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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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