Adrenal Disorders Nov2010

ADRENAL
DISORDERS
Dr. Atallah Al-Ruhaily
Conultant Endocrinolgist
Each gland weighs 4-5 g.
Location: in the retroperitoneum above or medial to

the upper poles of the kidneys.
Surrounded by a fibrous capsule.
The yellowish outer cortex comprises 90% of adrenal

weight.
Adult Adrenal Glands
The inner medulla 10% of adrenal weight.
AAnormal
normalright
rightadrenal
adrenalgland
glandisisshown
shownhere
herepositioned
positionedbetween
betweenthe
theliver
liverand
andthe
thekidney
kidneyin
in
the
retroperitoneum.
Note
the
amount
of
adipose
tissue,
some
of
which
has
been
reflected
the retroperitoneum. Note the amount of adipose tissue, some of which has been reflectedto
to
reveal
revealthe
theupper
upperpole
poleof
ofthe
thekidney
kidneyand
andthe
theadrenal.
adrenal.
Normal Adrenal Glands
Each
Eachadult
adultadrenal
adrenal gland
glandweighs
weighsfrom
from 44to
to66 grams.
grams.
Arterial Supply
Adrenal cortex is richly vascularised.
Main arterial supply from branches of:

Inferior phrenic artery
Renal arteries
Aorta.
Rt. adrenal vein drains directly in

the posterior aspect of I.V.C.
Venous Drainage
Lt. adrenal vein into Lt. Renal

vein.
Embryology of Adrenal Cortex

Adrenal Cortex is of mesodermal origin.
Identifiable as a separate organ at the 2 monthold-fetus.
At this stage, composed of:
Fetal zone
o additional zone in fetus
o makes up the main bulk of weight at this
time.
o lost in the 1st year (usually within 3 months
after birth).
Definitive zone

Fetal adrenal increases rapidly in size (Larger
than the kidney at mid gestation & much larger
than adult gland in relation to total body mass).
Fetal adrenal produces mainly DHEA & DHEA-S
(precursors of maternal-placental estrogen).
Definitive zone synthesizes many steroids mainly
cortisol.

The anatomic relationship of fetal and definitive
zones is maintained until birth.
Adrenocortical weight decreases gradually until the
fetal zone disappears 3 months after delivery.
During the first 3 years, the adult adrenal cortex
develops and differentiates into 3 adult zones:
Glomerulosa
Fasciculata
Reticularis
Embryology of Adrenal Medulla

Medullary chromaffin cells (the
principal cells of adrenal medulla)
are from the neural crest.
During
development
the
medullary cells migrate and lie
surrounded by the cortex.
Adrenal gland is composed of

2 distinct compartments
Adrenal cortex
produces many steroid hormones; the most
important of which are:
Cortisol
Aldosterone
Adrenal androgens
Adrenal Medulla
Produces Catecholamines:
Adrenaline (Epinephrine)
Noradrenaline (Norepinephrine)
Sectioning
Sectioningacross
acrossthe
theadrenals
adrenalsreveals:
reveals:
aagolden
goldenyellow
yellowouter
outercortex;
cortex; and
and
an
aninner
innerred
redto
togrey
greymedulla.
medulla.
Medulla
Zona Reticularis
Zona Fasciculata
Zona Glomerulsa
Microscopic
Microscopic Anatomy
Anatomy of
of Adrenal
Adrenal Gland
Gland
Periadrenal
Fatt
Fibrous
Capsule
Zones of Adrenal Cortex

Zona Glomerulosa
Zona Fasciculata
Zona Reticularis
Functionally considered as one unit.

The outermost.
the thickest
The innermost
Cells are small &

lipid-poor &
scattered beneath
the adrenal capsule.
Cells are larger,

contain more lipid
& termed clear
cells
Compact lipidpoor cells but

contain lipofuscin
granules.
Aldosterone
(Cannot produce
cortisol &
Androgens)
Cortisol &
Androgens
Cortisol &
Androgens
Regulated by
Renin-Angiotensin
System & K
Both structure and

function are
regulated by ACTH
Both structure and

function are
regulated by ACTH
Classification of Adrenal Steroids
classified into 3 groups based on their

predominant functions:
1.
Glucocorticoids
2.
Mineralocorticoids
3. Androgens
Major Classes of Adrenal Steroids

Steroid Class
Main
Hormones
Predominant
action
Main Zone of
production
Androgens
(C19)
Glucocorticoids
(C21)
Mineralocorticoids
(C21)
DHEA, DHEA-S
Androstenidione
Cortisol
Corticosterone
Aldosterone
Androgenic activity
metabolism of:
carbohydrates
and proteins
Z. Fasciculata
Z. Reticularis
(functionally as one unit)
metabolism of:
Na & K
Maintain the ECV
Z. Glomerulosa
Disorders of Adrenal glands

Adrenal Cortex
Cushings syndrome
Addisons disease
Hyperaldoteronism
Syndomes of congenital adrenal hyperplasia (CAH).
Hirsutism
Virilization
Adrenal Medulla
Pheochromocytoma
Adrenal Insufficiency
Adrenocortical insufficiency (hypofunction
of the adrenal cortex) includes all conditions
in which there is deficient production of:
adrenal glucocorticoid, and
mineralocorticoid hormones.
Types of adrenal insufficiency

These conditions are divided into 2 general
groups according to the level of hypofunction:
1. Primary adrenal insufficiency (Addisons diease)
due to primary hypofunction of the adrenal
cortex.
2. Secondary adrenal insufficiency
adrenocortical failure secondary to a primary
deficient secretion of ACTH from the pituitary
gland.
Etiology of adrenal insufficiency

Primary Adrenal Insufficiency
A. Anatomic destruction of gland (chronic & acute)
1. Idiopathic atrophy (autoimmune)
2. Surgical removal
3. Infection (Tb., fungal, viral-esp. AIDS)
4. Adrenal Hemorrhage
5. Invasion: metasteses, amyloidosis, sarcoidosis
B. Metabolic failure in hormone production

1. Congenital adrenal hyperplasia (CAH)
2. Enzyme inhibitors:
(metyrapone, ketoconazole, aminoglutethemide)
1. Cytotoxic agents: (mitotane)
C. ACTH-blocking Antibodies
Etiology of adrenal insufficiency

Secondary Adrenal Insufficiency
A. Hypopituitarism due to hypothalamic-pituitary
disease.
B. Suppresion of hypothalamic-pituitary axis.
1. Exogenous steroids (Iatrogenic)
2. Endogenous steroids (from tumors)
Incidence
Primary adrenal insufficiency:
relatively rare.
Occurs at any age.
affects both sexes equally.
Secondary adrenal insufficiency:
relatively common (because of common
therapeutic use of steroids).
Addisons Disease
Etiology and Pathogenesis
Addisons disease results from progressive

destruction of adrenal cortex.
At least 90% of gland is destroyed before
signs of insufficiency appear.
Addisons Disease
Etiology and Pathogenesis
50% of patients have +ve circulating adrenal Abs.
Some Abs destroy the adrenal glands, others block the
binding of ACTH to its receptors.
Some patients have +ve Abs to thyroid, parathyroid
and/or gonadal tissues.
Polyglandular Autoimmune (PGA) syndromes
Associated Autoimmune Disorders
Endocrine Disorders
Nonendocrine Disorders
Chronic lymphocytic
thyroiditis
Premature ovarian failure
DM type 1
Primary hypothyroidism
Hyperthyroidism
Pernicious anemia
Vitiligo
Alopecia
Chronic active hepatitis
Nontropical sprue
Myasthenia gravis
Common Symptoms
in chronic primary adrenal insufficiency
Symptoms
Frequency
Asthenia (weakness, tiredness, fatigue)

Anorexia
Gastrointestinal symptoms
Nausea
Vomiting
Constipation
Abdominal pain
Diarrhea
Salt craving
Postural dizziness
Muscular or joint pains
100
100
90
85
75
30
30
15
15
10
10
Common Signs
Signs
Frequency
Weight loss
Hyperpigmentation of skin
Pigmentation of mucous membrane
Decreased axillary and pubic hair (in women
only)
Hypotention (systolic BP <110 mm Hg) with
postural accentuation
Vitiligo (with autoimmune)
100
95
80
60
15
10
Common Laboratory findings

Laboratory Findings
Electrolytes disturbances
Hyponatremia
Hyperkalemia
Hypercalcemia
Azotemia
Anemia
Eosinophilia
Frequency
90
90
65
5
55
40
15
Hyperpigmentation
Generalized hyperpigmentation of skin &
mucous membrane (the classical physical

finding).
Along with other features, suggests primary
adrenocortical insufficiency.
One of earliest manifestations of Addisons
disease.
Hyperpigmentation
Increased at exposed areas and accentuated at pressure areas

(knuckles, toes, elbows, knees)
Associated with black or dark brown freckles.
Hperpigmentation of buccal mucosa & gum is preceded by

generalized hyperpigmentation of skin.
Other areas: palmar creases, nail beds, nipples, areolae,

perivaginal, perianal mucosa & scars that formed after onset
of ACTH excess (but not older scars).
Adrenal Imaging
Abdominal x-rays
Adrenal calcification
in 50% tuberculous cases & some other invasive or
hemorrhagic causes.
CT Scan
more sensitive for adrenal calcification & enlargement
Causes of bilateral adrenal enlargement:
Tb
Fungal infection
CMV infection
Infiltrative diseases (malignant or nonmalignant)
Adrenal hemorrhage
Rt Adrenal mass
Acute Adrenal Crisis

A state of acute adrenal insufficiency occuring in
patients with Addisons disease who are exposed to
any form of stress.
Precipitating stress factors:
1. Infection
2. Trauma
3. Surgery
4. Dehydration (Salt deprivation, vomiting, diarrhea)
5. Discontinuation of steroids replacement therapy
Common Clinical Features

Hypotension & shock
Fever (due to infection or hypoadrenalism per se)
Dehydration, volume depletion
Nausea, vomiting, anorexia
Abdominal pain (may mimic acute abdomen)
Weakness, apathy, depressed mentation
Hypoglycemia (more in children)
Shock and coma may rapidly lead to death in untreated patients.

Laboratory Findings Suggestive of Diagnosis
Hyponatremia & Hyperkalemia

(In a small number of acute
cases).
Azotemia (usual)
Lymphocytosis
Eosinophilia
Hypoglycemia
Acute Adrenal Hemorrhage
A progressively deteriorating
condition resulting from bilateral
adrenal hemorrhage and acute
adrenal destruction in an already
compromised patient with major
illness.

Manifestations:
Abdominal, flank or back pain & abdominal
tenderness (Less frequently, abdominal
distention, rigidity & rebound tenderness).
Hypotension & shock
Fever
Nausea & Vomiting
Confusion & disorientation
tachycardia

With
progression,
the
manifestations may ensue:
severe hypotention
volume depletion
Dehydration
Hyperpyrexia
Cynosis
Hypoglycemia
Coma
death
following

Causes
ACTH deficiency most commonly due
to exogenous glucocorticoid therapy.
Pituitary & Hypothalamus tumors the
most common causes of naturally

occuring pituitary ACTH
hyposecretion.

Pathphysiology
ACTH deficiency is the primary event.
This leads to:

decreased cortisol & androgen secretion.
But aldosterone secretion remains normal except in
few cases.

Pathphysiology
In early stages,
Basal ACTH & cortisol levels may be normal.
ACTH reserve is impaired. Response of ACTH &
cortisol to stress is subnormal.
With further loss of basal ACTH secretion,
There is atrophy of Z. Fasciculata & Z. Reticularis.

Basal cortisol secretion is decreased
The entire pituitary adrenal axis is impaired (i.e.
Decreased ACTH responsiveness to stress & decreased
adrenal responsiveness to stimulation with exogenous
ACTH).

Clinical Features
Usually chronic nonspecific manifestations.
Acute crisis occurs in:

Undiagnosed patients
Patients who do not receive increased steroid dosage
during periods of stress.

Clinical Features
Clinical features differ from primary in
that:
1.
2.
Hyperpigmentation does not occur (Because of

ACTH deficiency).
Manifestations of mineralocorticoid deficiency are
usually absent (Because Aldosterone secretion by Z.
G. is usually preserved). Therefore:
Volume depletion, dehydration & hyperkalemia usually absent.

Hypotention is usually absent except in acute presentations.
Hyponatremia may occur as a result of water retention.

Clinical Features
Prominent features (due to glucocorticoid
deficiency) are nonspecific & include:
Weakness, lethargy & easy fatigability

anorexia, nausea & occasionally vomiting
Arthralgias & myalgias
Hypoglycemia
Acute decompensation with severe hypotention or
shock unresponsive to vasopressors.

Associated Features
The following additional features may be present:

History of glucocorticoid therapy or Cushingoid
features.
Features of loss of other pituitary hormones
(hypogonadism & hypothyroidism).
Features of hypersecretion of GH or PRL from
pituitary adenoma.
Pressure symptoms from pituitary tumors.
Diagnosis of Adrenal Insufficiency

Basal levels of adrenocortical steroids in plasma
or urine may be normal in partial adrenal
insufficiency.
Tests for adrenocortical reserve are necessary to
establish the diagnosis.
Rapid ACTH Stimulation Test
Plasma ACTH Levels
Metyrapone Test
Insulin-induced Hypoglycemia
CRH Stimulation
Diagnosis of Adrenal Insufficiency

Other indirect clues:
Features of hypersecretion of GH or
PRL from pituitary adenoma.
Pressure symptoms from pituitary
tumors.
Evaluation of Suspected Adrenal Insufficiency

A. Abormal ACTH Stimulation Test:
Adrenocortical insufficiency +ve.
Which type?
Plasma ACTH level:
Elevated: Primary Adrenal
Insufficiency +ve
Normal or Low: Secondary Adrenal
Insufficiency +ve
Evaluation of Suspected Adrenal Insufficiency

B. Normal ACTH Stimulation Test:
This excludes Primary Adrenal Insufficiency &
Adrenal atrophy.
But does not exclude Decreased ACTH
Reserve
Metyrapone Test
or Insulin-hypoglycemia Test
or CRH stimulation Test:
Normal: Exclude Adrenal Insufficiency
Abnormal: Secondary Adrenal
Insufficiency +ve
Treatment of Adrenal Insufficiency

Acute Addisonian Crisis
Glucocorticoid Replacement
Cortisol (Hyrdocortisone succinate or phosphate) 100 mg
every 6 hrs. for 24 hrs.
When stable, reduce to 50 mg 6 hrs.
Taper to maintenance therapy by day 4 or 5 & add
mineralocorticoid as required.
If complications persist or occur, maintain or increase the dose
to 200-400 mg/d.
General or Supportive Measures

Correct volume depletion, dehydration, & hypoglycemia with
I.V. saline and glucose.
Evaluate and treat infection or other precipitating factors.

Maintenance Therapy
Life-long replacement therapy with glucocorticoid and

mineralocorticoid.
Preparations:
Cortisol (hydrocortisone) tablets
First choice
Maintenance dose: 15-30 mg/d.
Usually, divided into 2 doses (2/3 AM & 1/3 PM)
Cortisone acetate (37.5mg/d)
Absorbed rapidly from GIT
converted in the liver to cortisol.

Maintenance Therapy
Preparations:
Synthetic Steroids
- Prednisone or Prednisolone
5 mg of prednisone tab is equivalent to 20
mg of hydrocortisone.
-Fludrocortisone (9-alpha fludrocortisol)
Used for mineralocorticoid therapy
Usual dose: 0.05-0.1 mg/d PO AM
Treatment of Primary Adrenal Insufficiency
Regimen Therapy
Cortisol 15-20 mg AM & 10 mg at 4-5 pm
Or prednisone 5.0-7.5 mg AM
Fludrocortisone (Fluranif) 0.05 0.1 mg PO AM.
Clinical Follow up:
Maintenance of normal body weight,

electrolytes
Regression of clinical features
BP &
Patient education & identification card or

bracelet
Increased cortisol dosage during stress.

Adrenal Disorders Nov2010

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ADRENAL

Each gland weighs 4-5 g.

Location: in the retroperitoneum above or medial to

Surrounded by a fibrous capsule.

The yellowish outer cortex comprises 90% of adrenal

Adult Adrenal Glands

The inner medulla 10% of adrenal weight.

Normal Adrenal Glands

Main arterial supply from branches of:

Rt. adrenal vein drains directly in

Lt. adrenal vein into Lt. Renal

Embryology of Adrenal Cortex

Embryology of Adrenal Cortex

Embryology of Adrenal Cortex

Embryology of Adrenal Medulla

Adrenal gland is composed of

Zones of Adrenal Cortex

Functionally considered as one unit.

Cells are small &

Cells are larger,

Compact lipidpoor cells but

Both structure and

Both structure and

Classification of Adrenal Steroids

classified into 3 groups based on their

Major Classes of Adrenal Steroids

Disorders of Adrenal glands

Types of adrenal insufficiency

Etiology of adrenal insufficiency

B. Metabolic failure in hormone production

Etiology of adrenal insufficiency

Addisons disease results from progressive

Polyglandular Autoimmune (PGA) syndromes

Associated Autoimmune Disorders

Asthenia (weakness, tiredness, fatigue)

Common Laboratory findings

mucous membrane (the classical physical

Along with other features, suggests primary

One of earliest manifestations of Addisons

Increased at exposed areas and accentuated at pressure areas

Associated with black or dark brown freckles.

Hperpigmentation of buccal mucosa & gum is preceded by

Other areas: palmar creases, nail beds, nipples, areolae,

Causes of bilateral adrenal enlargement:

Acute Adrenal Crisis

Acute Adrenal Crisis

Common Clinical Features

Acute Adrenal Crisis

Hyponatremia & Hyperkalemia

Acute Adrenal Hemorrhage

Acute Adrenal Hemorrhage

Acute Adrenal Hemorrhage

Secondary Adrenal Insufficiency

to exogenous glucocorticoid therapy.

Pituitary & Hypothalamus tumors the

most common causes of naturally

Secondary Adrenal Insufficiency

ACTH deficiency is the primary event.

This leads to: