1. Alex Edwards ae11g11@soton.ac.uk
Adrenal Disease
Alex Edwards

2. DAPSICAMP Definition Aetiology Pathophysiology Signs and Symptoms
Investigations
Complications
Alternative Diagnosis
Management
Prognosis

3. Anatomy – Arterial Blood Supply
Inferior Phrenic Artery
Superior Suprarenal Artery
Adrenal Gland!
Middle Suprarenal Artery
Inferior Suprarenal Artery
Aorta
Renal Artery

4. Anatomy – Venous Drainage
Right Suprarenal Vein
Left Suprarenal Vein
Left Renal Vein
Inferior Vena Cava

5. Blood Supply - Summary Arterial Supply (same on both sides)
Superior Suprarenal Artery (from inferior phrenic)
Middle Suprarenal Artery (from aorta)
Inferior Suprarenal Artery (from renal artery)
Venous Drainage
LEFT Suprarenal Vein – into left renal vein
RIGHT Suprarenal Vein – into inferior vena cava

6. Adrenal Structure Cortex – secretes steroid hormones
Medulla – secretes cathecholamines

7. The Medulla Contains Chromaffin cells Secrete Adrenaline (80%)
Secrete Noradrenaline (20%)
Secretion in response to stimulation by sympathetic nerve fibres from thoracic segments
Pre-ganglionic fibres release Ach that binds to Nicotinic type 1 receptors on adrenal medulla
NA/A secreted into circulation

8. The Medulla - effects of cathecholamines
Sympathetic Fight or Flight response
Cause of excess catecholamines:
PHEOCHROMOCYTOMA – tumour of the adrenal medulla
Tachycardia, hypertension, tremor, sweating
High plasma glucose
NA/A cause an increase in lipolysis, gluconeogenesis and glycogenolysis

9. The Cortex – GFR! Zona Glomerulosa Mineralocorticoids ALDOSTERONE
Zona Fasciculata
Glucocorticoids
CORTISOL
Zona Reticularis
Androgens
TESTOSTERONE

10. The Key Step Progesterone Mineralocorticoids (ALDOSTERONE)
Cholesterol
Progesterone
Mineralocorticoids
(ALDOSTERONE)
Zona Glomerulosa
17α hydroxylase
Glucocorticoids
(CORTISOL)
Zona Fasciculata

11. Aldosterone - released by ZG in response to Angiotensin II
Angiotensinogen
Blood pressure
Renal blood flow
Catecholamines
Renin from Kidney JGA
Angiotensin I
ACE from surface of pulmonary and renal endothelium
Angiotensin II
ALDOSTERONE
Vasoconstriction

12. Aldosterone - effects Increases renal Na+ retention in the late DCT
Increases renal water retention in the early collecting ducts
Increases blood volume and blood pressure

13. Hyperaldosteronism - aetiology
Conn’s Syndrome (>80%)
Adrenal adenoma that secretes excess aldosterone
Bilateral Adrenal Hyperplasia (15%)
Other
Familial
Adrenal carcinoma (rare)
17α hydroxylase deficiency

14. Hyperaldosteronism - pathophysiology
Aldosterone acts on principle cells in the late DCT/early collecting ducts causing:
Expression of Na+ and K+ channels in luminal membrane
Activity of Na+/K+ pump on basolateral membrane
Therefore signs and symptoms include:
Hypernatremia
Hypokalemia
Hypertension
INTERSTITIUM
ALDOSTERONE

15. Hyperaldosteronism - investigations
Blood tests
U&Es
Spot renin and aldosterone levels
ECG – arrhythmias from electrolyte imbalance
CT/MRI
Special tests
Lying and standing aldosterone/renin levels
Salt loading and aldosterone/renin levels

16. Cortisol - released by ZF in response to ACTH
HPA axis:
Hypothalamus
Corticotropin Releasing Factor (CRF)
Anterior Pituitary Gland -Corticotrophs
Adenocorticotropic Hormone (ACTH)
Adrenal Cortex
(Zona Fasciculata)
CORTISOL

17. Cortisol - effects Cortisol is a catabolic stress hormone
Anti-insulin – increases plasma glucose
Increases muscle protein degradation
Increases lipolysis and fat deposition
Anti-inflammatory
Immunosuppressant

18. Hypercorticism (Cushing’s Syndrome) - aetiology
ACTH dependent (80-85%)
Secondary pituitary adenoma (80%) – Cushing’s Disease
Secondary ectopic tumour
Small cell lung cancer
Carcinoid tumour of the lung
Most endocrine tumours
ACTH independent
Primary adrenal adenoma (60%)
Primary adrenal carcinoma (40%)
Iatrogenic
Corticosteroids

19. Hypercorticism (Cushing’s Syndrome) - Signs and Symptoms
Anti-insulin and increased plasma glucose - HYPERGYLCAEMIA
Muscle protein degradation – MUSCLE WASTING
Lipolysis and fat deposition – BUFFALO HUMP and CENTRAL OBESITY
Anti-inflammatory and Immunosuppressant effects – EASY BRUISING

20. Hypercorticism (Cushing’s Syndrome) - investigations
U&Es
24 hour urinary free cortisol (3 collections)
Dexamethasone suppression test
Dexamethasone supressed corticotropin releasing hormone (CRH) test

21. Adrenal Insufficiency
ADDISON’S DISEASE
Adrenal cortex destruction
Rare
90% autoimmune
Aldosterone deficiency
Hypotension (postural)
Hyponatremia and hyperkalaemia
Cortisol deficiency
Hypoglycaemia
Skin pigmentation
Caused by increased ACTH from negative feedback
ACTH precursor causes pigmentation

22. Adrenal insufficiency - investigations
U&Es
Blood cortisol levels
ACTH stimulation (Synacthen) test
Fails to produce cortisol in adrenal failure
Managed by synthetic hormonal replacement

23. Summary

24. Any Questions?