoperable lesions

Front 37

Tx for Adrenal hyperplasia
(macro or micro)

Back 37

bilateral adrenalectomy

Front 38

Medical therapy for ectopic ACTH production or adrenocortical cancer with
residual or metastatic disease after resection

Back 38

1. Ketoconazole and metyrapone - inhibit steroid formation
2. Aminoglutethimide - inhibits cholesterol conversion
• Op-DDD ( mitotane) - adrenal - lytic, used for metastatic disease
,- --

Front 39

def.
inhibits tyrosine hydroxylase causing decrease synthesis of catecholamines

Back 39

Metyrosine

Front 40

Most common site of extramedullary tissue

Back 40

organ of Zuckerkandl (inferior
aorta near bifurcation)

Front 41

What can cause falsely elevated VMA

Back 41

coffee, tea, fruits, vanilla , iodine contrast, labetalol alpha and beta- blockers

Front 42

Def. rare benign, asymptomatic tumor of neural crest origin in the
adrenal medulla or sympathetic chain

Back 42

Gianglioneuroma