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First Medical Center health with us1 An unusual cause of Hypertension Adrenal Glands Disorders Dr. Babu Shersad MD, MACP Case Presentation by: Dr. Babu.

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Presentation on theme: "First Medical Center health with us1 An unusual cause of Hypertension Adrenal Glands Disorders Dr. Babu Shersad MD, MACP Case Presentation by: Dr. Babu."— Presentation transcript:

1 First Medical Center health with us1 An unusual cause of Hypertension Adrenal Glands Disorders Dr. Babu Shersad MD, MACP Case Presentation by: Dr. Babu Shersad MD, MACP American Board Certified Internal Medicine & Nephrology Venue : Dubai Sheraton Creek Date: 12/12/06 Credit Hours : 180 minutes (3hrs.) Approved by: Department of Health Dubai First Medical Center

2 health with us 2 Anatomy of the talk 1.Case study 2.Hypertension and what is secondary Hypertension? 3.Causes and Evaluation- ABCDE molecule 4.Hyper aldosteronism 5.Differential diagnosis 6.Rule of 9 7.Points to remember

3 First Medical Centerhealth with us 3 Hypertension: Pre Hypertension: blood pressure 120/80 mmHg to 139/89 mmHg not a disease category Hypertension: blood pressure of 140/90 mmHg or above three readings 6 hours apart

4 First Medical Centerhealth with us 4 A quick review on Hypertension

5 First Medical Centerhealth with us 5 Secondary hypertension Hypertension secondary to underlying, identifiable & often reversible cause Why did I choose to talk on this topic? 15 – 25 % of hypertensive cases constitute secondary HT Client report: 42 year old teacher with HT X 15 years. Referred for quadriparesis possibile plasma pheresis Admission work up: Serum potassium 1.80 mmol /l Serum bicarbonate 28 mmol / l

6 First Medical Centerhealth with us 6 Diagnosis of Secondary Hypertension : ABCDE molecule A - Accuracy, Apnea and Aldosteronism B - Bruits & bad kidneys (Renal parenchymal disease) C - Catecholamine, Co arctations & Cushings syndrome D - Drugs & Diet E - Erythropoietin & Endocrine disorders

7 First Medical Centerhealth with us 7 Conditions leading to secondary hypertension Renal artery stenosis Chronic renal disease Hyper aldosteronism Stress Sleep apnea Hyper or hypothyroidism Pheochromocytoma Pre eclampsia Aortic co-arctations

8 First Medical Centerhealth with us 8 HyperthyroidismLability, irritability, palpitations, muscle weakness, weight loss, diarrhea, heat intolerance, menstrual irregularity Tremor, fine hair, onycholysis, lid lag, proptosis, tachycardia, atrial fibrillation, wide pulse pressure. Elevated thyroid hormones, suppressed thyrotropin. Cushings syndromeWeakness, weight gain, amenorrhea Moon facies, acne, supraclavicular fat pad, purple stria on abdomen/thighs, edema Increased plasma cortisol, increased urinary 17-keto and hydroxysteroids Coarctation of the aorta Usually no suggestive clues on history. Occassionally a history of epistaxis, intermittent claudication, dizziness, or headaches. Diminished pulse/ blood pressure in vessels distal to coarctation (femoral, sometimes left brachial) Electrocardiogram shows left ventricular hypertrophy, chest radiograph may show notching of lower rib borders, angiography is diagnostic HyperparathyroidismMuscle weakness, nausea, anorexia, constipation, weight loss, polyuria, polydipsia, deafness, parasthesias, bone pain. Suggested by triad of peptic ulcer, urinary calculi, and pancreatitis. Band keratitis, hypotonia, weakness Hypercalcemia, hypophosphatemia, hypercalciuria, elevated alkaline phosphatase HyperaldosteronismOften none. Weakness, paralysis, paresthesias Weakness. Chvosteks or Trousseaus sign Hypokalemia or low-normal potassium Renal parenchymal disease. Varies, from none to overt uremia. May have history of previous renal disease, diabetes, previous urinary tract infections, abdominal surgeries, prostate disease, or family history of polycystic kidney or other renal disease. Many drugs can cause or worsen renal disease. Varies. Weakness, anorexia, weight changes, edema, palpable enlarged kidneys Urinalysis may reveal blood, protein or leukocytes. Sediment examination may reveal casts, oval fat bodies, or dysmorphic cells; however, completely bland sediment does not exclude renal disease Proteinuria should be quantified with 24-hour urine. Electrolytes reveal elevated blood urea nitrogen or creatinine in many, although calculation of creatinine clearance may be needed in the elderly or in patients with low muscle mass to identify those with normal serum creatinine but reduced glomerular filtration rate. Renal ultrasound, renal biopsy, and urine electrolytes may assist. ©2006 UpToDate ® Licensed to Babu Shersad

9 First Medical Centerhealth with us 9 Clinical features of the different causes of secondary hypertension ConditionHistoryPhysical Examination Laboratory Findings PheochromocytomaParoxysmal hypertension, dizziness, palpitations, headache, nausea, vomiting, sense of doom, worse with abdominal manipulations, postcoital, or with abdominal torsion, episodes of hyper- or hypotension related to anesthesia or surgery. Can have paroxysmal hypertension with beta blockade. Family or personal history suggestive of multiple endocrine neoplasia syndrome. Flushing or pallor, tachycardia, bounding pulses. May be normotensive or hypertensive on presentation; usually hypertensive during paroxysms; abdominal palpation may incite paroxysm. Elevated urine and plasma catecholamines. Renal artery stenosisUsually hypertension is severe, resistant to drug treatment, and often presents relatively acutely in previously normotensive individuals. Age usually 55. May have history of renal insufficiency, particularly after administration of an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Often a history of vascular disease. Abdominal bruit or bruits across other vascular beds suggestive of vascular disease. Duplex ultrasound or angiogram of the renal vessels. Laboratory data may confirm presence of renal insufficiency, often with bland urine. HypothyroidismDry skin, hair loss, weight gain, constipation, cold intolerance, cognitive slowing, menstrual irregularity. May be asymptotic in elderly. Round full face, slow speech, hoarseness, muscle weakness, delayed relaxation on reflex testing, cold skin, coarse brittle hair, normal or faint cardiac impulse, cardiac enlargement, bradycardia, edema. Low thyroid hormone levels, high thyrotropin

10 First Medical Centerhealth with us 10 Adrenal Gland Disorder : Hyper aldosteronism over production of aldosterone independent of renin- angiotensin regulator system Increased urinary excretion of potassium signals hyper-aldosteronism which should be suspected in all hypertensive patients with unprovoked hypokalemia fluid retention and increased blood pressure, weakness, and, rarely, periods of paralysis It leads to ….. Remember…..

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12 First Medical Centerhealth with us 12 Signs & Symptoms: Weakness Tingling and muscle spasm Periods of temporary paralysis Thirsty Fontal headache polyuria & polydypsia Abdominal distension Ileus from hypokalemia Findings related to complications of HTN Chvosteks or Trousseaus sign Aldosterone escape - due to spontaneous natruesis and diuresis that occurs in these patients (no signs of edema)

13 First Medical Centerhealth with us 13 Some times the clinical presentation of Hyper aldosteronism is not distinctive,the common clinical scenarios are: 1.Patients with spontaneous or unprovoked hypokalemia, especially if the patient is also hypertensive 2.Patients who develop severe and/or persistent hypokalemia in the setting of low-to-moderate doses of potassium-wasting diuretics 3.Patients with refractory HTN

14 First Medical Centerhealth with us 14 A.Primary Hyper aldosteronism (Conn's Disease) 1.Solitary adrenal adenomas (80-90%) 2.Bilateral adrenal hyperplasia (10-20%) a.Idiopathic hyper aldosteronism b.Accounts for 50% of cases at some referral centers 3.Adrenal Carcinoma (rare) 4.Unilateral Adrenal Hyperplasia (very rare) B.Secondary Hyperaldosteronism 1.Hypertensive States a.Primary reninism (rare renin producing tumor) b.Secondary reninism due to decreased renal perfusion 2.Edematous States a.Cirrhosis b.Nephrotic Types and causes:

15 First Medical Centerhealth with us 15 A.Serum Electrolytes 1.Serum Potassium decreased (Hypokalemia) 2.Serum Sodium increased (Mild) 3.Metabolic Acidosis B.Aldosterone to PRA ratio over Definitely significant if ratio >100 2.Aldosterone high and plasma renin low C.Saline suppression 1.IVF: cc/hour for 4 hours 2.Normal response a.Aldosterone usually under 0.28 b.Renin usually suppressed Diagnostic findings:

16 First Medical Centerhealth with us 16 Adrenal Adenoma Renal Artery Stenosis Reno vascular Hypertension Adrenal Carcinoma Conns syndrome Cushings syndrome Hypertension & Hypertension, Malignant Hypokalemia & metabolic Alkalosis Eclampsia Carcino Adrenal Surgery Bartter Syndrome C-11 hydroxylase deficiency & C-17 hydroxylase deficiency Encephalopathy, Hypertensive Pre eclampsia (Toxemia of Pregnancy) Differential diagnosis

17 First Medical Centerhealth with us 17 Differential Diagnosis: Hypertension with hypokalemia A.Cushings Disease Low Aldosterone and Low Plasma Renin A.Renal Artery Stenosis or other renal cause High Aldosterone and High Plasma Renin But what a physician should always rule out are:

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19 First Medical Centerhealth with us 19 Points to remember

20 First Medical Centerhealth with us 20 These are a must (Rule of 9) ECG Urine analysis Blood glucose (9 to 12 hr fasting) Hematocrit Serum potassium Serum creatinine Serum calcium Lipid profile (LDL & HDL with triglycerides) (9 to 12 hr fasting) Albumin creatinine ratio

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22 First Medical Centerhealth with us 22 Appropriate BP measurement With verification in the contra-lateral arm Examination of optic fundi BMI Auscultation of carotid, abdominal and femoral bruits Examination of heart, lungs and kidneys Seek abnormal aortic pulse Examination of edema and abnormal pulses in the lower extreme ties Neurological examination Proper physical evaluation is a must :

23 First Medical Centerhealth with us 23 All references from: Joint National Committees 7 th Report, Mayo Clinic & American Heart Association This is where the world is heading to Did you hear about the baby born in the high tech delivery room? It was cordless! No matter how hi-tech we go but a proper detection and evaluation is a must for an exact clinical diagnosis It is high time for us physicians to find every possible way to treat a patient for his/her root sickness. Like I say, things happen for a reason, believe…. Thank you

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