1. moon face
    striae and centropetal obesity
  2. what is Cushing's syndrome?
    excessive activation of GC receptors
  3. what is cushing's disease?
    • pituitary adenoma secreting ACTH
    • leading to high cortisol
  4. what is the most common cause of Cushing's syndrome?
    exogenous steroid use
  5. what is the commonest endogenous cause of Cushing's syndrome?
    what are other causes?
    • commonest endogenous cause - cushing's disease
    • other - ectopic ACTH secretion/iatrogenic ACTH therapy
  6. name two causes of ectopic endogenous ACTH secretion?
    • bronchial carcinoid tumour
    • small cell lung ca
  7. name an endogenous cause of Cushing's syndrome that is ACTH independent?
    adrenal adenoma/ca
  8. which zones of the adrenal cortex produce what?
    • G-salt
    • F-sugar
    • R-sex
  9. what receptors does NA work on and what are the effects?
    alpha -> vasoconstriction
  10. what receptors does adrenaline work on and what are the effects?
    • alpha -> vasoconstriction
    • beta -> vasodilatation, tachycardia, insulin receptors
  11. what type of Cushing's syndrome are more common among:
    a) women
    b) men?
    • a) cushing's disease, cortisol secreting adrenal tumour
    • b) ectopic ACTH small cell lung ca
  12. sex ratio of cushing's disease?
    4 women: 1 man
  13. 5 year mortality rate of Cushing's syndrome if untreated?
  14. what are the three clinical differences between Cushing's syndrome and high cortisol caused by depression?
    • bruising
    • HTN
    • proximal myopathy

    NOT seen in depression
  15. what can super-high cortisol levels do to potassium levels?
    • hypokalaemia
    • cortisol's MC effect
  16. test for Cushing's syndrome differentiation?
    • dexamethasone suppression test:
    • low dose doesn't decrease CORTISOL but high dose does -> cushing's disease
  17. apart from the dexamethasone suppression test, what else can you use to test for Cushing's syndrome?
    • insulin suppression
    • CRH test
    • check plasma ACTH levels
  18. what is nelson's syndrome?
    • pituitary macroadenoma that lacks negative feedback
    • high ACTH
    • brown skin
  19. how do you treat nelson's syndrome?
    irradiate pituitary
  20. what is mitotane? it may one day be used to treat cushing's
    adrenolytic drug
  21. can you just take out an adrenal gland for cushings?
  22. pred, dexamethasone, cortisone acetate, hydrocortisone are all what?
  23. side effects of GC therapy?
    • Cushing's syndrome
    • osetoporosis
    • DM due to insulin R
    • peptic ulcers
    • reactivation of latent TB
  24. what must you be wary of when withdrawing GC therapy?
    • prolonged use will reduce endogenous system
    • so withdrawal needs to be tapered and monitored to avoid:
    • low cortisol and androgens (MC are fine)
    • -> n&v and shock
  25. osteoporosis prophylaxis given with steroids?
    • bisphosphonates eg alandronate
    • calcium, vit D
    • strontium ranelate
    • PTH low dose
    • HRT
  26. addison's causes low:

    • C)
    • c
  27. three consequences of low MC?
    • hypotension
    • hyponatraemia
    • hyperkalaemia
  28. consequences of low GC?
    • weight loss
    • hypoglycaemia
    • hyponatraemia
    • hypercalcaemia
    • postural hypotension
    • N&V&D
    • weakness
  29. management of an adrenal crisis?
    • IV saline
    • IV hydrocortisone succinate
    • IV 10% glucose
    • treat hyperkalaemia
  30. treatment for hyperkalaemia (watch the heart!)?
    • IV calcium gluconate
    • ECG
    • inhaled salbutamol
    • insulin
    • furosemide and fluids

  31. diagnosis of adrenal insufficiency includes what?
    • inadequate secretion of cortisol
    • without or with low aldosterone too

  32. what is Addison's disease?
    • primary adrenal insufficiency
    • high ACTH
  33. causes of Addison's disease?
    • common:
    • TB
    • mets
    • AIDs
    • autoimmune

    • rare:
    • waterhouse-friedrihsens syndrome
    • amyloid
    • haemochromo
  34. what is waterhouse-friedrichsen syndrome?
    • intra adrenal bleed
    • post meningoccal infection

    causes addison's disease
  35. non-addison's disease adrenal insufficiency?
    • secondary adrenal insufficiency:
    • low ACTH

    more common!
  36. 2 causes of secondary adrenal insufficiency?
    • GC withdrawal
    • pituitary tumour
  37. someone presents with fatigue, hyponatraemia and hypotension, what do you suspect?
    adrenal insufficiency
  38. what is the ACTH stimulation test used for testing adrenal insufficiency?
    • give IM synacthen
    • measure cortisol and ACTH in serum
  39. what infections do you test for with adrenal insufficiency?
    • TB
    • HIV
  40. treatments in adrenal insufficiency:
    androgens in women?
    • GC - oral hydrocortisone
    • MC - oral fludrocortison
    • androgen - DHEA (given for decreased libido in women, men make androgens in testes so no need)
  41. what percentage of adults have an adrenal incidentaloma?
    how many are insignificant?

    85% of them are insignificant
  42. how can you test if an adrenal medulla mass is secreting NA/adr?
    urine metanephrines
  43. which of the following traits of an adrenal mass on CT is likely to make it a benign adenoma/incidentaloma:
    small and smooth
  44. when would you do a laparoscopic adrenalectomy for a benign mass?
    • if it's >5cm
    • if it's secreting stuff
  45. common cause of primary hyperaldosteronism?
    idiopathic bilateral adrenal hypertension
  46. what is Conn's syndrome?
    • rare cause of primary hyperaldosteronism:
    • aldosterone producing adenoma
  47. what are the symptoms of hyperaldosteronism?
    • sodium retention -> HTN
    • oedema
    • polyuria (nephrogenic DI)
    • hypokalaemia due to K+loss
    • metabolic alkalosis (H+ loss)
    • paralysis
    • tetany (metabolic alkalosis)
  48. what does aldosterone do?
    • ENaC - increase sodium reabsorption
    • ROMK - increase potassium excretion

    • increase proton exrection
  49. treatment for primary hyperaldosteronism?
    • spironolactone/amiloride - MC antagonist
    • laproscopic removal if Conn's (but HTN remains)
  50. which one is chromaffin positive:
    phaeo or paraganglioma?
  51. what percentage of adrenal medulla tumours are paragangliomas?
    • 20%
    • the rest are phaeochromocytomas
  52. what percentage of people presenting with HTN are because of an adrenal medulla secretory tumour?
  53. what percentage of phaeos are malignant?
  54. what percentage of phaeos are inherited?
  55. what tumour syndromes are phaeos linked to?
    • neurofiibromatosis
    • von Hippel-lindau
    • MEN II
  56. which of the following assoc with mutations in succinate dehydrogenase B,C and D?
    phaeo or paragangliomas?
  57. clinical presentation of phaeo/paraganglioma?
    • palpitations
    • sweats
    • headache
    • anxiety
    • pallor
    • abdo pain
    • vomiting
    • glucose intolerance
  58. why do people with a phaeo go through phases of hypotension?
    because of the HTN causing episodes of pressure natriuresis
  59. what does a serum chromogranin A result indicate?
    • tumour marker:
    • -a phaeo/paraganglioma met
    • -or a non secretory phaeo in situ
  60. what medication must someone with a phaeo take for 6 weeks before surgery?
    phenoxybenzamide - alpha receptor blocker

    NEVER just a beta receptor blocker!!!
  61. what meds can you give during surgery for HTN?
    • sodium nitroprusside
    • phenotolamine
  62. what do you do for phaeo with hepatic mets?

    radionuclide therapy
  63. explain the genetics of congenital adrenal hyperplasia?
    • autosomal recessive
    • dodgey 21 hydroxylase enzyme
  64. what are the following levels like in congenital adrenal hyperplasia:
    a) aldosterone and cortisol
    b) progesterone
    c) ACTH
    • a) low
    • b) high because the precursor to a) and b) are the same and so it's all converted to this
    • c) high, lack of negative feedback
  65. what does the heel prick test for congenital adrenal hyperplasia test for in babies?
    high levels of 17-hydroxyprogesterone
  66. who gets pseudo-precocious puberty?
    • kids with high ACTH
    • due to congenital adrenal hyperplasia
  67. why is there hypertension in congenital adrenal hyperplasia?
    pre-cortisol enzyme buildup
  68. treatment for CAH?
    • replaces GC
    • and this suppresses ACTH too so androgen levels come back down to normal
  69. cortisol (and therefore ACTH too) release is diurnal - T/F?
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