Adrenal Diseases

Cushing Syndrome
Pheocromasitoma
Disorders of adrenocortical function
Adrenocortical
Aldosteronism
Virilizing tumors
Androgens
Feminizing tumors Estrogens
Adrenocortical
Hypopituitarism
Hypoaldosteronism
Hypopituitarism
Androgens
Estrogens

hyperfunction
Glucocorticoids
Mineralocorticoids
hypofunction
Glucocorticoids
Mineralocorticoids

ADRENAL INCIDENTALOMAS
Masses found incidentally during radiographic imaging of the abdomen
Incidence : 0.35-4.36% in general population
In Evaluation such mass:
Is the mass benign or malignant?
Does the mass secrete hormones or mass disfunction
DD ADRENAL INCIDENTALOMA
Benign:
Non hormone secreting (lipoma,cyst, ganglioneuroma, adenoma)
Hormone secreting (pheochromocytoma, aldosteronism, subclinical
Cushings syndrome
Malignant
Adrenocortical carcinoma
Metastatic neoplasm
Lymphoma
Size is important:
Adrenal masses >4cm more likely
malignant surgical
resection should be consideration
The great majority (+ 89%) are benign, non functioning masses
A full biochemical workup should be completed before surgery is
done
CUSHINGS SYNDROME

Classification
ACTH-dependent
Pituitary adenoma (Cushing
disease) 70%
Nonpituitary
neoplasma (ectopic ACTH)
ACTH-independent
Latrogenic (glucocorticoid, megestrol acetat)
Adrenal neoplasma
(adenoma, carcinoma),
Hyperplasia
Factitious
CUSHINGS SYNDROME

Treatment:

CUSHINGdisease
Microsurgery, Radiation
therapy,
Adrenal tumors
Unilateral adrenalectomy
Ectopic ACTH syndrome
Benign surgical
treatment
Malignant : Ketokonazole,
metyrapone
IATROGENIK (CUSHINGOID)
Tapering of
Alternate day regimen
PSEUDO CUSHINGs
SYNDROME
Obesity
Chronic alcoholism
Depresion
Disorders of adrenocortical insufficiency
Deficient adrenalproduction of glucocorticoid and mineralocorticoid
Adrenocortical insufficiency
@ Primary adrenocortical insufficiency (Addisons disease)
@ Secondary : deficient pituitary ACTH secretion, glucocorticoid
therapy (most
common)
Addisons Disease
Etiologi: tbc (prior 1920), Autoimmune adrenalitis adrenal atrophy
(80%) Associated other immunologic and autoimmune endocrine
disorders, AIDS, malignant disease
Rare, female >>, 30-50 year
Clinical features: weakness, fatigue, anorexia, weight loss,
hyperpegmentasi, hypotension,
Laboratorium :
Hiponatrimia- hiperkalemia (classic) Radiologis /CT Scan
Diagnosis
Basal adrenokortical steroid Normal

Rapid ACTH stimulation test

ACTH plasma
Treatment:
Replacement therapy cortisol
Cortex Adrenal

Cortisol
Aldosterone
Primary Hyperaldosteronism
Accounts for about 0.7% of cases of hypertension, Women >>,
unilateral adrenocortical adenoma (Conns syndrome, 73%), 27%
bilateral
Hyperaldosteronism: hypertension, hypokalemia, alkalosis
Clinical finding: Hypertension, muscular weakness, paresthesias,
headache, polydipsia, polyuria, moderate hypertension (malignant is
rare)
Laboratory finding: Serum potassium low, 24 hours urine collection
aldosterone
Imaging: CT-scan
Treatment: Laparoscopic adrenalectomy, Spironolactone,
antihypertensive agent
Complication: Renal damage
Prognosis: Improved by early diagnosis and treatment, only 2%
malignant
Diseases of adrenal medulla

Pheochromocytoma
Pheochromocytomas are rare (<0,2% of hypertensive), cathecolamineproducing tumor of neurochromaffin cells. Extraadrenal Ph sympathetic
ganglia are called Paraganggliomas
Incidence 3-4th
decades,autosomal dominat hereditary, malignant 10-15% cases
Hypertension is caused by excessive plasma level epinephrine by tumor
located either or both adrenals & anywhere along sympathetic nervus chain (
90% adrenal)
Pheochromocytoma

 Symptoms and Signs

Usually lethal unless diagnosed and treated severe headache, perspiration,
palpitation, anxiety, tremor, tachycardia
Attack cyanosis, facial pallor
Classical symptomatic triad: headache, sweating, palpitations
Laboratory finding
Urinary cathecolamines, metanephrine, creatinine, Urinary VMA
Localisation
CT scanning
Overall accuracy 90%-95% for adrenal tumours
Less accurate for extra adrenal tumours
Isotope scintigraphy (MIBG scanning)
131I-MIBG stored in chromaffin granule
Sensitivity 99%
False negative 11%
False positive 2%
Blood and Urine analysis
Plasma catecholamine levels > 1000micrograms
Urinary VMA and Metanephrine levels
Treatment
Surgery Preoperative preparation
To control hypertension & prevent CVS complications.
Alpha adrenergic blockade
Phenoxybenzamine 10 mg qds 1-2 weeks before surgery
Beta blockade propanolol 10 mg qds 2-3 days
Intraoperatively
Phentolamine
Sodium nitroprusside
Treatment Laparoscopic removal of the tumor treatment of choice,
open laparatomy
Prognosis
Depends early diagnosis is made

Disorders of the Thyroid

Usually Complain thyroid disease

Thyroid enlargement which may be diffuse or nodular
Symptom of thyroid deficiency or Hypothyroidism
Symptoms of thyroid hormon excess, or Hyperthyroidism
Complications of a Spesific form hyperthyroidism: Graves disease
which may present which prominence of the eyes or exophthalmos
and
Thickening of the skin over the lower
legs (rare) or thyroid
dermopathy

Physical Examination
Inspection : Good light coming
from behind the examiner, The
patient is instructed to swallow a
sip of water, Observe the gland
as it moves up and down.
Enlargement and nodularity can
often be noted.
On physical examination the
normal thyroid gland about 2cm
in vertical dimension and about
1cm in horizontal dimention
above the isthmus
Enlarged thyroid gland is called Goiter
The generalized enlargement is termed diffuse goiter, irreguler or
lumpy enlargement is called nodular goiter

Diffuse goiter
Simple diffus goiter
Hypertiroidism
Hashimoto thyroiditis
Nodular goiter
1. Thyroid nodul
2. Thyroid cyst
3. Adenomatosa goiter
4. Subacut /chronis thyroiditis
5. Plummer thyroiditis