ADRENAL GLANDS

Suprarenal glands
Weighs approx 4-6 g
2 distinct parts:
Cortex
Medulla

ADRENAL CORTEX
Outer region secreting steroid hormones
3 layers:
GLomerulosa
Outermost layer
Produces mineralocorticoid- aldosterone
Fasciculate
Middlemost layer
Produces glucocorticoids (cortisone and cortisol)
Reticularis
Innermost layer (androgens and minute estrogen)
ALDOSTERONE
The chief mineralocorticoid
Promotes the reabsorption of sodium and water by the kidney to help
maintain blood pressure and tonicity
Electrolyte regulation
Sodium retention
Potassium excretion
Retention of water and expansion of extracellular fluid volume
Increases blood pressure
CORTISOL
17- hydroxycorticosteroid- Most important glucocorticoid
Increased Protein nitrogen catabolism
Gluconeogenesis
Increased blood glucose concentration
Decrease glucose tolerance
Increased liver glycogen
Increased liver glycogenolysis
Decreased peripheral uptake and utilization of glucose
Fat synthesis and redistrubution
URINE FREE CORTISOL MEASUREMENT

24 hour urine sample

HPLC- most specific assay

RIA- performed following chromatography

ACTH
ACTH- great value in establishing the differential diagnosis of patients with
Cushing syndrome
Specimen should not be allowed to have contact with glass
Storing specimens at 4 C reduces enzymatic degradation of ACTH
RIA used to measure ACTH
Chemiluminescent immunoassay
ADRENAL CORTEX ABNORMALITIES

Addisons disease (Hypocortisolism)

Cushings disease (Hypercortisolism)

ADDISONS DISEASE
Generalized adrenal cortex hyposecretion

Peculiar BRONZE tone of the skin

Electrolyte and water imbalance
Muscles become weak
hypoglycemia
Other symptoms of Addisons disease include hypoglycemia, a
lessened ability to cope with stress, suppression of the immune
system, and increased susceptibility to infection.

DIAGNOSTIC PROCEDURES:

Basal Hormone Measurements

<3 g/dL (83 nmol/L) is indicative of adrenal insufficiency
ACTH Stimulation Test
Injection of Cosyntropin
Normal response is the doubling of serum cortisol
Insulin Tolerance test
Gold standard
If the HPA axis is intact, insulin-induced hypoglycemia stimulates
the hypothalamus and the pituitary to secrete CRH and ACTH,
respectively, which, in turn, leads to a rise in cortisol.
Overnight Metapyrone Test
An abnormal response is defined by 11-deoxycortisol less than 7 g/dL
accompanied by cortisol less than 5 g/dL

Corticotropin-Releasing Hormone Test

used not only to diagnose hypocortisolism, but to localize the site of
damage

CUSHINGS DISEASE

Hypersecretion, usually results from tumors

Lab findings :
Excessive persistent production to cortisol
Loss of circadian rhythm of ACTH and Cortisol
Hyperglycemia
Hypertension, Hirsutism (atypical growth of hair: excessive growth
of hair, e.g. on a woman's face or body), Obesity
Buffalo hump
Unusual behavior (depression, personality changes, fatigability)
Facial features (moonface, hirsutism in women)
Fat (truncal obesity)
ACTH and cortisol in blood elevated
Loss of muscle mass
Overextended skin (abdominal striae with easy bruisability)
Hypertension, Hyperglycemia, Hypernatremia
Urinary Cortisol elevated
Menstrual irregularities
Porosity of the bones (Osteoporosis)

DIAGNOSTIC PROCEDURES
24 hour urinary free cortisol
Reflection of the unbound circulating cortisol that is freely filtered by
the glomerulus
HPLC or gas chromatography with mass spectrometry
Values greater than four times the upper limit of normal are diagnostic
of Cushings syndrome.
Overnight dexamethasone suppression test
Simple test
Dexamethasone is also used in a diagnostic context, namely in
its property to suppress the natural pituitary-adrenal axis.
The overnight dexamethasone suppression test is a much simpler test
to perform. The patient takes 1 mg of dexamethasone orally between
the hours of 11 pm and 12 midnight. The plasma cortisol is drawn the
following morning between 8 am and 9 am The original criterion for an
abnormal response was failure to suppress the morning cortisol level
to <5 g/dL (138 nmol/L); however, this has been revised downward to
<1.8 g/dL (50 nmol/L)

Salivary midnight cortisol level

The late-night (11 pm) salivary cortisol is a simple test that carries high
diagnostic sensitivity and specificity
The sample is analyzed by immunoassay or by liquid chromatographymass spectrometry (LC-MS/MS)

ADRENAL MEDULLA
Inner region of the adrenal gland

Capable of synthesizing catecholamines through the process of amine

precursor uptake and decarboxyalation
Epinephrine and Norepinephrine

Modified neurons called chromaffin cells

releases catecholamines (epinephrine, NE)
Long lasting hormonal effect

alertness, anxiety, or fear

BP, heart rate and air flow

raises metabolic rate
inhibits insulin secretion
stimulates gluconeogenesis and glycogenolysis
Stress causes medullary cells to stimulate cortex

Norepinephrine:
Originates from dopamine
Function as a neurotransmitter in both CNS and SNS

Epinephrine:
fight or flight hormone

PHEOCHROMOCYTOMA
Small vascular tumor of the adrenal medulla resulting into uncontrolled
secretion of hormones

Signs

and symptoms of pheochromocytomas often include:

High blood pressure
Rapid or forceful heartbeat
Profound sweating
Severe headache
Tremors
Paleness in the face
Shortness of breath

Diagnosis:
24 hr urine collections for VMA, Metanephrines or Catecholamines
determination
CT Scan/ MRI

Total Metanephrines:
Most sensitive urine screening test for pheochromocyotoma
Determined by HPLC

Vanillylmandelic acid
A
VMA
test
was
once
frequently
ordered
to
detect
pheochromocytomas, but the preferred tests are now plasma free
metanephrines, urine metanephrines, and urine or plasma
catecholamine tests. The VMA test may still be ordered along with one
or more of these tests to help detect and rule out a
pheochromocytoma.

NEUROBLASTOMA
Childhood malignant tumor usually occurring before the age of 3

(inc) Urinary Homovanillic acid (HMA) and Vanillymandelic acid (VMA) results