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Adrenal Disorders Associate Professor Geoff Braatvedt

Adrenal Disorders Associate Professor Geoff Braatvedt. Cholesterol. Pregnenolone. DHEAS. Physiology. Cortex (steroids). Cholesterol. Pregnenolone. DHEAS. Progesterone. 170H PROG. Testosterone. Physiology. Cortex (steroids). Cholesterol. Pregnenolone. DHEAS. Progesterone.

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Adrenal Disorders Associate Professor Geoff Braatvedt

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  1. Adrenal DisordersAssociate ProfessorGeoff Braatvedt

  2. Cholesterol Pregnenolone DHEAS Physiology Cortex (steroids)

  3. Cholesterol Pregnenolone DHEAS Progesterone 170HPROG Testosterone Physiology Cortex (steroids)

  4. Cholesterol Pregnenolone DHEAS Progesterone 170HPROG Testosterone Aldosterone (Mineralocorticoid) Physiology Cortex (steroids)

  5. Cholesterol Pregnenolone DHEAS Progesterone 170HPROG Testosterone *21 Hydroxylase Aldosterone (Mineralocorticoid) Cortisol (Glucocorticoid) Physiology Cortex (steroids)

  6. Medulla (catecholamines)

  7. Circadian Stress + + HigherCentres + Hypothalamus CRF + - Pituitary ACTH + - Adrenal Glucocorticoid Control

  8. Exogenous steroids Glucocorticoid Mineralo Corticoid Daily Replacement Potency Potency Dose Hydrocortisone 1 1 25 mg

  9. Exogenous steroids Glucocorticoid Mineralo Corticoid Daily Replacement Potency Potency Dose Hydrocortisone 1 1 25 mg Cortisone Acetate 0.9 0.8 25 - 30 mg

  10. Exogenous steroids Glucocorticoid Mineralo Corticoid Daily Replacement Potency Potency Dose Hydrocortisone 1 1 25 mg Cortisone Acetate 0.9 0.8 25 - 30 mg Prednisone 5 0.8 5 - 7 mg

  11. Exogenous steroids Glucocorticoid Mineralo Corticoid Daily Replacement Potency Potency Dose Hydrocortisone 1 1 25 mg Cortisone Acetate 0.9 0.8 25 - 30 mg Prednisone 5 0.8 5 - 7 mg Dexamethasone 50 0 0.5 mg

  12. Exogenous steroids Glucocorticoid Mineralo Corticoid Daily Replacement Potency Potency Dose Hydrocortisone 1 1 25 mg Cortisone Acetate 0.9 0.8 25 - 30 mg Prednisone 5 0.8 5 - 7 mg Dexamethasone 50 0 0.5 mg 9 Flurocortisone 0 125 0.1 - 0.2 mg

  13. Side Effects • CVS • GIT

  14. Side Effects • CVS • GIT • CNS • Bone

  15. Side Effects • CVS • GIT • CNS • Bone • Endo • Renal • Immune • Skin

  16. Advice • Life long

  17. Advice • Life long • Steroid card / bracelet

  18. Advice • Life long • Steroid card / bracelet • IMI hydrocortisone

  19. Advice • Life long • Steroid card / bracelet • IMI hydrocortisone • Illness • Withdrawal: • acute dosing • chronic dosing

  20. Cushing’s Syndrome

  21. Presentation may be • Psychiatric - depression, hypo mania etc • Endocrine - ‘spot’ diagnosis, diabetes, hirsuitism, amenorrhoea etc • Orthopaedic - osteoporosis, fractures • Cardiac - BP etc

  22. Clinical aspects of Cushing's syndrome

  23. Diagnosis • 24 hour urinary free cortisol high • 1 mg overnight dexamethasone suppression test –fails to suppress = the syndrome of Cushings Now is it pituitary or adrenal or ectopic??

  24. Pituitary dependent Cushing’s • ACTH measurably normal to high • 8 mg dex test suppresses • MRI positive • Consider petrosal sinus sampling

  25. Inferior petrosal sinus sampling for adrenocorticotropic hormone after corticotropin-releasing hormone

  26. Hypothalamic-pituitary-adrenal axis in ACTH-dependent Cushing's syndrome Cortisol  ACTH /

  27. Adrenal Cushing’s • ACTH unmeasurably low • MRI / CAT scan of adrenals

  28. Hypothalamic-pituitary-adrenal axis in ACTH-independent Cushing's syndrome Cortisol  ACTH 

  29. Ectopic Cushing’s • ACTH may be very high • Fails to suppress to high dose dexamehtasone • Normal pituitary MRI • Negative petrosal sinus sampling • Possibly CXR / CT chest

  30. Hypothalamic-pituitary-adrenal axis in ACTH-dependent Cushing's syndrome Cortisol  ACTH //

  31. Hypoadrenalism • Exogenous steroids

  32. Hypoadrenalism • Exogenous steroids • 1° Addison’s

  33. Hypoadrenalism • Exogenous steroids • 1° Addison’s • 2° to pituitary disease

  34. Hypoadrenalism • Exogenous steroids • 1° Addison’s • 2° to pituitary disease • Adrenal enzyme deficiencies = CAH

  35. Cholesterol Pregnenolone DHEAS Progesterone 170HPROG Testosterone *21 Hydroxylase Aldosterone (Mineralocorticoid) Cortisol (Glucocorticoid) Physiology Cortex (steroids)

  36. Hypoadrenalism • Exogenous steroids • 1° Addison’s • 2° to pituitary disease • Adrenal enzyme deficiencies = CAH • (21 OH progesterone) • Addison’s: • autoimmune (glucocorticoid and mineralocorticoid) • adrenal destruction - TB

  37. Symptoms • Weight loss • Pigmentation • Anorexia • Abdominal pain

  38. Symptoms • Weight loss • Pigmentation • Anorexia • Abdominal pain Signs • Pigmentation

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