Sie sind auf Seite 1von 45

Cushings,

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.

3.23: Adrenal gland hormones


o Recognise signs and symptoms of Addisons disease, confirm diagnosis and
initiate immediate management of Addisonian crisis.
o Recognise symptoms and signs of Cushings syndrome, confirm diagnosis,
participat in management of Addisons disease and Cushings syndrome.

3.24: Pituitary gland hormones


o Recognise the circumstances when hypopituiarism might occur, recognise
possibility of hypopituitism with non-specific symptoms, investigate
causes.
o Initiate investigation for posterior pituitary function in patients with
polyuria.
o Recognise acromegaly, initiate investigation for acromegaly, outline to
patients the possible treatments for acromegaly.

Aims

HPA Axis
Adrenal glands
Cushings syndrome/disease
Addisons
Acromegaly

HPA Axis

Hypothalamus

GnRH

TRH Dopamine CRH

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

Right, now onto the stuff


you actually want to
know

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.

Untreated Cushings disease has a 50% 5 year mortality

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

U&Es low Na+/high K+


Glucose low
Random serum cortisol
Short synacthen test
Plasma renin
TFTs etc (?hypopituitism)
FBC (?perncious anaemia)
Gonadal function
HIV test
Plasma aldosterone

Imaging

AXR (?adrenal calcification


CT or MRI of adrenals

The short synacthen test


Why do we do it?
How do we do it?
What result do we see in a positive
test? (Ruling out Addisons)

250g synacthen IM

Positive test (ruling out Addisons):


Serum
cortisol
at
Plasma cortisol >460nmol/L
at
30
0 minutes
minutes
Serum cortisol at
30 minutes

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

Most common cause?


Pituitary macroadenoma

Your turn!

Impress your examiner

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

Medical (second line):


o Somatostatin analogues (octreotide, lanreotide)
o Dopamine agonists
o GH receptor antagonists (pegvisomant)

Surgery (first line):


o Trans-sphenoidal surgical debulking of pituitary
adenoma

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.
http://www.fipapatients.org/pictures/big/pituitary_normal.jpg
http://www.autismpedia.org/wiki/images/b/b9/Adrenal-core.gif
http://www.ghorayeb.com/files/Transsphenoid_Lateral_380x332.jpg
http://www.nosleeplessnights.com/wp-content/uploads/2013/03/dexamethasone.jpg
http://classconnection.s3.amazonaws.com/319/flashcards/1117319/jpg/addisons_disease1332524676283.jpg
http://upload.wikimedia.org/wikipedia/commons/2/2e/Addisons_hyperpigmentation.jpg
http://globalvoicesonline.org/wp-content/uploads/2012/05/syringe-drawing-320x300.jpg
https://lh5.googleusercontent.com/-qF8wwWfCtFI/TXRv47Ax4xI/AAAAAAAABR8/4jsTaDOngtc/s1600/
Synacthen.JPG
http://www.gloshospitals.org.uk/SharePoint11/Pathology%20Web%20Images/Specimen%20containers/
Gold_top_with_cap.jpg
http://www.sehha.com/diseases/endocrine/Addison12.gif
http://www.hdwallpapersinn.com/wp-content/uploads/2012/09/bigshow-img.jpg
http://www.examiner.com/images/blog/wysiwyg/image/andre-the-giant.jpg
http://upload.wikimedia.org/wikipedia/commons/1/15/Bitempvf.png
http://www.s2c8.co.uk/wp-content/uploads/2013/01/man-boob.jpg
http://www.physio-pedia.com/images/6/61/Moon_facies_in_Cushings.jpg
http://www.passpaces.com/images/acromegaly_MRCP.jpg

Das könnte Ihnen auch gefallen