cushing s addison s and acromegaly n.
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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

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.
slide3
Aims
  • HPA Axis
  • Adrenal glands
  • Cushing’s syndrome/disease
  • Addison’s
  • Acromegaly
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
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.

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

slide21

Not excluded

Abstinence

?EtOH excess

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…

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)
slide32

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
definition1
Definition?
  • A condition caused by excessive secretion of growth hormone
most common cause
Most common cause?
  • Pituitary macroadenoma
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