Ipapburke Endo Test 1- Adrenal Cortex

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HORMONES MADE IN THE OUTER CORTEX

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CORTISOL, ALDOSTERONE, AND ANDROGENS (DHEA, DHEAS, TESTOSTERONE, ESTROGEN)

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HORMONES SECRETED BY THE INNER MEDULLA

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EPINEPHRINE AND NOREPINEPHRINE

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WHERE IS CORTICOTROPIN RELEASING HORMONE (CRH) PRODUCED?

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HYPOTHALAMUS

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WHAT DOES CRH DO IN THE PITUITARY?

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STIMULATES ACTH SYNTHESIS

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WHEN IS SECRETION OF ACTH INCREASED?

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STRESSFUL EVENTS

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WHAT INHIBITS THE SECRETION OF ACTH?

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CORTISOL IN BLOOD (NEGATIVE FEEDBACK0

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WHAT HORMONES DO THE ADRENALS SECRETE?

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ALDOSTERONE AND CORTISOL

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THIS HORMONE IS SECRETED DIURNALLY WITH HIGHEST LEVEL IN EARLY AM

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ACTH

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INCREASED SECRETION OF CORTISOL OCCURS WHEN?

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EXERCISE, TRAUAM, INFECTION---STRESS IN GENERAL

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HOW DOES CORTISOL AFFECT CARBOHYDRATE METABOLISM?

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INHIBITS INSULIN SECRETION. INHIBITS GLUCOSE UPTAKE (CAUSES ELEVATED BLOOD GLUCOSE), AND INCREASES HEPATIC GLUCONEOGENESIS

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HOW DOES CORTISOL EFFECT FAT METABOLISM?

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INCREASES LIPOLYSIS AND QUANTITY OF FREE FATTY ACIDS

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HOW DOES CORTISOL EFFECT PROTEIN METABOLISM?

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INCREASES PROTEIN BREAKDOWN SO THERE ARE MORE AMINO ACIDS AVAILABLE FOR CONVERSION TO GLUCOSE

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MAJOR BIOLOGIC EFFECTS OF INCREASED CORTISOL

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TRUNCAL OBESITY/WEIGHT GAIN; SUPPRESSION OF INFLAMMATION/IMMUNE SYSTEM; SUPPRESSION OF BONE FORMATION AND DECREASED ABSORPTION OF CALCIUM; EASY BRUISING, ABDOMINAL STRIAE, THIN SKIN, NA/H20 RETENTION, GROWTH FAILRE IN KIDS; ALTERED MOOD/COGNITION

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WHAT ARE THE POSSIBLE CAUSES OF EXCESS CORTISOL?

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LONG TERM DOSES OF GLUCOCORTICOIDS****(MC); ACTH PRODUCING PITUITARY TUMOR AS IN CUSHING'S DISEASE**; ADRENAL ADENOMA/CARCINOMA; ECTOPIC SECRETION

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BILATERAL EDEMA, GAINED 60 LBS IN 3 YRS; EASILY BRUISES, PURPLE STRIAE; FAT PADS, BUFFALO HUMP---THINK WHAT AND RUN WHAT TEST?

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THINK HYPERCORTISOLISM (CUSHING'S)----DO 24 HR UFC X 3

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WHAT IS THE MOST PROBABLE CAUSE OF WEIGHT GAIN IN CUSHING'S?

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SODIUM AND WATER RETENTION

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FIRST TEST DONE FOR SCREENING OF CUSHING'S SYNDROME?

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OVERNIGHT DEXAMETHASONE SUPPRESSION TEST

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WHAT RESULT OF OVERNIGHT DEXAMETHASONE SUPPRESSION TEST RULES OUT CUSHING'S SYNDROME?

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CORTISOL LESS THAN 5 MCG/ML

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IF OVERNIGHT DEXAMETHASONE SUPPRESSION TEST IS ABNORMAL (ELEVATED), WHAT IS THE NEXT TEST DONE?

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24 HR URINARY FREE CORTISOL X 3

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WHAT RESULT IN THE 24 HR UFC CONFIRMS HYPERCORTISOLISM?

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ELEVATED URINE CORTISOL

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WHAT WILL THE ACTH AND CORTISOL LEVEL BE IN AN ACTH-DEPENDENT CAUSE OF HYPERCORTISOLISM?

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ELEVATED ACTH AND ELEVATED CORTISOL

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WHAT ARE ACTH DEPENDENT CAUSES OF HYPERCORTICOLISM?

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CUSHING'S DISEASE (PITUITARY TUMOR) OR ECTOPIC ACTH SECRETION I.E. SMALL CELL LUNG CANCER

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LEVELS OF CORTISOL AND ACTH IN ACTH-INDEPENDENT HYPERCORTICOLISM?

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ACTH SUPPRESSED AND HIGH CORTISOL

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WHAT CONFIRMS PRESENCE OF ACTH SECRETING TUMOR IN CUSHING'S DISEASE?

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MRI

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WHAT CONFIRMS ADRENAL ADENOMA OR ADRENAL CORTICOCARCINOMA?

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CT OF ADRENAL GLANDS

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TWO CONDITIONS IN ACTH-INDEPENDENT HYPERCORTICOLISM?

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EXOGENOUS CORTICOSTEROID USE; ADRENAL ADENOMA/CORTICOCARCINOMA

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WHAT DOES THE HIGH DOSE DEXAMETHASONE SUPPRESSION TEST DO?

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DETERMINES WHETHER HYPERCORTICOLISM IS CAUSED BY ECTOPIC ACTH SECRETION OR CUSHING'S DISEASE

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TX OF CUSHING'S SYNDROME

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IF EXOGENOUS USE OF DRUGS IS CAUSE---REDUCE DOSE; IF THERE IS A TUMOR----REMOVE

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20 Y/0- WEAKNESS, FATIGUE, POOR APPETITE, WEIGHT LOSS, DIARRHEA, AMENORRHEA, LIGHTHEADNESS X SEVERAL MONTHS; LABS SHOW LOW SODIUM, ELEVATED POTASSIUM---BP IS LOW AND UNSTABLE----WHAT SHOULD YOU THINK?

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ALDOSTERONE DEFICIENCY

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MAIN ETIOLOGY OF ADDISON'S (PRIMARY ADRENAL INSUFFICIENCY)

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AUTOIMMUNE ADRENALITIS

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PTS WITH ADDISON'S PRESENT WITH THESE SYMPTOMS

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WEAKNESS, FATIGUE, HYPERPIGMENTATION, NAUSEA, VOMITING, ANXIETY

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IN CHRONIC CASES OF ADDISON'S, WHAT WILL BE THE LEVELS OF CORTISOL AND ALDOSTERONE AND WHAT WILL THOSE ABNORMALS CAUSE?

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LOW CORTISOL (SERUM ACTH WILL BE ELEVATED AS A RESULT) AND LOW ALDOSTERONE (SERUM NA IS LOW AND K HIGH AS A RESULT)

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ADDISON'S MORE COMMON IN MEN OR WOMEN

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WOMEN

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ADDISON'S IS OFTEN ASSOCIATED WITH THESE OTHER CONDITIONS

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OTHER AUTOIMMUNE ENDOCRINE DISORDERS LIKE VITILIGO, HASHIMOTO'S THYROIDITIS, AND DM

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WHAT CAUSES HYPERPIGMENTATION IN ADDISON'S?

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ELEVATED ACTH STIMULATES MELANOCYTES TO MAKE MELANIN

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WHAT CAUSES HYPONATREMIA AND HYPERKALEMIA IN PRIMARY ADRENAL INSUFFICIENCY?

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LOW ALDOSTERONE LEVELS

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WHAT IS THE MAJOR ISSUE IN SECONDARY (PITUITARY) ADRENAL INSUFFICIENCY

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INADEQUATE SECRETION OF ACTH BY THE PITUITARY GLAND

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MOST COMMON CAUSE OF INADEQUATE SECRETION OF ACTH BY THE PITUITARY GLAND

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SUDDEN/RAPID WITHDRAWAL OF LONG TERM EXOGENOUS CORTICOSTEROID TX THAT HAS SUPPRESSED ACTH

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WHAT ARE OTHER CAUSES OF SECONDARY ADRENAL INSUFFICIENCY (BESIDES DRUG WITHDRAWAL)?

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PITUITARY TUMORS, POSTPARTUM PIT. INFARCT

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S/S OF SECONDARY ADRENAL INSUFFICIENCY

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SAME AS PRIMARY EXCEPT THERE IS PALLOR INSTEAD OF HYPERPIGMENTATION (ACTH IS LOW); ELECTROLYTES ARE USUALLY NORMAL B/C ALDOSTERONE IS NOT AFFECTED

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WHAT ARE NORMAL CORTISOL LEVELS AND ACTH LEVELS IN AM WHEN THERE IS PRIMARY ADRENAL INSUFFICIENCY?

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LOW AM CORTISOL LEVEL AND ELEVATED PLASMA ACTH (ACTH IS BEING RELEASED BY PITUITARY, BUT ADRENALS ARE NOT RESPONDING TO MAKE CORTISOL)

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PRIMARY ADRENAL INSUFFICIENCY PROVEN BY WHAT TEST

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SIMPLIFIED COSYNTROPIN (ACTH) STIMULATION TEST

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NORMAL RESPONSE TO COSYNTROPIN STIMULATION TEST

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INCREASED CORTISOL LEVEL

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AN INCREASED CORTISOL LEVEL IN COSYNTROPIN TEST RULES OUT WHAT

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ADDISON'S DISEASE

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WHAT IS COSYNTROPIN?

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SYNTHETIC ACTH

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IF SCREENING TEST CONFIRMS PRIMARY ADRENAL INSUFFICIENCY, WHAT DO WE DO TO FIND THE SOURCE?

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AN ABDOMINAL CT (ADRENALS)

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THERE IS LOW OR INAPPROPRAITELY NORMAL ACTH AND INCREASED CORTISOL W/ ACTH STIMULATION (SCREENING TEST) IN THIS TYPE OF ADRENAL INSUFFICIENCY

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SECONDARY ADRENAL INSUFFICIENCY

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THERE IS LOW CORTISOL LEVEL WITH ACTH STIMULATION (SCREENING TEST) IN THIS TYPE OF ADRENAL INSUFFICIENCY

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PRIMARY ADRENAL INSUFFICIENCY

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HOW DO YOU LOCALIZE A CAUSE OF PRIMARY ADRENAL INSUFFICIENCY

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ABDOMINAL CT; CHEST XRAY OF OTHER THEN ADDISON'S IS SUSPECTED

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HOW DO YOU LOCALIZE A CAUSE OF SECONDARY ADRENAL INSUFFICIENCY?

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EXAMINE DRUGS BEING TAKEN; PITUITARY MRI

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WITH EITHER TYPE OF HYPOCORTICOLISM, WHAT MUST BE DONE?

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REPLACEMENT THERAPY- HYDROCORTISONE AND PREDINOSINE IN SPLIT DOSES (AM/PM 2/3) AND REPLACEMENT OF ALDOSTERONE BY FLUDROCORTISONE

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WHAT ARE SICK DAY RULES?

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IN PATIENTS WITH ADDISON'S, DOUBLE THE GLUCOCORTICOID DOSE DURING STRESS, ILLNESS, SURGERY, ETC.

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BESIDES REPLACEMENT, WHAT SHOULD ALL HYPOCORTICOLISM PATIENTS HAVE (2 ITEMS)?

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EMERGENCY STEROID KIT WITH IM INJECTION OF HYDROCORTISONE AND A MEDICAL ALERT TAG

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TX OF SECONDARY ADRENAL INSUFFICIENCY?

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CORTISOL REPLAACEMENT, REMOVE/SHRINK TUMOR, SAME AS PRIMARY W/ EMERGENCY KIT, BRACELET, AND SICK DAYS

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WHEN DOES ADRENAL CRISIS OCCUR?

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DURING INSUFFICIENT GLUCOCORTICOID TX OR IN UNDIAGNOSED ADRENAL INSUFFICIENCY

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WHAT ARE PRECIPITATING SITUATIONS FOR ADRENAL CRISIS?

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STRESS, SUDDEN WITHDRAW OF GLUCOCORTICOID THERAPY, BILATERAL ADRENALECTOMY, ADRENAL TRAUMA, OR PITUITARY NECROSIS

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SYMPTOMS OF ADRENAL CRISIS

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NAUSEA, VOMITING, AND HA; ALSO WEAKNESS, DEHYDRATION, HYPOTENSION, FEVER, HYPOGLYCEMIA, CONFUSION, COMA

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DIAGNOSIS FOR ADRENAL CRISIS

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DRAW BLOOD SAMPLE FOR ASAP CORTISOL ASSAY TO DIFFERENTIATE F/ OTHER CAUSES OF SHOCK; THEN AMDMINISTER SIMPLIFIED COSYNTROPIN STIMULATION TEST

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IF THERE IS ACUTE ADRENAL INSUFFICIENCY, WHAT WILL HAPPEN WHEN THE SIMPLIFIED COSYNTROPIN STIMULATION TEST IS DONE

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THE SYNTHETIC ACTH WILL BE UNABLE TO STIMULATE A NORMAL INCREASES IN SERUM CORTISOL IN ADRENAL CRISIS, SO CORTISOL WILL REMAIN LOW

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TX FOR ADRENAL CRISIS

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HIGH DOSE GLUCOCORTICOID VIA IV IMMEDIATELY, TAPER OFF SLOWLY TO ORAL MEDS OVER WEEKS, ALSO TREAT THE UNDERLYING STRESS AND ADMINISTER BROAD SPECTRUM ANTIBIOTICS FOR BACTERIAL INFECTIONS THAT ACTED AS TRIGGERS FOR CRISIS

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WHAT SECRETES ALDOSTERONE?

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ADRENAL CORTEX

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ALDOSTERONE STIMULATED BY WHAT THREE PROCESSES

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INCREASED PLASMA K; LOW RENAL PERFUSION PRESSURE; INCREASED SYMP. NERVOUS SYSTEM ACTIVITY

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PRIMARY ETIOLOGY OF HYPERALDOSTERONISM

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EXCESS ALDOSTERONE PRODUCTION FROM ADRENAL GLANDS

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SECONDARY ETIOLOGIES OF HYPERALDOSTERONISM

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EXCESS RENIN PRODUCTION BY THE KIDNEYS (MOST COMMON B/C OF RENAL ARTERY STENOSIS)

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SYMPTOM OF ALDOSTERONISM

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MODERATE HYPERTENSION

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DIAGNOSIS OF HYPERALDOSTERONISM

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HYPOKALEMIA IN THE ABSENCE OF DIURETIC USE; ELEVATED ALDOSTERONE IN 24 HR ALDOSTERONE LEVEL