6b67upper gastrointestinal bleeding

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DR M ABDUR RAHIM

M.D.,

ASST PROFESSOR OFMEDICINE



ADRENAL GLANDS



INTRODUCTION

Several separate endocrine glands within a

single Anatomical structure

Adrenal Medula- Extension of the

sympathetic Nervous System which

secretes Catecholamines into capillaries



Adrenal Cortex – Secrete cortisol, Adrenal

androgens and part of HPA axis.

Small outer Glomerulosa of cortex

secretes Aldosterone under the control of RAS

Integrated control of CVS, metabolic andImmune responses to stress



Subtle alterations in adrenal function

contributes to Hypertension, Obesity and

Type II DM

Classical syndrome of adrenal hormone

excess and deficiency are rare



ANATOMY



PHYSIOLOGY



FUNCTIONS

Glucocorticoids :- CortisolHighest in Morning

Lowest in Midnight

Rises during Stress95% Cortisol binds Globulin

Free fraction only is active

Binds Glucocorticoid receptors to

regulate transcription of many genes



Mineralocorticoids: Aldosterone

Binds to receptors in Kidney and

causes Sodium retention, increased

excretion of Potassium and Protons



Catecholamines : Norepinephrine

Converted to Epinephrine by

enzyme COMT induced by

Glucocorticoids.

Blood flow in Adrenaline is

Centripetal.

No consequences of insufficiency

even after surgical removal of

Adrenal Medullae.



Adrenal Androgens

Abundant in blood stream

Important in intiation of Puberty &

Female Libido



ADRENAL DISEASES

Hormone Excess

Cushing’s Syndrome

Primary HyperAldosteronism

Phaeochromocytoma

Hormone DeficiencyAddison’s Disease

Congenital Adrenal Hyperplasia



CUSHING’S SYNDROME

Caused by Excessive activation of Glucocorticoid receptors

Iatrogenic – Common

EQUIVALENT DOSES OF GLUCOCORTICOIDS

- Dexamethasone 0.5mg

- Prednisolone 5mg

- Hydrocortisone 20mg

- Cortisone Acetate 25mg



ETIOLOGY



Cushing’s Disease – 80%

4 times more common in Women.

Ectopic ACTH common in Men.



Clinical Features



Investigations



Management

Medical management : InhibitCorticosteriod biosynthesis

- Metyrapone & Ketaconazole

Surgical management :

Cushing’s Disease – Trans-sphenoidal

Surgery- Alternatively

Bilateral Adrenalectomy

(Nelson’s Syndrome)



Adrenal Tumours – Laparoscopic / Loin

Incision removal of Adenomas

Ectopic ACTH Syndrome -

Surgical removal of Localized

Tumour

Incurable Malignancy-Medical Therapy /

Bilateral Adrenalactomy



PRIMARY HYPERALDOSTERONISM



CLINCAL FEATURES

Usually Asymptomatic Features of Sodium retention

- Oedema

Features of Potassium loss- Muscle weakness

Polyuria

Tetany

Hypertension



INVESTIGATIONS

Serum Electrolytes

Imaging – CT or MRI – indentify APAs



MANAGEMENT

Spironolactone Eplerenone

Amiloride

Laparoscopic Surgery



Phaeochromocytoma

Rare Neuro-endocrine Tumours

80% occur in Adrenal Medula

20% in Sympathetic Ganglia

Associated with Inherited disorders



INVESTIGATIONS

Plasma / Urine Metanephrine andNormetanephrine

Serum Chromogrenin A

CT or MRI



MANAGEMENT

Medical Therapy before Surgery

Minimum 6 weeks

Alpha Blocker Phenoxybenzamine

(10-20mg, 6 – 8 hrly)



ADRENAL INSUFFICIENCY

Inadequate secretion of Cortisol and or

Aldosterone

Variable in presentation & Fatal

High index of suspicion



ETIOLOGY



CLINICAL FEATURES



INVESTIAGATION

Assessment of Glucocorticoids

Mineralocorticoids

Adrenal Androgens

6b67upper gastrointestinal bleeding

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