1. Adrenal Insufficiency
Prof . El Sayed Abdel Fattah Eid
Lecturer of Internal Medicine
Delta University

2. Adrenal Anatomy & Physiology
The adrenals are endocrine organs that sit on top of each kidney Each adrenal gland has two parts :
Adrenal Medulla (inner area)
• Secretes catecholamines which mediate stress response (help prepare a person for stress).
• Hormones (Norepinephrine, Epinephrine & Dopamine)
Adrenal Cortex (outer area, encloses Adrenal Medulla)
• Secretes steroid hormones
• Glucocorticoids: exert effect on metabolism of carbohydrates and proteins
• Mineralocorticoids: are essential to maintain sodium and fluid balance
• Sex hormones (secondary source)

4. Adrenal Cortex consists of 3 anatomic zones:
1- The outer zone (zona glomerulosa): secretes mineralocorticoid aldosterone.
2- The intermediate zone (zona fasciculata): secretes cortisol.
3- The inner zone (zona reticularis): secretes adrenal androgens.

5. The Essential Steroids
Primary glucocorticoid: Cortisol (hydrocortisone)
Primary mineralocorticoid: Aldosterone
A functioning adrenal cortex is essential for survival.

6. Cortisol (Glucocorticoid)
- Frequently referred to as the stress hormone. Released in response to physiological or psychological stress
- Critical actions on many physiologic systems, including:
- Maintains cardiovascular function
- Provides blood pressure regulation
- Enables CHO metabolism (acts on the liver to maintain normal glucose levels)
- Immune function actions (reduces inflammation & suppresses immune system)
- When cortisol is not produced or released by the adrenal glands, humans are unable to respond appropriately to physiologic stressors.

8. Aldosterone (Mineralocorticoid)
- Regulates body fluid by influencing sodium balance
- The human body requires certain amounts of sodium and water in order to maintain normal metabolism of fats, carbohydrates and proteins
- Water/sodium balance is maintained by aldosterone.
- Without aldosterone, significant water and sodium imbalances can result in organ failure/death.

9. Who has adrenal insufficiency?
- In adrenal-insufficient individuals experiencing a physiologic stressor, the vascular smooth muscle will become non-responsive to the effects of norepinephiine and epinephrine, resulting in vasodilation and capillary ‘leaking’.
- In adrenal-insufficient individuals under increased physiologic stress, the liver is unable to metabolize carbohydrates properly, which may result in profoundly low blood sugar
- In adrenal insufficiency, there is a risk of life-threatening hyponatremia, hyperkalemia, hypoglycemia, seizures and cardiovascular collapse, in particular at times of physiologic stress to the body, such as in injury or illness

10. Who has adrenal insufficiency?
• Long-term administration of steroids (Organ transplant patients, COPD, Asthma, rheumatoid arthritis)
• Pituitary gland problems, including growth hormone deficiency, tumor, etc.
• Trauma, including head trauma that affects pituitary
• Loss of circulation to adrenals/removal of tissue • Auto-immune disease
• Cancer and other diseases (TB and HIV may cause) • There is also an inherited form of adrenal insufficiency (CAH)
Adrenal insufficiency Can occur from long-term administration of steroids

11. Why long-term administration of steroids causing adrenal insufficiency?
Adrenal glands tend to get ‘lazy’ when steroids are regularly administered by mouth, I.M. injection or I.V. infusion. To illustrate how quickly; Just 4 weeks of daily oral cortisone administration is sufficient to cause the adrenals to be slightly less responsive to stressors.

12. Primary Adrenal Insufficiency
- Glucocorticoid insufficiency can be primary, resulting from the destruction or dysfunction of the adrenal correx,
- or secondary, resulting from ACTH hypo secretion.
- Usually both Glucocorticoids & mineralocorticoid secretion are diminished
- 80% of the time, damage is caused by an auto-immune response that destroys the adrenal cortex
Causes
- Autoimmune (Atoimmune disease (Addison’s disease))
- Infectious (Tuberculosis, Fungal, cytomegalovirus, HIV)
- Vascular (Bilateral adrenal hemorrhage, Sepsis, Coagulopathy, Thrombosis, embolism, Adrenal infarction)

13. Clinical manifestations
Weight loss, increasing fatigue, postural dizziness may also occur. Vomiting, diarrhea or anorexia with salt craving Muscle and joint pain, abdominal pain, Signs of increased pigmentation (initially most marked on the extensor surfaces, palmar creases, and buccal mucosa)
Pigmentations

15. Diagnosis Laboratory tests: - ACTH & ACTH stimulation tests
- Blood chemistries (hyponatremia, hyperkalemia, hypoglycemia, ↑BUN)
- CBC (↑ Eosinophils & lymphocytes)
- Serum cortisol (am and pm)
- 24 hour urines for 17-hydroxycorticosteroids
ECG:
Hyperkalemia Changes
Abdominal CT

16. Treatment
Life long hormone replacement — Glucocorticoids: Dexamethasone 0.5mg or Prednisone 5mg daily — Mineralocorticoids: Fludrocortisone with adequate salt intake Patient & Family teaching CRITICAL: — Hormone replacement therapy- LIFELONG — Use of patient Card — ↑corticosteroids during illness & stress

17. Acute manifestation of Addison’s (Addison Crisis)
- Severe vomiting/diarrhea, dehydration
- Sudden, severe pain in back, belly or legs
- The patient may present with any illness or injury as the precipitating event.
- Hypotensive, often unresponsive to fluids/pressors
- Hypoglycemia, often refractory to glucose
- May have neurologic deficits (Headache/confusion/seizure, lethargy /unresponsive )
- Cardiovascular collapse & Death
- Children may deteriorate into adrenal crisis from a simple fever, a gastrointestinal illness, a fall from a bicycle or some other injury
- For these patients, standard shock management requires supplementation with corticosteroid medication (Solu-Cortef or Solu- Medrol)

18. Patient Management
- Follow standard ABC and shock management treatment.
- Notify ALS intercept as soon as possible; transport without delay
- ALS: administer steroid IM/IV/Oral as soon as possible after initial life-threat and shock management have been initiated.
- Transport without delay to appropriate hospital with early notification .

19. Thank You