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6 Cards in this Set
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Adrenal Incidentaloma |
Workup: CT chest/abd/pelvis, 24 hr urine for cortisol, VMA, catecholamines, and metanephrines. Serum electrolytes, aldosterone, renin, K and NA; rule out breast CA, colon CA, and skin lesions When do you consider biopsy: if CT/MRI unequivocal, or imaging suggests ominous characteristics, young patient Surgery: Functional, > 5cm, enlarging, positive biopsy |
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How do to a laparoscopic adrenalectomy |
Left: Right lateral decubitus, allow the medial rotation of the spleen and pancreas and dissect peritoneum free from the interface between the adrenal and the spleen. Find the adrenal vein. Take with harmonic. Remove through an endocatch bag. Right: Left lateral decubitus. Divide lateral hepatic attachments to find IVC and adrenal. Clip the short adrenal vein going to IVC. Then dissect around the gland. |
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Workup for Cushing syndrome Medical therapy for Cushing |
Workup: 24 hr cortisol > 300 mcg/ml abnormal. Get ACTH. If ACTH low and cortisol high, then its adrenal and get abd CT. If ACTH high then its pituitary or ectopic and must give high dose dexamethasone suppresssion test and measure urine cortisol. If suppressed then its pituitary, if nto suppressed then its ectopic. drugs: Metyrapone inhibits steroid formation, Aminoglutethimide inhibits cholesterol conversion, Ketoconazole inhibits steroid, mitotane is adrenolytic |
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Pheochromocytoma: Workup, Preop prep, Treatment, Follow up |
workup: 24 hr urine for epi, NE, VMA, metanephrines. Send calitonin to rule out medullary Carcinoma. Check electrolytes. Dont forget about MEN. Clonidine suppression test is giving 0.3 mg clonidine and check metanephrines 3 hrs later < 500 is normal. Then Localize with CT or MIBG scan with 131. Preop: Alpha block with phenozybenzamine or prazosin until orthostatic then propranolol and give lots of voume Tx: Have nipride, esmolol, dopamine and phenylephrine ready. Ligate vein first. Follow up : annual 24 hr urine test, MIBG q3 months if malignant, chemotherapy is cyclophosphamide, vincristine, dacarbazine. XRT bony mets. |
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Aldosteronoma |
Workup: Serum renin and aldosterone, potassium and sodium, plasma aldosterone/renin > 20, salt suppression test to confirm diagnosis where you eat 3 gms Na for 3 days and 24 hr urine Na > 200 confirms load and urine aldosterone > 14 proves the diagnosis. CT scan should be done to rule out bilateral dz. Adrenal venous sampling if you cant localize Tx; If adenoma then excise. Preoperatively givee spironolactone. Bilateral treated with medical therapy alone. Bilateral adrenalectomy if medical tx fails and need steroids postop |
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