Adrenal Diseases

Cushing Syndrome
Pheocromasitoma

Disorders of adrenocortical function

Adrenocortical hyperfunction
Glucocorticoids
Aldosteronism Mineralocorticoids
Virilizing tumors Androgens
Feminizing tumors Estrogens
Adrenocortical hypofunction
Hypopituitarism Glucocorticoids
Hypoaldosteronism Mineralocorticoids
Hypopituitarism Androgens
Estrogens

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), cathecolamine-producing 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