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ADRENAL DISORDER
HISTORY
The anatomy of the adrenal glands was described almost 450 years
ago.
4 gm
5*2*1 cms
Above the kidney on its posteromedial surface
The right adrenal vein is short, draining directly into the inferior vena
cava,
whereas the longer left adrenal vein usually drains into the left renal
vein.
BLOOD FLOW
75%
PHYSIOLOGY
Mitochondria
ACTH
Pregnenolone
M
M
M
NEURAXIAL CONTROL OF CORTISOL
CRH (41)
Pre-pro-opiomelanocortin
Reduce glycogenolysis.
Increase gluconeogenesis.
Increase lipolysis.
Reduce uptake of glucose in cells.
Fat redistribution (long term effect).
ADRENO CORTICAL DISEASES
DISORDERS OF GLUCOCORTICOIDS
Loss of diurnal variation with high night serum cortisol or salivary cortisol
LDDST fails to suppress cortisol
Increased 24 hour urine free cortisol
What is the cause
Morning ACTH ( 9-52pg/ml Normal values ).
Hypokalemic alkalosis is present in more than 95% of
patients with the ectopic ACTH syndrome but in fewer
than 10% of those with Cushing disease.
Inferior petrosal sinus sampling ratio of ACTH >3 when
compared to plasma ACTH after 1 mcg/kg CRH ( 0, 1, 15
mins).
TREATMENT
Surgery
Drugs: Metyrapone- 11B- hydroxylase inhibitor
250mg BD to 1.5gm QID.
Ketoconazole
400-1600 mg/day.
Mitotane
5gm/day
GLUCOCORTICOID DEFICIENCY
PRIMARY
CENTRAL
PRIMARY: Autoimmune
Infections ( Tuberculosis, Fungal, CMV, HIV )
METS
Infiltrates
Intra adrenal haemorrhage (sepsis)
Congenital hypoplasia (X-Linked )
ACTH resistance syndromes (Autosomal recessive)
Bilateral adrenalectomy
CENTRAL: Exogenous glucocorticoids.
Hypopituitarism
Pituitary surgery and craniopharyngeoma
pituitary apoplexy
Granulomatous disease
Secondary tumour deposits
Sheehan syndrome
Isolated ACTH/Multiple pituitary hormone deficiency
Pituitary irradiation
Clinical
features
INVESTIGATIONS
Prevalence is 5 – 12 % .
Much higher in hypertensive patients with hypokalemia.
CAUSES
potassium depletion
sodium retention
hydrogen depletion that can cause metabolic alkalosis
Aldosterone excess may cause direct damage to the
myocardium and the kidney glomeruli, in addition to
secondary damage due to systemic hypertension.
Severe hypokalemia can be associated with muscle
weakness, overt proximal myopathy, or even
hypokalemic paralysis. Severe alkalosis contributes to
muscle cramps and, in severe cases, can cause tetany.
SALINE INFUSION TEST
Surgery
Mineralocorticoid receptor antagonist spironolactone. It
can be started at 12.5–50 mg bid and titrated up to a
maximum of 400 mg/d to control blood pressure and
normalize potassium.
Selective MR antagonist eplerenone can also be used.
Doses start at 25 mg bid, and it can be titrated up to 200
mg/d.
Sodium channel blocker amiloride (5–10 mg bid).
Treatment of GRA consists of administering
dexamethasone, using the lowest dose possible to
control blood pressure. Some patients also require
additional MR antagonist treatment.
Biosynthesis of catecholamines
PHEOCHROMOCYTOMA
CT
MRILUORO
MIBG
FLUORO-DOPA PET
Differential diagnosis
Essential hypertension,
anxiety attacks,
Use of cocaine or amphetamines,
Mastocytosis,
Carcinoid syndrome,
Clonidine withdrawal,
autonomic epilepsy.
TREATMENT
NF-1 ( 1% ).
MEN 2 ( 50% ).
VHL ( 20-30% ).
References