Adrenal insufficiency

1. Adrenal
Insufficiency Shreya DAS 303
Orenburg State
Medical University

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• etiology
• CLINICALFEATURES
• DIAGNOSIS
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• DISPOSITIONANDFOLLOW-UP

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• The adrenal glands are located on both sides of the body
in the retroperitoneum, above and slightly medial to the
kidneys
• The adrenal glands (also known as suprarenal glands)
are endocrine glands that produce a variety of hormones
including adrenalineand the steroids aldosterone and
cortisol.
• Each gland has an outer cortex which produces steroid
hormones and an inner medulla.
• The adrenal cortex itself is divided into three zones: the

5. •Mineralocorticoids (such as aldosterone)
produced in the zona glomerulosa help in
the regulation of blood pressure and
electrolyte balance
•The glucocorticoids cortisoland cortisone
are synthesized in the zona fasciculata;
their functions include the regulation
of metabolism and immune system
suppression.
•The innermost layer of the cortex, the zona
reticularis, produces androgens that are
converted to fully functional sex hormones in

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•Mineralocorticoids :
•In the kidneys, aldosterone acts on the distal
convoluted tubules and the collecting ducts by
increasing the reabsorption of Na and the excretion of
both k+ and hydrogen ions
•Angiotensin II and extracellular potassium are the two
main regulators of aldosterone production
•Aldosterone deficiency symptoms include
dehydration, syncope, salt craving, and hypotension

7. Glucocorticoi
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•Cortisolis the main glucocorticoid in humans
•They increase the circulating level of glucose
Glucocorticoids also have effects unrelated to the
regulation of blood sugar levels, including the
suppression of the immune system and a potent anti
inflammatory effect. Cortisol reduces the capacity of
osteoblasts to produce new bone tissue and decreases
the absorption of calcium in the gastrointestinal tract.
•Secretion occurs in a diurnal rhythm, with higher levels
secreted in themorning and lower levels in the evening
•Regulate fat, glucose, protein metabolism

8. Catecholamines
• Adrenaline and noradrenaline act
at adrenoreceptors throughout the body
•Effects that include an increase in blood
pressure and heart rate.
•Actions of adrenaline and noradrenaline are
responsible for the fight or flight response
characterised by a quickening of breathing and
heart rate, an increase in blood pressure, and
constriction of blood vessels in many parts of
the body.[32]

9. REGULATION
• Glucocorticoids are under the regulatory influence
of the hypothalamus-pituitary-adrenal (HPA) axis.
• Glucocorticoid synthesis is stimulated
by adrenocorticotropic hormone (ACTH), a
hormone released into the bloodstream by the
anterior pituitary. In turn, production of ACTH is
stimulated by the presence of corticotropin-
releasing hormone(CRH), which is released by
neurons of the hypothalamus.
• Mineralocorticoid secretion is regulated mainly by
the renin–angiotensin–aldosterone system(RAAS),
the concentration of potassium, and to a lesser
extent the concentration of ACTH

10. Adrenal
Insufficiency
1.Primary = failure of adrenal glands
2. Secondary = failure of HPA axis
– Usually due to chronic
exogenous glucocorticoid
administration
_pituitary failure
•3. Tertiary = Hypothalamic
dysfunction

11. PRIMARY ADRENAL
INSUFFICIENCY
1.80% are due to an autoimmune disease called
Addison's disease or autoimmune adrenalitis
2.One subtype is called idiopathic
3.Other cases are due to congenital adrenal
hyperplasia or an adenoma (tumor) of the adrenal
gland
TB = m.c. infectious cause worldwide

13. Addison's
disease
•primary hypoadrenalism, which is a deficiency in
glucocorticoid and mineralocorticoid production by the
adrenal gland.
•Addison's disease is most commonly an autoimmune
condition
•. A distinctive feature of Addison'sdiseaseis hyperpigmentation of
the skin.
•Under certain circumstances, an adrenal crisis may occur with low
blood pressure, vomiting, lower back pain, and loss of
consciousness.

14. SECONDARY ADRENAL
INSUFFICIENCY:
Secondary adrenal insufficiency is caused by
impairment of the pituitary gland or
hypothalamus.
HPA axis failure
– deficiency of glucocorticoids and adrenal
androgens
– mineralcorticoids are unaffected
Less common causes
– Postpartum necrosis (Sheehan syndrome)
– Adenoma hemorrhage
– Pituitary destruction from head trauma
– typically have associated focal neurologicalchanges, visual deficits,
diabetes

16. •Characterized by depressed adrenocorticotropic
hormone secretion, which reduces cortisol
production, butaldosterone levels remain normal
because of preserved stimulation byboth the
renin-angiotensin axis and potassium.
•Adrenal sex hormone production is also
preserved.
•The most common cause of secondary adrenal
insufficiency is longterm
therapy with pharmacologic doses of
glucocorticoids

17. Tertiary adrenal insufficiency :
Due to hypothalamic disease and a decrease
in the release of corticotropin releasing
hormone (CRH)

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• Adrenal crisis is shock refractory to volume resuscitation and
pressors.
• It can result from acute destruction of the hypothalamic-pituitary
axis or the adrenal glands or from acute stressors in the setting of
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primaryor secondary adrenal insufficiency.
•Life-threatening emergency
• Stressor : Acute infection, especially gastrointestinal infection;
surgery; extremephysical activity; acute severe injury or burns;
and cessation of chronic glucocorticoid replacement

20. Other symptoms include
severe abdominal pain, nausea,and vomiting, mimicking
an acute abdomen.
CNS symptoms of confusion,disorientation, and lethargy
.There may be associated sepsis, even without fever.
Consider adrenal crisis in situations of unexplainedhypotension,
especially in patients with a history of
glucocorticoidtherapy; those with acquired
immunodeficiency syndrome, tuberculosis,
autoimmune disease, or severe head trauma; those with a
history ofchronic fatigue and hyperpigmentation

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YSTUDIESANDIMAGING
GRBS CBC
Serum Electrolyte,ca, cortisol LFT, RFT
ECG- POTTASIUM IMBALANCE URINE ANALYSIS
CXR- TB,PNUEMONIA
CT ABDOMEN -TUMORS, ADRENAL GLAND HEMORRHAGE
HEAD CT / MRI- TUMORS

22. Primary adrenal insufficiency
Hyponatremiaand hyperkalemia due to aldosterone deficiency
High ACTH level
Low serum glucose
Low cortisol
Secondary adrenalinsufficiency
Low ACTH
LOW Cortisol
•serum cortisol>18 micrograms/dL generally rules out adrenal
insufficiency.
•ACTH stimulation test :250 microgram cosyntropin is given iv
if serum cortisol increases --- secondary

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• Primary adrenal insufficiency
• Daily dosing of glucocorticoidand mineralocorticoid, usually
for life.
• Androgen replacement may be recommended for women.
• The goal of treatment is to stabilize hormone levels and
relieve symptoms.
• Mineralocorticoids are replaced with an oral, synthetic
mineralocorticoid drug such as fludrocortisone The dose is
tailored to manage blood pressure and fluid balance.
• Secondary adrenalinsufficiency
• Only glucocorticoid replacement is required.
• Dose is 20 mg/day of oral hydrocortisone.
•Stress dose is three times daily dose

25. DISPOSITION AND FOLLOW UP
Admit patients with adrenal crisis to an intensive
care unit for careful clinical monitoring, IV steroid
administration, and confirmation of diagnosisand
identification of etiology.
Discharge can only be considered for mildcases of adrenal
insufficiency with identified etiologies and after a clear plan
of management is established.
Endocrinology consultation

26. PATIENTS ON CHRONIC CORTICOSTEROIDS
Hypothalamus-pituitary-adrenal axis function is inhibited with
chronic use of steroids. Always consider adrenal insufficiency in
patients with chronic steroid use presenting with any acute illness
PREGNANCY WITH ADRENAL INSUFFICIENCY
Most women with primary adrenal insufficiency are able to undergo
healthypregnancy, labor, and delivery.
Give hydrocortisone 100mg iv bolus during labour. Dose
adjustment may be needed

28. “Unexplained hyponatremia and
hyperkalemia in the setting of hypotension
unresponsive to catecholamine and fluid
administration… We should concider
ADRENAL CRISIS as an d/d in the emergency
medicie dept.
TAKE HOME MESSAGE !!