Adrenal Gland

Adrenal Glands

▪ Also known as suprarenal glands

▪ Two small glands that are located superior to each kidney

▪ Pyramidal in structure and weighs 4g

▪ The inner part of the adrenal gland is called the “medulla.”

▪ The outer part of the gland is called the “cortex.”

• Zona glomerolusa

• Zona fasciculata

• Zona reticularis

Hormones of the Adrenal Medulla

▪ Approximately 80% of the hormones released from the adrenal gland medulla are epinephrine or adrenaline (and adrenaline-like chemicals called catecholamines).

▪ The remaining 20% is nonepinephrine

Hormones of the Adrenal Cortex

▪ Mineralocorticosteroids (Aldosterone)

▪ Glucocorticosteroids (Cortisol)▪ Androgens (Sex hormones)

Disorders in the Adrenal Gland

1. Pheochromocytoma2. Addison's Disease

PHEOCHROMOCYTOMA

PHEOCHROMOCYTOMA

• A tumor that is usually benign and originates from the adrenal medulla (originating in the chromaffin cells), or extra-adrenal chromaffin tissue that secretes excessive amounts of catecholomines (epinephrine and norepinephrine)

PHEOCHROMOCYTOMA

• The cause of high blood pressure in 0.1% of patients with hypertension.

• May occur as a single tumor or as more than one growth

• It usually develops in the center (medulla) of one or both adrenal glands.

• Sometimes this kind of tumor occurs outside the adrenal gland.

Extra-Adrenal Sites

• Within the sympathetic nerve chain along the spinal cord (orange spots)

• Overlying the distal aorta (the main artery from the heart) (green spots)

• Within the ureter (collecting system from the kidney (yellow spot)

• Within the urinary bladder (blue spot)

• Remember, 90% are in the adrenal glands (red spots on the kidneys)

Stages of Malignant Pheochromocytoma

1. Localized: present in only one area of body and has not spread

2. Regional: spread beyond original area and into lymph nodes or tissue surrounding original tumor

3. Metastasis: spread beyond lymph nodes and tissues

4. Recurrent: disease returned after being successfully treated

Signs & Symptoms

▪ headache (usually severe)

▪ excessive sweating

▪ palpitations

▪ Tachycardia

▪ tremors

▪ anxiety w/ panic attacks

▪ nausea & vomiting

▪ weight loss

▪ nervous shaking

▪ pain in the lower chest and upper abdomen

▪ weakness

▪ fever, heat intolerance, sugar intolerance

▪ low blood pressure when standing up

Assessment Findings

▪ hypertension (may be persistent, fluctuating, intermittent, or paroxysmal)

▪ pounding headaches

▪ hyperglycemia and glucosuria

▪ tachycardia, apprehension, palpitations

▪ profuse sweating, cold extremities

▪ nausea, vomiting

▪ dilated pupils

Nursing Assessment

▪ The “Five Hs”–Hypertension–Headache–Hyperhidrosis–Hypermetabolism–Hyperglycemia

Note: Presence of these signs has a 93.8% specificity & 90.9% sensitivity for Pheochromocytoma.

Exams & Tests

▪ Reliable levels of adrenal hormones (adrenaline and noradrenaline) and their breakdown products (metanephrines) through blood or urine can usually help your doctor make a diagnosis.

▪ There are three ways your doctor can do this: blood tests, urine tests, and x-ray tests

▪ Blood tests

▪ Glucagon stimulation test

▪ Clonidine

▪ 24-hour urine collection suppression test

▪ CT scan

▪ MRI

▪ MIBG scan

▪ Selective vena cava sampling

Medical Management

▪ Pharmacologic Therapy

Decrease BP •Alpha-adrenergic blocking agents.(eg. Phentolamine [Regitine])•Smooth muscle relaxants.-(eg. Na nitroprusside [Nipride])

Before and During Surgery

• Long-acting alphablocker. (Phenoxybenzamine [Dibenzyline])• Ca Channel Blockers.-(Nifedipine [Procardia])•Beta-adrenergic blocking agents.-(Propranolol [Inderal])•Cathecholamine synthesis inhibitors.(Methyrosine [Demser])

▪ Surgical Management–Adrenalectomy–Nipride–IV Corticosteroid replacement:

Solu-Medrol–Oral Corticosteroids: Prednisone

Nursing Management

▪ Stabilize patient:1) Prescribed Bed rest2) Pharmacologic Treatment

▪ Patient teaching:– Treatment– Prognosis

▪ Prepare patient for treatment

▪ Monitor: ECG changes, arterial pressures, fluid and electrolyte balance, and blood glucose levels.

▪ Patient teaching: Self-Care, Follow-up visits.

Addison’s Disease

Addison’s Disease

▪ An Endocrine or hormonal disorder that occurs when the adrenal glands do not produce enough of certain hormones

▪ Symptoms include bronzing of the skin, worsening fatigue, loss of appetite, severe dehydration, and weight loss

▪ Can be fatal if left untreated

▪ It includes the underproduction of hormones that the adrenal cortex produces

Gland Affected

▪ The Adrenal gland, specifically the adrenal cortex, is the gland affected.

▪ Addison’s disease develops when the level of adrenal cortex hormone is low due to hyposecretion (lack of secretion).

Causes

▪ Failure to produce adequate levels of cortisols, or adrenal insufficiency, can occur for different reasons.

▪ The problem may be due to a disorder of the adrenal glands themselves ( primary adrenal insufficiency) or to inadequate secretion of ACTH by the pituitary gland (secondary adrenal insufficiency)

Signs & Symptoms▪ chronic, worsening fatigue

▪ muscle weakness

▪ loss of appetite

▪ emaciation ( extreme weight loss)

▪ hyperpigmentation of the mucuos membranes and the skin

▪ nausea

▪ vomiting

▪ diarrhea

▪ low blood pressure that falls further when standing, causing dizziness or fainting

▪ irritability and depression

▪ hyperkalemia

▪ a craving for salty foods due to salt loss

▪ hypoglycemia, or low blood glucose

▪ headache

▪ sweating

▪ in women, irregular or absent menstrual periods

Diagnostic Tests

▪ ACTH stimulation test – to differentiate primary to secondary adrenal insufficiency and from normal adrenal function

▪ Primary insufficiency – more than 22.0pmol/L plasma ACTH level

- serum concentration lower than 165nmol/L

Other laboratory findings..

▪ Hypoglycemia

▪ Hyponatremia

▪ Hyperkalcemia

▪ Leukocytosis ( increased WBC count)

Medical Management

1. Administering fluids and corticosteroids

2. Monitoring vital signs

3. Placing patient into Recumbent position with the legs elevated

4. Administer vasopressor amines may be required if hypotension persists

5. Antibiotics administration if infection has precipitated adrenal crisis

Nursing Management

1. Assessed the patient: health history and examination focus on the fluid imbalance

2. Monitor blood pressure: when lying, sitting and standing position

3. Watched out for signs & symptoms indicative of addisonian crisis, includes shock; hypotension; pallor, rapid RR; weak pulse

4. Encourage increased fluid intake

5. Instructs the patient’s family to administer hormone replacement as prescribed

6. If patient’s condition stabilized, instruct patient to avoid unnecessary activity and stress

Future Trends in Congenital Adrenal Hyperplasia (CAH) ResearchExpanding the Phenotype of CAH

New Endocrine Abnormalities

▪ Adrenomedullary Dysfunction: Cortisol is necessary for the normal development and functioning of the adrenal medulla.  Cortisol turns on the enzyme necessary for the production of epinephrine (adrenaline), which  is a major regulator of blood glucose and suppresses insulin, by the medulla. Classic CAH not only affects cortisol, aldosterone and androgen production in the adrenal cortex, but also severely compromises the adrenal medulla. The implications of this dysfunction are impaired epinephrine response during short-term high-intensity exercise with no increase in blood glucose. More studies are needed on the risk of low blood glucose in CAH as well as the function of the adrenal medulla in patients with NCAH.

Thank you!