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Addisons and
Acromegaly
Dr Edward Hutchison FY1 (Geriatrics)
Phase II Objectives
3.21: Investigations
o Request appropriately the more common tests of thyroid, adrenal and
pituitary gland function, seeking advice where necessary.
Aims
HPA Axis
Adrenal glands
Cushings syndrome/disease
Addisons
Acromegaly
HPA Axis
Hypothalamus
GnRH
GHR
H
Pituitary
Sphenoid sinus
Adrenal Glands
Remember:
GFR!
Functions of Cortisol?
Insulin resistance/gluconeogenesis
Protein catabolism
Immunosuppresion
CVS regulation e.g. increasing BP
CNS actions e.g. increased appetite, impaired
memory
Increased bone turnover
Gastric acid secretion
Reduced skin collagen
Fluid retention
Cushings
disease or syndrome?
Which is which?
Syndrome
Excessive activation of
glucocorticoid
receptors.
Disease
Excessive production
of ACTH caused by a
pituitary adenoma.
Classification
ACTH-dependent
Pituitary adenoma
Ectopic ACTH production e.g. small cell lung cancer, neuroendocrine
tumours
Iatrogenic ACTH therapy
ACTH-independent
Iatrogenic steroid therapy
Adrenal adenoma/carcinoma
Pseudo-Cushings
EtOH excess
Major depressive disorder
Primary obesity
Clinical features
Over to you
Symptoms
Depression
Confusion
Weight gain
Poor glucose control (diabetics)
Weakness rising from a chair (proximal
myopathy)
Investigation
Bedside
Blood
Imaging
Not excluded
Abstinence
?EtOH excess
ACTH level?
Management
Conservative
Medical
Surgical
Patient education
Reduce oral steroid
therapy if possible
Inhibit biosynthesis of
corticosteroids e.g.
ketoconazole and
metyrapone
Trans-sphenoidal
resection of pituitary
(requires lifelong
hormone
replacement).
Laparoscopic
resection of adrenal
tumour.
Ectopic ACTH: treat
underlying cause
bilateral
adrenalectomy.
Remember
Not only oral corticosteroids can cause Cushings
syndrome, large amounts of topical and inhaled
steroid may be absorbed into the systemic
circulation.
Patients on large amounts of oral corticosteroids
will require their dose to be tapered slowly to
avoid an Addisonian-like crisis.
You also will need to manage the effect of longterm steroid therapy e.g. diabetes,
hypertension, thin skin, osteporosis.
Addisons disease
(Or adrenal insufficiency, to be more correct).
Definition?
A syndrome resulting from
inadequate secretion of
corticosteroid hormones from
progressive destruction of the
adrenal cortex.
Causes
autoimmune (90% of
A cases)
D degenerative (amyloid)
D drugs (e.g. ketoconazole)
I infective (TB, HIV)
S secondary (ACTH, hypopituitism)
O other (e.g. adrenal bleeding)
N neoplasia (metastases)
Clinical Features
Over to you
Investigations
Test
Bedside
Lying/standing BP
Bloods
Imaging
250g synacthen IM
Management
Glucocorticoid replacement
o Hydrocortisone BD, usually 15mg on
waking/5mg around 1800hrs
o Excessive weight gain = over replacement
o Educate patient increase hydrocortisone
when unwell
Mineralocorticoid replacement
o Fludrocortisone 50-100g daily
o Titrate according to symptoms and U&Es
Addisonian Crisis
Features:
Severe shock hypotension, tachycardia
Fever, abdominal pain, nausea & vomiting
Hyponatraemia/hyperkalaemia
hypercalcaemia, hypoglycaemia
Management:
ABCDE assessment
Correct volume depletion
Replace glucocorticoids
Correct metabolic abnormalities
Treat underlying cause
Acromegaly
Definition?
A condition caused by excessive
secretion of growth hormone
Your turn!
Hypopituitis
Investigations
Bedside
Collateral Hx
Serial photographs
BP
ECG
Bloods
Serum GH (unreliable)
Oral glucose tolerance test
Serum IGF-1
TFTs/FSH/LH/PRL etc
Imaging
CT/MRI brain
Echo
Other
Colonoscopy
Management
Conservative:
o Patient education
Radiotherapy:
o Employed if acromegaly persists after surgery
References
Walker, BR., Colledge, NR., Ralston, SH., Davidsons Principles of Clinical Medicine 21 st edition, Churchill
Livingstone, (2010).
Kumar, P., Clarke, M. Clinical Medicine 7th edition, Saunders, 2009.
Longmore, M. et al Oxford Handbook of Clinical Medicine 8 th edition, Oxford University Press, 2010.
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