Conditions Affecting Adrenal

Cortex

Adrenocortical Hyperfunction

Cushing’s syndromeIncreased glucocorticoid levels

HyperaldosteroneExcessive water retention Ht

Adrenocortical Insufficiency

Acute Adrenocortical InsufficiencyChronic Adrenocortical Insuffeciency (Addison’s)

DEFINITION

Addison's disease (Adrenal insufficiency) or Adrenocortical Insufficiency.

1st described in 1855 by Dr. Thomas Addison

-An Endocrine or hormonal disorder that occurs when the adrenal glands do not produce enough of certain hormonesCan be fatal if left untreated.It includes the underproduction of hormones that the adrenal cortex produces. the gland affected is the adrenal cortex.Addison’s disease develops when the level of adrenal cortex hormone is low due to hyposecretion (lack of secretion).

•Addison's disease is hypo function of the adrenal cortex.•There is a decrease in adrenal steroids which are: glucocorticoids, mineral corticoids, andandrogen.•The adrenal cortex function is inadequate to meet thepatients need for cortical steroids.•Addison's disease occurs when 90% of the adrenalcortex has been destroyed

Hormones Involved

Adrenocorticotropic (ACTH)Glucocorticoids (cortisol)Mineralocorticoids (aldosterone)

How Are the Hormones Affected?When Addison’s disease goes into affect, the Anterior

pituitary produces excessive but ineffective amounts of Adrenocorticotropic (ACTH) to the adrenal cortex thus hindering its ability to produce and release hormones (Glucocorticoids and Mineral corticoids).

Since there is no ACTH to stimulate the adrenal cortex to release its hormones, the adrenal cortex can not release hormones to regulate processes in the body.

Function of cortisol Cortisol is normally produced by the adrenal gland

It belongs to the class of hormone called, glucocorticoids.

cortisol perform the following vital tasks:

Maintain BP and Cardiovascular function

Helps slow the immune system’s inflammatory responses

Helps balance the effects of insulin in breaking sugar for energy; and

Helps to regulate the metabolism of proteins,carbohydrates and fats.

Functions of Aldosterone

• Aldosterone is a mineralocorticoid secretedby the adrenal cortex.• Aldosterone regulates sodium and potassiumbalance by causing the kidney to- excrete potassium- reabsorb sodium.• Aldosterone is secreted in response to- low blood volume- low blood pressure- low blood [sodium]- high blood [potassium

AldosteroneDecreased Aldosterone causes:

• Hyponatremia

• Polyuria with loss of salt & H2O eventually may cause CV collapse & circulatory shock.

• Dehydration with polydipsia

• Orthostatic (postural) hypotension

• Decreased cardiac output

• Hyperkalemia

• Salt craving

Decreased GlucocorticoidsDecreased Glucocorticoids cause:

•Hypoglycemia

•Poor tolerance to stress (infections, trauma, surgery) causing an “adrenal crisis” with hypoglycemia, hypotension & shock, lethargy, weakness.

Addison patients need a medical alert bracelet

•Lethargy

•Weakness

•GI symptoms (anorexia, nausea, vomiting,weight loss)

•fever

Excess of ACTHExcess ACTH in Addison patients causes

hyperpigmentation of the skin, gums, mouth from formation of a derivative of ACTH (Melanocyte Stimulating Hormone - MSH) that targets the skin.

• Signs of hyperpigmentation distinguishes Addison Disease (Primary Adrenal Insufficiency) from Secondary Adrenal Insufficiency due to lack of ACTH.

Addison’s diseasecauses

PRIMARY destruction of adrenal cortex

- autoimmune disorders- tuberculosis- chronic infection

SECONDARY Lack of ACTH

- drugs- tumors and infections of pituitary gland

In short the cause is the following.•Autoimmune or idiopathic atrophy of the adrenalglands is responsible for 80% to 90% of cases.•Surgical removal of both adrenal glands•Infection of the adrenal glands•Tuberculosis and histoplasmosis are the most common infections that destroy

adrenal gland tissue.•Inadequate secretion of ACTH from the pituitarygland. (Decreased stimulation of the adrenal cortex)•Therapeutic use of corticosteroids.

SIGNS AND SYMPTOMS

Manifestations of Addison Disease result from• Lack of Aldosterone• Lack of Glucocorticoids• Elevated ACTH.• Early signs: Tiredness, Weakness, Loss of appetite, Weight loss Dizziness when standing, Muscle aches, Nasuea, vomiting,

Diarrhea Patches of darkened, skin or unexplained tanning, Depression•Late signs: Sharp pain in the lower back,abdomen, or legs, Loss of too much

fluid From body.(Dehydration) Hypotension, Loss of consciousness

HOW IS IT DIAGNOSED?

Early stages difficult to diagnose.

Check Cortisol levels

•ACTH Stimulation Test

•CRH Stimulation Test

•Other tests

X-RAY

Physical findings

HyperpigmentationHypotensionOrthostatic changesWeak pulsesShockLoss of axillary/pubic hair

(women)

Laboratory findings

Hyponatremia

Hyperkalemia

Hypoglycemia

Narrow cardiac silhouette on CXR

Low voltage EKG

Treatment

Treatment

Addison Disease - Treatment• Addison Disease is a chronic disorder requiringlifelong hormone replacement therapy with higher doses

given in times of stress.• Hormones used are Oral hydrocortisone (glucocorticoid

with some salt retention effects) & a mineralocorticoid (flurocortisone).

• Female patients may also be given an adrenal androgen to promote muscle mass, hemopoiesis & support sexual libido (all normal functions of adrenal androgens in females).

• Addison patients must be monitored carefully forsigns of infection & hypoglycemia & need scheduledmeals.

treatmentREPLACEMENT THERAPY

CORTISOL_HYDROCORTISONE

ALDOSTERONE_FLUDROCORTISONE

TREATMENT continued..

• Hormone replacement therapy

•Depending on which hormone is low (if not all

three)

Glucocorticoid twice a day

Mineralcorticoid once a day

Aldosterone therapy involves increased sodium

ADDISONIAN CRISIS

Symptoms include sudden penetrating pain in:

lower back

abdomen or legs

severe vomiting

diarrhea

followed by dehydration

low blood pressure

loss of consciousness