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Adrenal Gland

Krishna W SuciptoDivisi Endokrin, Metabolik dan DiabetesBagian Ilmu Penyakit Dalam FK Unsyiah - Banda Aceh

Adrenal Gland

› Location On top of each kidney

Suprarenal gland

› Composed of: Adrenal cortex Adrenal Medulla

Hormone & Function

Adrenal Cortex› Mineralocorticoids

( Aldosterone )› Function

Regulates electrolyte & fluid homeostasis ( ↑ reabsorbsi Sodium and ↑ secretion Potassium at Distal Tubule )

Hormone & Function Adrenal Cortex

› Glucocorticoids Cortisol Hydrocortisone

› Function Stimulated gluconeogenesis & h

blood glucose Anti-inflammatory Anti-immunity Anti- allergy

Hormone & Function

Adrenal Cortex› Androgen

Sex hormones› Function

Female Stimulated Sex drive

Men Negligible

Hormone & Function

Adrenal Medulla› Epinephrine

Adrenaline› Function

Prolong & h SNS (sympathetic nervous system) response to stress

Hormone & Function

Adrenal Medulla› Norepinephrine› Function

Prolong & h SNS (sympathetic nervous system) response to stress

Effects of Epinephrine & Norepinephrine

a. h cardiac outputb. h metabolic ratec. Vasoconstrictiond. h respiratory rate

Adrenal Cortex

The cortex synthesizes & secretes 30+ different steroids. › Glucocorticoids› Mineralocorticoids› Androgens

Learning Tip

SALT, SUGAR & SEX Aldosterone = promotes salt

retention Cortisol= sugar Androgens = sex hormones

Negative feedback loop

Stress Hypothalamus Stimulates Anterior Pituitary Secretes ACTH target cell Adrenal cortex Secretes Cortisol specific action h metabolic activity Helps manage stress

Cushing disease/ syndrome

Description› Cortisol excess

Cushing disease/ syndrome

Patophysiology› Diurnal rhythm

h in AM› Normal secretion of cortisol h in times of

stress› In Cushing's, cortisol is hypersecreted

without regard to stress or time of day.

Cushing disease/ Syndrome

Etiology› h secretions ACTH› Pituitary Tumor› Lung Tumor› Prolonged use of glucocorticoid meds for

inflammatory disorders Rheumatoid arthritis COPD

Cushing disease/ syndrome

Etiology› Iatrogenic

Caused by treatment or diagnostic procedure

› Females > Male

Cushing disease/ syndrome

Signs & Symptoms› Adiposity

Deposits of adipose tissue in the face, neck & trunk

Moon shaped face Buffalo hump

Cushing disease/ syndrome

Signs & Symptoms› Weight gain› Na & H20 retention

› K+ is lost Hypokalemia

› Purple striae on the abdomen› Hirsutism

Cushing disease/ syndrome

Signs & Symptoms› Extremities muscle wasting› Boys = early onset of puberty› Girls = masculine characteristics› fatigue, muscle weakness, sleep disturbance,

amenorrhea, i libido, irritability, emotional labiality

Cushing disease/ syndrome

Signs & Symptoms› Could be:

Petechiae Echymoses i wound healing Swollen ankles

Cushing disease/ syndrome

Complications h calcium reabsorption from the bone

leading to osteoporosis & pathologic fractures

Cortisol causes insulin resistance and ↑hepatic gluconeogenesis and insulin

resistance Leads to glucose intolerance and

diabetes mellitus

Cushing disease/ syndrome

Complications Frequent infections & slow wound

healing› Suppressed inflammatory response can

mask severe infections› Cortisol is an immunosuppressive

Deceased ability to handle stress› Psych problems i.e. mood swings

Cushing disease/ syndrome

Diagnosis› Plasma Corticol level› ACTH level› Adrenalangiograpy

Cushing disease/ syndrome

Medical management Early dectection key goal = restore hormonal balance Usually meds.

Cushing disease/ syndrome

Med. Management Tx based on causative factor If adrenal cancer

› Surgery If caused by steroid meds

› Change regiment› Risk to benefit analysis

Cushing disease/ syndrome

Surgical management If pituitary gland

› Hypophysectomy If adrenal tumor

› Adrenalectomy

Cushing disease/ syndrome

Ketoconazole (Nizoral)› Action

Antifungal Inhibits adrenal steroidogenesis

Cushing disease/ syndrome

Aminoglutethimide (cytadren)› Action

Inhibits synthesis of adrenal steroids› Side Effect

Dizziness or drowsiness

Cushing disease/ syndrome

Diet High in protein High K+

Low sodium Reduces carbs & calories

Adrenalectomy

Pre-op› Electrolyte imbalance› Hyperglycemia› Prevent adrenal crisis

Administer glucocorticoids! Sudden drop in hormones crisis

Adrenalectomy

Post-op› Fluid & electrolyte changes› Replace glucocorticoids,

mineralocorticoids for life› Bilateral???

Addison’s Disease

Description› i corticol› Adrenal hypofunction› Adrenal insufficiency› Adrenalcortical insufficiency

Addison’s Disease

Pathophysiology› 90% of adrenal gland destroyed› Autoimmune disease› Primary

ACTH may be high› Secondary

ACTH will be low

Addison’s Disease

Etiology Primary

› Bilateral adrenalectomy Secondary

› i ACTH from pituitary› i hypothalamus stimulation

Addison’s Disease

Etiology Prolonged use of coticosteroid Rx i ACTH i hormonal release from adrenal

gland esp. at risk if drugs abruptly DC’ed

› Taper dose

Addison’s Disease: Signs & Symptoms

Hypotension› Lack of aldosterone › Na+ & H2O loss

› K+ reabsorption Tachycardia Orthostatic hypotension

Addison’s Disease: Signs & Symptoms

Bronze coloration of skin Hypoglycemia Vitiligo Fatigue, muscle weakness Weight loss Crave salty foods

Addison’s Disease: Signs & Symptoms

i tolerance for stress› Anxious› Irritable› Confused

Pulse› Weak

GI upset› Nausea and vomiting› Anorexia

Addison’s disease: Complications

Adrenal Crisis› Signs & Symptoms

Na+ & H20 loss Hypotension Dehydration Tachycardia

› Intravenous & administer hydrocortisone

Addison’s disease: Complications

Adrenal crisis› Acute Addison’s dis› May occur

Trauma Surgery Stress Abrupt withdrawl of cortisone meds

Addison’s disease: Medical Management

Restore fluid and electrolyte balance Replacement of deficient adrenal

hormones› Glucocorticoids (hydrocortisone)› Mineralocorticoids (fludrocortisone)

Addison’s disease: Pharmacological

Lifetime steroids Glucocorticoids

› Hydrocortisone (hydrocortone) Mineralocorticoids

› Fludrocortisone acetate (Florinef) Diurnal rhythm

› 2/3 AM› 1/3 PM

Addison’s disease: Diet

High in Na+

Low in K+

Hypofunction Hyperfunction

Disorder Addison’s disease Cushing syndrome

Signs & Symptom

Na+ & H20 lossHypotensionHypoglycemiaFatigueHyperkalemia

Na+ & H20 retention Wt. gainHyperglycemiaBuffalo humpMoon faceHypokalemia

SUMMARY

Hypofunction Hyperfunction

Usual tx GlucocorticoidsMeneralocorticoidRestore fluid

Alter steroid RxSurgery

Diet h Na+i K+

i Na+h K+

SUMMARY (CON’T)

Pheochromocytoma:Description

Chromaffin cell tumor Rare disease Characterized by paroxysmal or

sustained hypertension› excess secretion of epinephrine and

norepinephrine

Pheochromocytoma:Pathophysiology

Caused by a tumor› Usually Right adrenal

Etiology› Idiopathic

Stress can bring on an attack

Pheochromocytoma:Signs & Symptoms

Hypertension› > 115 mmHg diastolic› Intermittent› Unstable

Tachycardia Profuse diaphoresis Palpitation

Pheochromocytoma:Signs & Symptoms

Visual disturbances Feeling of apprehension Elevated blood glucose levels

Pheochromocytoma:Complications

Stroke Retinopathy Heart disease Kidney damage

Pheochromocytoma:Medical Management / Surgical

Treatment of choice is…› Surgery

Stable a surgery Adrenal gland removed Blood Pressure

Pheochromocytoma:Pharmacological

Phentolamine mesylate (Regitine) Nitroprusside sodium (Nipride)

› Hypertension

Pheochromocytoma:Diet

h protein Avoid caffeine

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