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Origin of superior adrenal artery
Inferior phrenic artery
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Origin of middle adrenal artery
Aorta
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Origin of inferior adrenal artery
Renal artery
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Destination of left adrenal vein
Left renal vein
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Destination of right adrenal vein
IVC
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Surgical indications for adrenal mass
>4-6cm, functioning, enlarging
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Labwork after asymptomatic/incidental adrenal mass is found (3 categories)
Urine metanephrines/VMA/catecholamines, plasma rennin/aldosterone, CXR/stool guiac/colonoscopy/mammogram
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Common tumors that metastasize to adrenals (4)
Breast, melanoma, renal, lung
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Layers of adrenal cortex (from outside to inside)
Glomerulosa, fasiculata, reticularis
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Primary hormone secreted by adrenal glomerulosa
Aldosterone
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Primary hormone secreted by adrenal fasciculate
Glucocorticoids
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Primary hormone secreted by adrenal reticularis
Androgens/estrogens
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Nerve innervation to adrenals
Cortex (none) and medulla (splanchnics)
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Hormone causing adrenal cortisol release
ACTH
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Hormones that stimulate aldosterone release
ACTH, angiotensin II, hyperkalemia
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Actions of aldosterone (4)
Inc renal Na resorption, inc potassium, H+, and ammonia secretion
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Enzyme defect in cortisol synthesis causing aberrant sex hormone excretion
Congenital adrenal hyperplasia
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Enzyme deficiency causing precocious puberty in males and virilization in females , and increase in 17-OH progesterone
21-hydroxylase deficiency
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Enzyme deficiency causing precocious puberty in males, virilization in females, and increase in 11-deoxycortisone
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Enzyme deficiency causing ambiguous genetalia in males at birth
17-hydroxylase deficiency
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Disease with HTN from sodium retention hypokalemia, weakness, polydipsia and polyuria
Conn?s syndrome (hyperaldosteronism)
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Causes of primary Conn?s syndrome (3)
Adenoma (#1), hyperplasia, cancer
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Causes of secondary Conn?s syndrome (6)
CHF, renal artery stenosis, liver failure, pregnancy, diurectics, renin-secreting tumor
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Diagnostic tests for primary Conn?s (5)
Urine aldosterone after salt load (will be high), serum K, urine K, serum Na, plasma renin activity
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Localizing studies for Conn?s syndrome
NP-59 scintigraphy, adrenal vein sampling, MRI
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Diagnostic studies indicating cancer in adrenal mass + Conn?s syndrome
Suppressed aldosterone and renin in upright position, high 18-OH corticosterone
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Diagnostic studies indicating hyperplasia in adrenal mass + Conn?s syndrome
Increased aldosterone and renin in upright position, low 18-OH corticosterone
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Adrenal disease causing hypotension, fever, lethargy, abdominal pain, dec mental status
Adrenal insufficiency (Addison?s disease)
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Most common cause of adrenal insufficiency
Steroid withdrawl
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Most common cause of primary renal insufficiency
Autoimmune disease
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Diagnostic studies for adrenal insufficiency/Addisons (3)
Serum Na, serum K, ACTH stimulation test
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Diagnostic study for Cushing syndrome
24 hour urine cortisol, dexamethasone suppression test
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Most common noniatrogenic cause of Cushing?s
Pituitary adenoma
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#2 iatrogenic cause of Cushings
Ectopic ACTH from tumors (SCLC)
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High cortisol, not suppressed with dex test: diagnosis?
Ectopic ACTH or adrenal adenoma
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High cortisol, suppressed with dex test: diagnosis?
Pituitary adenoma
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Treatment of adrenal hyperplasia
Bilateral adrenalectomy
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Drugs for ectopic ACTH or adrenal cancer that inhibit steroid formation (2)
Ketoconazole, metyrapone
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Drugs for ectopic ACTH or adrenal cancer that inhibit cholesterol conversion
Aminoglutethimide
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% of adrenal carcinomas that are functioning
50
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Treatment of adrenal carcinoma
Radical adrenalectomy, mitotane (adrenal-lytic)
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Rate limiting step in creation of catecholamines
Tyrosine hydroxylase
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Enzyme that converts norepinephrine to epinephrine
PNMT
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Only tumor that produces epinephrine
Adrenal pheochromocytoma
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Enzyme that converts norepinephrine to normetanephrine and epinephrine to normetanephrine
MAO (monoamine oxidase)
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Most common site of extra-adrenal rest of neural crest tissue
Organ of Zuckerkandl
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Adrenal tumor arising from ectopic neural crest cells causing HTN, headache, diaphoresis, palpitations
Pheochromocytoma
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Congenital syndromes that pheochromocytoma is associated with (5)
MEN 2a, MEN 2b, von Recklinghausen?s, tuberous sclerosis, Sturge-Weber
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Diagnostic studies for pheo
Urine metanephrines, VMA
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Localization study for pheo
MIBG scan
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Preoperative drugs for pheochromocytoma
Alpha blocker THAN beta blocker
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Order of vessel ligation in pheochromocytoma
Vein first, then arteries
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Drug inhibiting tyrosine hydroxylase causing decreased catecholamine synthesis
Metyrosine
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Other sites of pheochromocytomas (4)
Vertebral bodies, opposite adrenal, bladder, aortic bifurcation
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Rare, benign asymptomatic tumor of neural crest origin in the adrenal medulla
Gaglioneuroma
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