Presentation is loading. Please wait.

Presentation is loading. Please wait.

Adrenal Dr Sohail Inam FRCP(Ed), FRCP Consultant Endocrinologist

Similar presentations

Presentation on theme: "Adrenal Dr Sohail Inam FRCP(Ed), FRCP Consultant Endocrinologist"— Presentation transcript:

1 Adrenal Dr Sohail Inam FRCP(Ed), FRCP Consultant Endocrinologist
Prince Sultan Military Medical City Riyadh, Saudi Arabia


3 CRH AVP Renin substrate Kidney Renin ACTH Angiotensin I Angiotensin II Cortisol Aldosterone Androgens

4 Cortisol Energy metabolism Maintain circulation
Increases glucose Increases fat breakdown Protein breakdown Maintain circulation Increasing blood volume Increase in vascular tone Control of inflammation

5 Aldosterone Mineralocorticoid
Increase blood volume Kidney & GIT Na reabsorption K excretion Vascular endothelium Cardiac

6 Adrenal Andogrens DHEAS, Androstenedione
Axillary & pubic hair Libido Muscle strength Immune modulation Bone health

7 X CRH AVP Renin substrate Kidney Renin ACTH Angiotensin I
Angiotensin II Cortisol Aldosterone Androgens

8 X ↑Renin CRH AVP Renin substrate Kidney ACTH Angiotensin I
Angiotensin II Cortisol Aldosterone Androgens

9 Primary Adrenal Insufficiency
Damage to adrenal gland All 3 hormones are affected Increase compensation due to lack of feed back High ACTH levels High Renin levels

10 X ↓ACTH CRH AVP Renin substrate Kidney Renin Angiotensin I
Angiotensin II ↓Cortisol Aldosterone ↓Androgens

11 Central Adrenal Insufficiency
Damage to pituitary/hypothalamus ACTH levels are low Only cortisol & androgens are affected

12 Causes Primary Adrenal Insufficiency
Autoimmune Infection TB, CMV, HIV, Fungal Hemorrhage or infarction Malignancy Infiltrative Sarcoidosis, hemochromatosis, amyloidosis Adrenal leukodystrophy Drugs

13 Causes Central Adrenal Insufficiency
Exogenous steroid (commonest) Pituitary tumors Infection Inflammation Hemorrhage & infarction Infiltrative Trauma Radiation

14 Clinical presentation
Adrenal Insufficiency Clinical presentation

15 Chronic Presentation Asthenia Weight loss GIT Postural dizziness
Anorexia Nausea, vomiting and abdominal pain Diarrhea Postural dizziness Pigmentation (primary)


17 Chronic Presentation Become very unwell with stress
Low BP with postural drop and tachycardia Electrolyte disturbances Hypoglycemia

18 Acute Adrenal Insufficiency Presentation
Adrenal crisis (Non-specific) Hypotension Postural Recumbent Abdominal pain Electrolyte disturbances Hypoglycemia

19 Electrolyte Abnormalities Adrenal Insufficiency
Primary Central Na Low K High or high normal Normal or low normal Urea High Normal or high Creatinine Low normal Calcium

20 Acute Adrenal Insufficiency Precipitating factors
Omission of corticosteroids Increased requirements Infection Physical stress Drugs

21 Diagnosis Measurement of adrenal hormones Cortisol, DHEAS, Aldosterone
Primary versus central ACTH, Renin Determine cause

22 Diagnosis Cortisol Random 8-9 am level Level during stress Stimulated

23 ACTH Stimulation Test Standard (250 mcg)
Can be performed any time though preferably 8-9 am. 0, 30, 60 minute Any value  550 nmol/l excludes adrenal insufficiency in non-critically ill patients Test is abnormal in almost all patients with primary adrenal insufficiency & 90% individuals with central adrenal insufficiency

24 Pituitary Stimulation Tests
Insulin tolerance test (ITT) Gold standard for central disease Risk from hypoglycemia CRH Metyrapone Other

25 Determine Cause Careful history of previous steroid use Radiology
Adrenal CT (Primary) Pituitary MRI (Central) Autoantibody Tests specific for suspected etiology

26 Acute AI Management Fluids Glucocorticoids Treat underlying cause
Resuscitate 0.9% NaCl Glucose Glucocorticoids Treat underlying cause Precipitation event Etiology

27 Steroid Therapy Acute crisis Chronic Stress dose adjustment
IV Hydrocortisone drug of choice Natural compound & mineralocorticoid activity 50 mg 6-8 hourly Taper dose early No additional benefit of mineralocorticoids Chronic Maintenance glucocorticoid ± mineralocorticoid Stress dose adjustment

28 Cushing's Syndrome

29 Cushing’s Syndrome Chronic tissue exposure to excess cortisol
Exogenous Endogenous

30 Clinical features Weight gain Skin changes Proximal muscle weakness
Central fat distribution Skin changes Thinning Striae Easy bruising Proximal muscle weakness Osteoporosis

31 Cushing’s Syndrome Clinical features
Hypertension Glucose intolerance Psychiatric disturbance Hypogonadism Infections



34 Cushing’s Syndrome Cause
ACTH dependent 75-80% Pituitary adenoma (Cushing’s disease) 60-70% Ectopic 10-15% ACTH independent Exogenous steroids Adrenal adenoma & carcinoma (18-20%) Bilateral adrenal hyperplasia

35 Ectopic ACTH Secretion
Lung Carcinoid Small cell carcinoma Pancreas Neuroendocrine tumors Thymus Other carcinomas

36 Diagnosis Clinical suspicion Documenting hypercortisolism
Symptoms & signs Documenting hypercortisolism Determining the cause

37 Diagnosis of Cushing’s Syndrome Documenting Excess Cortisol
Exclude exogenous steroid use Excess cortisol 24 Hour urine for free cortisol (>3 x Normal) Loss of diurnal variation Midnight or late night cortisol (3 samples) Abnormal regulation Dexamethasone suppression test At least 2 out of 3 should be abnormal

38 Diagnosis of Cushing’s Syndrome Falsely Abnormal Tests
Patients who are physically stressed Sick patients Patients with severe obesity Malnutrition, Anorexia nervosa, Severe exercise Patients with psychological stress Severe major depressive disorder Chronic alcoholism Drugs

39 Determining the cause ACTH
ACTH suppressed (Independent) Adrenal tumors Exogenous steroids ACTH normal or elevated (Dependent) Cushing’s disease Ectopic Cushing’s

40 Determining the Cause ACTH Dependent
MRI pituitary Inferior petrosal venous sampling CT chest and abdomen High dose dexamethasone suppression test Functional nuclear scans

41 Treatment Adrenal tumors Cushing’s disease Surgical resection Surgery
Medical therapy Radiotherapy Bilateral adrenalectomy

42 Treatment Ectopic ACTH secretion
Treat the underlying tumor (surgical resection) Medical therapy Somatostatin analogues Adrenal blocking drugs Bilateral adrenalectomy

43 Treatment Medical Therapy
Inhibit ACTH release Somatostatin receptor analogues D2 receptor analogues (cabergoline) Block cortisol synthesis Ketaconozole, Metyrapone, Mitotane Block the cortisol receptor Mifepristone

44 Thank You

Download ppt "Adrenal Dr Sohail Inam FRCP(Ed), FRCP Consultant Endocrinologist"

Similar presentations

Ads by Google