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237490810895Adrenal Problems00Adrenal Problems15220951442085Zona glomerulosa: outer; aldosteroneZona fascitulata: middle; cortisolZona reticularis: inner; androgens00Zona glomerulosa: outer; aldosteroneZona fascitulata: middle; cortisolZona reticularis: inner; androgens2349501444625Anatomy00Anatomy15220952135505CRH from hypothalamus ACTH from APG Cortisol from adrenal cortexEffects of cortisol: ? release of CRH and ACTH Gluconeogenesis, lipolysis ? ketogenesis, ? insulin release ? BSL ? effects of cytokines, ? cell mediated immunity, anti-inflammatoryRAA aldosterone from adrenal cortexEffects of aldosterone: ? Na (? reabsorption), ? H20 excretion ? K (? excretion) in DCT alkalosis (? H excretion)00CRH from hypothalamus ACTH from APG Cortisol from adrenal cortexEffects of cortisol: ? release of CRH and ACTH Gluconeogenesis, lipolysis ? ketogenesis, ? insulin release ? BSL ? effects of cytokines, ? cell mediated immunity, anti-inflammatoryRAA aldosterone from adrenal cortexEffects of aldosterone: ? Na (? reabsorption), ? H20 excretion ? K (? excretion) in DCT alkalosis (? H excretion)2343152135505Pathophysiology00Pathophysiology15220953773805Cause: Iatrogenic (steroids, ACTH; most common cause) Pituitary adenoma (Cushing’s disease) Adrenal adenoma / cancer / hyperplasia Ectopic CRH (eg. Pancreas, bronchial carcinoid, thymic cancer) Ectopic ACTH (20%; eg. Oat cell cancer lung)Examination: moon face, buffalo hump, truncal obesity, acne, striae, hursutism, atrophic skin, osteoporosis, HTN, peri oedema, diabetes, psych (>70%), bitemporal hemianopia, adrenal cancer If 2Y to ACTH – no Cushingoid fetaures, but HTN, oedema, prox myopathy, hyperpigmentation, cachexiaInvestigations: hyper HTN / glycaemia Hypo K Metabolic alkalosis ? Hb, ? neutrophils Cortisol: at 00:00; >200 = Cushings 24hr urinary cortisol: 85% sensitivity; false –ive if dilute urine Corticotropin Dexamethasone suppression test: 24hr urine for 2/7; cortisol and ACTH blood test at 09:00; dexamethason 1mg given at 11pm; normal should be ? to <50% baseline level00Cause: Iatrogenic (steroids, ACTH; most common cause) Pituitary adenoma (Cushing’s disease) Adrenal adenoma / cancer / hyperplasia Ectopic CRH (eg. Pancreas, bronchial carcinoid, thymic cancer) Ectopic ACTH (20%; eg. Oat cell cancer lung)Examination: moon face, buffalo hump, truncal obesity, acne, striae, hursutism, atrophic skin, osteoporosis, HTN, peri oedema, diabetes, psych (>70%), bitemporal hemianopia, adrenal cancer If 2Y to ACTH – no Cushingoid fetaures, but HTN, oedema, prox myopathy, hyperpigmentation, cachexiaInvestigations: hyper HTN / glycaemia Hypo K Metabolic alkalosis ? Hb, ? neutrophils Cortisol: at 00:00; >200 = Cushings 24hr urinary cortisol: 85% sensitivity; false –ive if dilute urine Corticotropin Dexamethasone suppression test: 24hr urine for 2/7; cortisol and ACTH blood test at 09:00; dexamethason 1mg given at 11pm; normal should be ? to <50% baseline level2343153774440Adrenal OVERLOAD (Cushing’s syndrome)00Adrenal OVERLOAD (Cushing’s syndrome)2343156677025Aldosterone OVERLOAD00Aldosterone OVERLOAD15240006677025Cause: 1Y: Conn’s syndrome (F:M 2:1; adenoma in F, hyperplasia in M) 2Y: due to RAA from ? blood flow or perfusion pressure; underlying oedematous disorder; congestive cardiac failure, chronic liver / renal failure, renal artery stenosis; Bartter’s syndrome (normal BP, no oedema, hypoNa)Examination: HTN, weakness, paraesthesia, polyuriaInvestigation: hyper Na / volaemia / HTN Hypo K / Ca Metabolic alkalosis Renin and aldosterone mid-morning00Cause: 1Y: Conn’s syndrome (F:M 2:1; adenoma in F, hyperplasia in M) 2Y: due to RAA from ? blood flow or perfusion pressure; underlying oedematous disorder; congestive cardiac failure, chronic liver / renal failure, renal artery stenosis; Bartter’s syndrome (normal BP, no oedema, hypoNa)Examination: HTN, weakness, paraesthesia, polyuriaInvestigation: hyper Na / volaemia / HTN Hypo K / Ca Metabolic alkalosis Renin and aldosterone mid-morning 15309851592580Cause: can be precipitated by: surgery, MI, general anaesthetic, hypoglycacemia, hypothermia, trauma, psych illness, drugs 1Y: there is an aldosterone deficiency hypovolaemia, high K adrenal haem (anticoagulants, neonates, sepsis – Freidrich-Waterhouse syndrome) Addison’s disease (80%) Autoimmune diseases (70%; eg. Antiphospholid syndrome) Surgical removal Drugs (long term steroids most common cause – recovery post-steroids takes 1-12/12; ketoconazole) Infection (TB – most common infectious cause worldwide, AIDS – mot common infectious cause in USA (20%), protozoa, CMV, HSV); 60% patients with sepsis have decr cortisol Cancer (usually 1Y; lung and lymphoma most common cause of 2Y) Congenital adrenal hyperplasia: vague presentation at 2wks; look for virilisation Other (sarcoidosis, haemochromatosis, hereditary) 2Y: aldosterone is normal euvolaemia, low K pituitary failure, hypothalamic failure, head trauma, meningitis, irradiation / post op, Sheehan syndromePathophysiology: 90% of gland must be destroyed to cause hypoadrenalismResults in: 1Y: Hypo Cl / Na / osmolality / volaemia (Na rarely <120; total body depletion + intracellular movement) Hyper K (rarely >7; extracellular mvmt + decr excretion) Non- anion gap metabolic acidosis Always consider if fluid-resistant hypotension 2Y: no volume depletion; low K; high / low Na; little other change in elecrolytes as aldosterone normalSymptoms: anorexia, nausea and vomiting, diarrhoea, abdominal pain, lethargy, weight loss, weakness, postural syncopeExamination: pigmentation if 1Y; SBP <100 with postural dropInvestigation: as above + ? creatinine, mild ? Ca (in 10-20%), mild hypoglycaemia; anti-adrenal antibodies Cortisol: within 1hr of waking; <200 = insufficiency; 200-500 = needs ACTH stimulation test ACTH stimulation test: bloods Synacthen IM bloods 30mins bloods 60mins cortisol >550 = normal; if normal response = 2Y ACTH: high = 1Y; low = 2YMng: IV fluid (may need ++); treat hypoglycaemia; treat K if needed; vasopressors may be needed If uncertain diagnosis: Dexamethasone 10mg IV stat 4mg QID If certain: hydrocortisone 250mg IV stat 100mg QID; 25mg IV if neonate, 50mg IV toddler to school child, 100mg to adolescents00Cause: can be precipitated by: surgery, MI, general anaesthetic, hypoglycacemia, hypothermia, trauma, psych illness, drugs 1Y: there is an aldosterone deficiency hypovolaemia, high K adrenal haem (anticoagulants, neonates, sepsis – Freidrich-Waterhouse syndrome) Addison’s disease (80%) Autoimmune diseases (70%; eg. Antiphospholid syndrome) Surgical removal Drugs (long term steroids most common cause – recovery post-steroids takes 1-12/12; ketoconazole) Infection (TB – most common infectious cause worldwide, AIDS – mot common infectious cause in USA (20%), protozoa, CMV, HSV); 60% patients with sepsis have decr cortisol Cancer (usually 1Y; lung and lymphoma most common cause of 2Y) Congenital adrenal hyperplasia: vague presentation at 2wks; look for virilisation Other (sarcoidosis, haemochromatosis, hereditary) 2Y: aldosterone is normal euvolaemia, low K pituitary failure, hypothalamic failure, head trauma, meningitis, irradiation / post op, Sheehan syndromePathophysiology: 90% of gland must be destroyed to cause hypoadrenalismResults in: 1Y: Hypo Cl / Na / osmolality / volaemia (Na rarely <120; total body depletion + intracellular movement) Hyper K (rarely >7; extracellular mvmt + decr excretion) Non- anion gap metabolic acidosis Always consider if fluid-resistant hypotension 2Y: no volume depletion; low K; high / low Na; little other change in elecrolytes as aldosterone normalSymptoms: anorexia, nausea and vomiting, diarrhoea, abdominal pain, lethargy, weight loss, weakness, postural syncopeExamination: pigmentation if 1Y; SBP <100 with postural dropInvestigation: as above + ? creatinine, mild ? Ca (in 10-20%), mild hypoglycaemia; anti-adrenal antibodies Cortisol: within 1hr of waking; <200 = insufficiency; 200-500 = needs ACTH stimulation test ACTH stimulation test: bloods Synacthen IM bloods 30mins bloods 60mins cortisol >550 = normal; if normal response = 2Y ACTH: high = 1Y; low = 2YMng: IV fluid (may need ++); treat hypoglycaemia; treat K if needed; vasopressors may be needed If uncertain diagnosis: Dexamethasone 10mg IV stat 4mg QID If certain: hydrocortisone 250mg IV stat 100mg QID; 25mg IV if neonate, 50mg IV toddler to school child, 100mg to adolescents2432051593215Adrenal Insufficiency00Adrenal Insufficiency ................
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