Endocrine - Adrenal

Front 1

Layers of the adrenal cortex and what they secrete

Back 1

Zona glomerulosa - Mineralocorticoids (aldosterone), Zona Fasciculata - glucocorticoids (cortisol), Zona Reticularis - androgens (DHEA/S)

Front 2

What is the normal cycle of cortisol throughout the day?

Back 2

Rising starting around 3-4am, peaking at around 9am, falling until baseline at around 10-11pm.

Front 3

Which has more influence over aldosterone? RAAS or ACTH

Back 3

RAAS

Front 4

What would be the effect on Aldosterone, Cortisol, Androgens if you were ACTH Deficient? Had primary adrenal insufficiency? Panhypo pit?

Front 5

What is aldosterone's primary function?

Back 5

Regulate sodium and potassium balance. When acting, it increases sodium reabsorption and potassium secretion.

Front 6

What hormone will be high when there is excess adrenal sex steroids? What is the converted to?

Back 6

DHEA, DHEA-S

Front 7

What does excess adrenal sex steroids do for men and women?

Back 7

Not much in men, hirsutism, acne, clitoromegaly.

Front 8

Nausea, body aches, orthostatic hypotension are signs of what endocrine problem?

Back 8

Primary adrenal insufficiency

Front 9

Why would someone with adrenal insufficiency have hyperpigmentation?

Back 9

The POMC gene, which contains ACTH, also contains MSH. A large increase in ACTH then means a large increase in MSH.

Front 10

How will your Na+, K+, Glucose, and Cortisol react to primary adrenal insufficiency? Why?

Back 10

Na+ (low d/t lack of aldosterone production), K+ (high d/t lack of aldosterone), Glucose (low d/t gluconeogenesis from cortisol), Cortisol (low in the morning).

Front 11

How do you test for low cortisol when you suspect primary adrenal insufficiency?

Back 11

Give synthetic ACTH - Cortrosyn IV and check cortisol levels after 1 hour.

Front 12

What is the leading U.S. cause of primary adrenal insufficiency? In the world? What may cause primary adrenal insufficiency in HIV patients? What drug could induce it?

Back 12

US: Autoimmune. World: TB. HIV patients can get it secondary to MAI or CMV. Ketoconazole can inhibit cortisol synthesis and simulate adrenal insufficiency.

Front 13

Tx of adrenal insufficiency - children, adults

Back 13

Children: Hydrocortisone (watch carefully for growth changes). Adults: Prednisone. Fludrocortisone for aldosterone replacement. Titrate to minimum effective dose.

Front 14

How to titrate doses of glucocorticoids

Back 14

Individualize - find the dose that keeps them from aching, make sure they're hitting milestones, then don't go much higher.

Front 15

Why do people with Addison's have salty sweat?

Back 15

Sweat glands have aldosterone receptors, which when stimulated reduce salt loss.

Front 16

Sick/Trauma management of adrenal insufficiency

Back 16

Sick: Double dose. Significant infection: Triple it. Major trauma: Quadruple it.

Front 17

What is hyporeninemic hypoaldosteronism?

Back 17

Problem with JG apparatus, causing decreased function of renin typically in DM2 patients. Precursor to renal insufficiency.

Front 18

How can you treat hypotensive patients that are unresponsive to fluids?

Back 18

Steroids. Also, epi/norepi won't work until you have steroids on board, because they are a requisite factor.

Front 19

What is the relative strength of these steroids: Hydrocortisone, Prednisone, Dexamethasone

Back 19

From least to most potent: Hydro, Pred, Dexa

Front 20

How can you check for Secondary Adrenal insufficiency?

Back 20

Combine an insulin bolus (decrease blood sugar, causes pituitary to release ACTH) with history. You don't need to do two tests.

Front 21

Physical findings for Cushing's syndrome

Back 21

Plethora, Supraclavicular fat pad, Thoracodorsal fat pad, Purple striae

Front 22

Four possible etiologies for Cushing Syndrome

Back 22

Pituitary adenoma, Ectopic ACTH, Adrenal adenoma, Exogenous steroids

Front 23

Three possible tests for Cushing syndrome

Back 23

Gold standard: Suppress ACTH with dexamethasone (1 mg), if the AM cortisol is high, test is +. 24 hour urine cortisol (test for cortisol in urine). Late night salivary test: Test salivary cortisol (x2 nights).

Front 24

What to do with a positive result on the cortisol test?

Back 24

Confirm: Urine free cortisol OR slug of dexamethasone (2 mg) to be sure to shut off the pituitary. (But an endocrinologist will do this)

Front 25

With a positive result for excess cortisol, what is the most common outcome?

Back 25

Cushing Disease (Pituitary adenoma)

Front 26

How might you differentiate between Cushing's disease and an ectopic ACTH tumor?

Back 26

Ectopic will typically have low K+ as well.

Front 27

Tx of Cushing's Disease

Back 27

Transphenoidal resection (followed by irradiation and chemo)

Front 28

Treatment of Adrenal Tumors (Cushing Syndrome w/o ACTHoma)

Back 28

Unilateral adrenalectomy. If you can't operate, take Mitotane (adrenal toxin, reduces all steroids), also Ketoconazole.

Front 29

How does an adrenal carcinoma act?

Back 29

Junk tumor - secretes everything, but cortisol is the biggest problem.

Front 30

MOA of Mitotane

Back 30

Permanent destruction of adrenal cells.

Front 31

MOA of Ketoconazole in the context of adrenal tumor

Back 31

Cortisol-reducing effects in higher doses.

Front 32

What is the 21 Hydroxylase defect? What does it cause? Common sxs.

Back 32

It is an enzyme that converts precursors to cortisol (and aldosterone). Without it, cortisol production gets shunted to testosterone production, and as a result there is nothing inhibiting ACTH. Sxs: Women - hirsutism, infertility, acne, male pattern baldness. Men - adrenal rest tissue in gonads, oligospermia. Common in Ashkenazi jews.

Front 33

In what population is 21 Hydroxylase defect most common in?

Back 33

Ashkenazi jews.

Front 34

How is 21 Hydroxylase defect treated?

Back 34

Small amounts of cortisol inhibit ACTH and rectify the lack of cortisol. Mostly fixes everything.

Front 35

Classical vs. Nonclassical 21 Hydroxylase defect

Back 35

Classical - full deficiency, shows up in small children, screened for. Nonclassical - partial deficiency, shows up later, not screened for.

Front 36

How can you check for 21 Hydroxylase defect?

Back 36

Check baseline 17-OH Progesterone (during follicular phase) against ACTH stimulated by Cortrosyn. Higher levels indicate more blockade.

Front 37

What is a pheochromocytoma? Sxs? Screen/Dx? Tx?

Back 37

A catecholamine secreting tumor. Sxs: Headaches, Palpitations, Sweating, Nausea, Anxiety, FID. Elevated urine metanephrines. Alpha then Beta blockade followed by complete adrenalectomy.

Front 38

Following adrenalectomy for a pheochromocytoma, what will happen?

Back 38

BP will drop and volume expands d/t sudden lack of catecholamines.

Front 39

What is the biochemical workup for an incidental adrenal mass?

Back 39

Urine metanephrines - for pheochromocytoma. Overnight dexamethasone - for cortisol secreting tumor. Renin/Aldosterone ratio - for aldosterone secreting adenoma. No screen for sex steroid.

Front 40

Incidentaloma size and what to do

Back 40

Less than 4 cm, CT again in 6 months (and then annually) and compare size. Greater than 6 cm, surgery unless it looks benign AND has no associated symptoms.

Front 41

If you have high aldosterone levels which you can't suppress with dexamethasone, but you also can't anything on CT, what might it be?

Back 41

It might be one of the crazy familial forms of aldosteronism.