1. Ultrasound of the Abdomen Part II
The Adrenal Glands
Holdorf
Ultrasound of the Abdomen Part II

2. Outline Location Quick facts Spatial anatomy Normal anatomy Cortex
Medulla
Disorders
Cushing’s disease
Cortical Carcinoma
Pheochromocytoma
Addison’s Disease
Neuroblastoma
Adenoma
Myelolipoma

3. Outline Adrenal lymphoma Adrenal Metastases Adrenal Hemorrhage
Adrenal Cortical cancer
Kaposi’s Sarcoma
Adrenal Cysts

4. The Kidneys and adrenal glands lie within the peri-renal space and are separated from the pararenal spaces by the anterior and posterior renal fascia (Gerota’s Fascia).

7. ACTH
Adrenocorticotropic hormone (ACTH), also known as corticotropin is a polypeptide tropic hormone produced and secreted by the anterior pituitary gland. It is an important component of the hypothalamic-pituitary-adrenal axis and is often produced in response to biological stress. Its principal effects are increased production and release of cortisol by the cortex of the adrenal gland.

8. The following structures are located in the retroperitoneum:
Kidneys
Adrenal Glands
Ascending and Descending Colon
2nd, 3rd, and 4th parts of the duodenum
Pancreas
Aorta and IVC
Ureters
Renal vessels
Superior mesenteric vessels
Gonadal vessels
Lymphatics
Prostate

9. Adrenal Gland Quick Facts
Smallest paired organs found within the abdomen
Located at the level of the 11th or 12th thoracic rib
2-3 cm in width x 4-6 cm in length and 3-6 mm in thickness
Composed of CORTEX and MEDULLA

10. Spatial anatomy of the Adrenal Glands
Right Adrenal Gland is posterior to the IVC
Right Adrenal Gland is anterior to the crus of the diaphragm
Right Adrenal Gland is inferior to the liver
Left Adrenal Gland is situated between the spleen and upper pole of the Left Kidney
Left Adrenal Gland is posterior to the tail of the pancreas

11. More facts…
The Adrenal Glands play a significant role in the maintenance of homeostasis through hormone secretion
CT Scan is regarded as the gold standard imaging modality for the adrenal gland

13. Adrenal Glands
The adrenal glands and kidneys are located within the perirenal space
The right adrenal gland is shaped like a triangle and pyramid. It is located on the superior, anterior and medial aspect of the upper pole of the right kidney. Portions of the gland extend posterior to the IVC. The curs of the diaphragm lies medial and posterior to the right adrenal gland.
The left adrenal gland is crescent shaped and is located antero-medial to the upper pole of the left kidney. The aorta and curs of the diaphragm are located medial to the left adrenal gland. The tail of the pancreas is located anterior to the left adrenal gland.

15. Cross-Sectional Adrenal Glands

19. Normal Anatomy
The adrenal cortex is hypoechoic and typically is less echogenic than the surrounding retroperitoneal fat.
The adrenal medulla is seen as an echogenic linear structure within the adrenal gland.
Three arteries supply each adrenal gland:
Suprarenal branch of the inferior phrenic artery
suprarenal branch of the aorta
suprarenal branch of the renal artery
A single vein drains each adrenal gland:
Right suprarenal vein drains into IVC
Left suprarenal vein drains into the left renal vein (just like the left Gonadal vein)

20. Blood Supply to the Adrenal Gland

21. Normal Adrenal Glands

22. Adrenal Cortex
The adrenal cortex produces steroid hormones. (The pituitary gland and Adrenal gland “watch” each other and work in harmony).
Mineralocorticoids (aldosterone)
Glucocorticoids (cortisol)
Androgens
The adrenal cortical hormones (ACH) are regulated by the adrenocorticotropic hormones (ACTH) of the pituitary gland.

23. The adrenal Cortex–X section

24. Adrenal Cortex cont…
The adrenal gland and the anterior pituitary gland function together to regulate hormone production. A decrease in adrenal cortical function leads to an increased ACTH which then stimulates the adrenal cortex. An increase in adrenal hormones leads to a drop in ACTH secretions, which in turn leads to a drop in the activity of the adrenal cortex.
Tumors of the adrenal gland and anterior pituitary gland may overproduce or under produce ACTH and ACH.

25. Adrenal Medulla The adrenal medulla produces Adrenal masses
epinephrine (adrenalin)
Norepinephrine
Adrenal masses
Sonographic appearances of adrenal masses does not allow differentiation between adenoma, carcinoma, Pheochromocytoma and metastases.

26. Adrenal Medulla x-section

27. Adrenal Medulla cont… Adrenal Adenoma
Adrenal adenomas can be hyper functioning or nonhyperfunctioning. Adrenal cortical hyper functioning can be caused by adrenal hyperplasia (congenial or acquired), adenomas or adenocarcinomas. The following syndromes are the result of adrenal hyper functioning:

28. Cushing’s syndrome-excessive cortisol secretion associated with adrenal adenomas.
Cushing’s disease – excessive cortisol secretion due to increase in ACTH form a pituitary adenoma.
Conn’s Disease – excessive aldosterone secretion associated with adrenal adenoma.
Hirsutism – may be caused by androgen secreting adrenocortical and ovarian disorders (Cushing’s syndrome, Cushing’s disease, polycystic ovarian syndrome).
When endocrine studies are negative, indicating a non-hyper functioning adrenal mass, resection is based on its size (>3cm)
In patients with a known primary malignancy, biopsy is often performed to exclude metastatic disease.

30. Petechiae (Puh-TEE-Kee-ee)
Hyperglycemia
High blood sugar: an excessive amount of glucose circulates in the blood plasma.
Petechiae (Puh-TEE-Kee-ee)
Pinpoint, round spots that appear on the skin as a result of bleeding

31. Adrenal cortical Carcinoma
Adrenal cortical carcinoma is a rare tumor with a poor prognosis. The majority of patients present with Cushing’s syndrome. Many patients present with metastatic involvement.
Differentiation from a benign adenoma is difficult. Tumor removal (or biopsy) is based on size (3-6 cm)
Adrenal cortical carcinomas have a tendency to invade the renal veins and IVC.

33. Pheochromocytoma Benign Rare Appears in 4th to 6th decade of life
Arise from adrenal medulla
Secrete nor-epinephrine and epinephrine

35. Pheochromocytomas secrete
Pheochromocytoma originates in the adrenal medulla but may occur in ectopic locations such as along the para-aortic sympathetic nerve chair. The majority of pheochromocytomas are benign.
Pheochromocytomas secrete
Norepinephrine
epinephrine
Pheochromocytomas are associated with multiple endocrine neoplasia (MEN) AKA Von Hippel-Lindau disease.

37. ADDISON’S DESEASE
Addison’s disease, also known as primary adrenal insufficiency, is a long term endocrine disorder in which the adrenal glands do not produce enough steroid hormones. Symptoms generally come on slowly and may include abdominal pain, weakness, and weight loss. Darkening of the skin in certain areas may also occur. Under certain circumstances an adrenal crisis may occur with low blood pressure, vomiting, lower back pain, and loss of consciousness. An adrenal crisis can be triggered by stress, such as from an injury, surgery, or infection.[1]

39. Adrenal Neuroblastoma
Adrenal Neuroblastoma is a malignant tumor that occurs 65% of the time in the abdomen (45% adrenal medulla and 25% sympathetic nervous chain). It typically presents as a palpable abdominal mass in children.
Most common extra cranial solid childhood malignancy.
Most common tumor occurring during infancy.
Age ranges from 1-10 years (36% before 1 yr, 75% before 4 years). Age at diagnosis is typically younger than that for Wilm’s tumor.

41. Adrenal Neuroblastoma
Accounts for approx. 8% of childhood cancers
It typically displaces the kidneys inferiorly into the pelvis, opposed to the Wilm’s tumor, that originates from and destroys the kidney.
Increase in urinary by-products
More than 50% of patients present with metastatic disease.

42. Adenoma Benign Found in 3% of adult autopsies Most are non functioning
Reported in patients with
Hypertension
Diabetes
Hyperthyroidism
Renal cell carcinoma

43. Adenoma Hyper-functioning adrenal adenomas most commonly give rise to:
Cushing’s syndrome (caused by excessive cortisol secretion)
Conn’s Disease (Caused by increased aldosterone)
Adenoma Tumors tend to be less than 2 cm in size

45. Adrenal Adenoma

46. Myelolipoma
Myelolipomas are benign, nonfunctioning adrenal masses that contain fat and bone elements.
Sonographically, are seen as hyperechoic masses in the adrenal bed.
Associated with propagation speed artifact due to fat composition.

48. Myelolipoma Benign Rare, non functioning tumors
Composed of varying proportions of fat and bone marrow
Mostly less than 5cm in diameter

49. Lymphoma Malignant tumor Rare Hypoechoic
May arise from lymphoid element found in normal adrenal or contiguous spread from retroperitoneal diseases
Necrosis and calcifications are rare

50. Adrenal Lymphoma
Adrenal involvement with lymphoma is common and frequently bilateral. Involvement may be diffuse, resembling hyperplasia or mass-like.
Non-Hodgkin disease is the most common cell type.

52. Adrenal Metastases
The adrenal glands are the 4th most common metastatic site after lungs, liver and bone. The most common primary sites are lung, breast, skin (melanoma), kidney, thyroid, and colon cancers.
Differentiation from a unilateral adrenal mass (benign adenoma vs. a metastatic lesion) is difficult in a patient with a primary cancer.

54. Adrenal Hemorrhage
Adrenal hemorrhage is most common in the neonate. They are caused by the large size of the neonatal adrenals and their high degree of vascularity which make them vulnerable to birth trauma.
Sonographically, the appearance of an adrenal hemorrhage varies due to blood coagulation. The normal evolution of a hematoma ends with a pseudocyst formation. If a mass is identified adjacent to the adrenal glands of a newborn, it is most likely a hemorrhage.

56. Adrenal Hemorrhage

57. Other Adrenal cortical cancer Rare
More common in females in the 4th decade
Highly malignant: has tendency to invade the adrenal veins , IVC, and lymph nodes
Recurs following surgery

58. Kaposi’s Sarcoma Patients with AIDS are more affected
90% or more of the adrenal gland is damaged by infection
Adrenal insufficiency occurs

59. Kaposi's Sarcoma
Kaposi's sarcoma is a cancer that causes patches of abnormal tissue to grow under the skin, in the lining of the mouth, nose, and throat or in other organs.
The patches are usually red or purple and are made of cancer cells and blood cells. The red and purple patches often cause no symptoms, though they may be painful.
If the cancer spreads to the digestive tract or lungs, bleeding can result. Lung tumors can make breathing hard.

60. Kaposi’s Sarcoma

61. Adrenal Cysts Rare Benign Typically unilateral 3rd to 5th decade
3:1 female ratio
Asymptomatic unless compression of adjacent structures: Abdominal pain, nausea, and back pain.

62. Adrenal Cysts

63. Adrenal Gland Cyst

64. Questions:
What is the most common adrenal mass in the newborn?
Adrenal hemorrhage
What is the most likely diagnosis in a newborn with an abdominal mass and decreasing hematocrit?
Wilm’s tumor
Adrenal Neuroblastoma
hepatoblastoma
adrenal hemorrhage

65. FIN