Endocrine disorders

Cushing syndrome
- Endocrine disorder characterized by elevated cortisol levels in
the blood
- Results from excessive production of cortisol form the adrenal
cortex
- In some cases, elevated cortisol levels are secondary to an
ACTH-secreting pituitary adenoma, which is called Cushing
disease

Review of A&P or cortisol production

- Normally, the hypothalamus secretes corticotropin-releasing hormone (CRH), which
stimulated the pituitary gland to secrete adrenocorticotropic hormone (ACTH)
- ACTH then travels to the adrenal cortex
- The adrenal cortex is subdivided into 3 layers:
o Zona glomerulosa
o Zona fasciculata
o Zona reticularis
- In the zona fasciculata, ACTH stimulates cortisol secretion
- Cortisol is a glucocorticoid, which maintains glucose levels, BP, suppression of the
inflammatory and immune response, influence mood, degrade collagen and connective
tissue within the tissues
- Free cortisol levels have to stay within normal range by using negative feedback, which
means high levels of cortisol make hypothalamus and pituitary to secrete less CRH and
ACTH
- Results in decreased stimulation of the zona fasciculata, so cortisol levels go down

Aldosterone and cortisol

- Role of adrenal cortex: releases steroid hormones and sex hormones
- Role of aldosterone: regulates blood pressure through RAAS system, helps retain sodium
and secretes potassium
- Role of cortisol: stress hormone helps the body deal with stress such as illness or injury,
increases blood glucose through glucose metabolism, break down fats, proteins, and
carbs, regulated electrolytes
Cushing’s syndrome vs Cushing’s disease
- Syndrome: caused by an outside cause or medical treatment such
as glucocorticoid therapy
- Disease: caused from an inside source due to the pituitary gland
producing too much ACTH which causes the adrenal cortex to
release too much cortisol

Signs and symptoms

- Skin fragile
- Truncal obesity with small arms
- Rounded face (moon face)
- Reproductive issues (amenorrhea and ED in males)
- Ecchymosis
- Elevated BP
- Striae on extremities and abdomen
- Excessive body hair
- Electrolyte imbalance (hypokalemia)
- Dorsocervical fat pad
- Depression

Diagnostics
- PMHx and physical examination
- 24 hr urine collection for free cortisol measurement
- Blood chemistry evaluation for sodium, potassium, and glucose
- CBC
- CT, MRI
- Dexamethasone suppression test
- Examination of visual field
- Measurement of plasma ACTH level
- Measurement of plasma cortisol levels for diurnal variations
- Mental status examination

Collaborative therapy
- Adrenocortical adenoma, carcinoma, or hyperplasia
o Adrenalectomy
o Drug therapy
▪ Ketoconazole (Nizoral)
▪ Mitotane (Lysodren)
- Pituitary adenoma
o Radiation therapy
o Trans-sphenoidal resection
- Ectopic ACTH-secreting tumour
o Treatment of the tumour responsible (surgical removal)
- Exogenous corticosteroid therapy
o Discontinuance of or alteration in administration of exogenous corticosteroids
Drug therapy
- Used when surgery is contraindicated or as an adjunct to surgery
- Goal of drug therapy is the inhibition of adrenal function
- Mitotane suppresses cortisol production, alters peripheral metabolism of cortisol, and
decreases plasma and urine corticosteroid levels
- Ketoconazole can be used to inhibit cortisol synthesis
- These drugs are used cautiously because they are often toxic at doses needed to reduce
corticosteroid synthesis

Nursing management
- Prep pt. for hypophysectomy to remove the pituitary tumor
- Prep pt. for adrenalectomy:
o If this is done educate pt. about cortisol replacement therapy after surgery
- Risk for infection, skin breakdown
- Monitor electrolytes, blood sugar, potassium, sodium, calcium levels