Cushing s addison s and acromegaly
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Cushing’s, Addison’s and Acromegaly. Dr Edward Hutchison FY1 (Geriatrics). Phase II Objectives. 3.21: Investigations – Request appropriately the more common tests of thyroid, adrenal and pituitary gland function, seeking advice where necessary. 3.23: Adrenal gland hormones

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Cushing’s, Addison’s and Acromegaly

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Cushing s addison s and acromegaly

Cushing’s, Addison’s and Acromegaly

Dr Edward Hutchison FY1 (Geriatrics)


Phase ii objectives

Phase II Objectives

  • 3.21: Investigations–

    • Request appropriately the more common tests of thyroid, adrenal and pituitary gland function, seeking advice where necessary.

  • 3.23: Adrenal gland hormones

    • Recognise signs and symptoms of Addison’s disease, confirm diagnosis and initiate immediate management of Addisonian crisis.

    • Recognise symptoms and signs of Cushing’s syndrome, confirm diagnosis, participat in management of Addison’s disease and Cushing’s syndrome.

  • 3.24: Pituitary gland hormones

    • Recognise the circumstances when hypopituiarism might occur, recognise possibility of hypopituitism with ‘non-specific’ symptoms, investigate causes.

    • Initiate investigation for posterior pituitary function in patients with polyuria.

    • Recognise acromegaly, initiate investigation for acromegaly, outline to patients the possible treatments for acromegaly.


Cushing s addison s and acromegaly

Aims

  • HPA Axis

  • Adrenal glands

  • Cushing’s syndrome/disease

  • Addison’s

  • Acromegaly


Hpa axis

HPA Axis


Hypothalamus

Hypothalamus

GnRH

GHRH

TRH

Dopamine

CRH


Pituitary

Pituitary

Sphenoid sinus


Adrenal glands

Adrenal Glands

Remember:

GFR!


Functions of cortisol

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

Right, now onto the stuff you actually want to know…


Cushing s

Cushing’s…

…disease or syndrome?


Which is which

Which is which?

Syndrome

Disease

Excessive activation of glucocorticoid receptors.

Excessive production of ACTH caused by a pituitary adenoma.


Classification

Classification


Clinical features

Clinical features

Over to you…


Symptoms

Symptoms

  • Depression

  • Confusion

  • Weight gain

  • Poor glucose control (diabetics)

  • Weakness rising from a chair (proximal myopathy)


Investigation

Investigation

Bedside

Blood

Imaging


Cushing s addison s and acromegaly

Not excluded

Abstinence

?EtOH excess


Acth level

ACTH level?


Management

Management

Untreated Cushing’s disease has a 50% 5 year mortality


Remember

Remember

  • Not only oral corticosteroids can cause Cushing’s 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 long-term steroid therapy – e.g. diabetes, hypertension, thin skin, osteporosis.


Addison s disease

Addison’s disease

(Or adrenal insufficiency, to be more correct).


Definition

Definition?

A syndrome resulting from inadequate secretion of corticosteroid hormones from progressive destruction of the adrenal cortex.


Causes

Causes

A

D

D

I

SO

N

– autoimmune (90% of cases)

– neoplasia (metastases)

– degenerative (amyloid)

– drugs (e.g. ketoconazole)

– infective (TB, HIV)

– secondary (ACTH, hypopituitism)

– other (e.g. adrenal bleeding)


Clinical features1

Clinical Features

Over to you…


Investigations

Investigations


The short synacthen test

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 Addison’s)


Cushing s addison s and acromegaly

250µg synacthen IM

Positive test (ruling out Addisons):

Plasma cortisol >460nmol/L at 30 minutes

Serum cortisol at 0 minutes

Serum cortisol at 30 minutes


Management1

Management

  • Glucocorticoid replacement

    • Hydrocortisone BD, usually 15mg on waking/5mg around 1800hrs

    • Excessive weight gain = over replacement

    • Educate patient – increase hydrocortisone when unwell

  • Mineralocorticoid replacement

    • Fludrocortisone 50-100µg daily

    • Titrate according to symptoms and U&Es


Addisonian crisis

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

Acromegaly


Definition1

Definition?

  • A condition caused by excessive secretion of growth hormone


Most common cause

Most common cause?

  • Pituitary macroadenoma


Cushing s addison s and acromegaly

Your turn!


Impress your examiner

Impress your examiner…

Hypopituitism


Investigations1

Investigations


Management2

Management

  • Conservative:

    • Patient education

  • Medical (second line):

    • Somatostatin analogues (octreotide, lanreotide)

    • Dopamine agonists

    • GH receptor antagonists (pegvisomant)

  • Surgery (first line):

    • Trans-sphenoidal surgical debulking of pituitary adenoma

  • Radiotherapy:

    • Employed if acromegaly persists after surgery


References

References

  • Walker, BR., Colledge, NR., Ralston, SH., “Davidson’s Principles of Clinical Medicine” 21st edition, Churchill Livingstone, (2010).

  • Kumar, P., Clarke, M. “Clinical Medicine” 7th edition, Saunders, 2009.

  • Longmore, M. et al “Oxford Handbook of Clinical Medicine” 8th 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


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