Adrenal Gland PDF

L 7.8 ADRENAL GLAND Assistant Prof. DR. Sameer alkhawaja Alhussen university colloge THE HYPOTHALAMIC-PITUITARY-ADRENAL (HPA) AXIS  ADRENAL GLANDS The adrenal glands are 1.small (6–8 g) endocrine glands 2.located bilaterally at the superior pole of each kidney.also...

L 7.8 ADRENAL GLAND Assistant Prof. DR. Sameer alkhawaja Alhussen university colloge THE HYPOTHALAMIC-PITUITARY-ADRENAL (HPA) AXIS  ADRENAL GLANDS The adrenal glands are 1.small (6–8 g) endocrine glands 2.located bilaterally at the superior pole of each kidney.also called suprarenal gland. 3.Each gland contains an outer cortex and an inner medulla 4.The adrenal medulla functions as a sympathetic ganglion and secretes catecholamines, primarily epinephrine. 5.The adrenal cortex secretes several steroid hormones with multiple actions The adrenal cortex makes up about 90% of the gland and consists of three zones.  The outer zone is the zona glomerulosa. Secretes mineralocorticoids,(aldosterone).  The middle zone is the zona fasciculata, secretes glucocorticoids  the innermost zone is the zona reticularis. secretes androgens, or sex hormones. . All are derived from cholesterol and share a common molecular nucleus  Aldosterone 1.a mineralocorticoid is the predominant hormone of the zona glomerulosa 2. is that responds to hormones made by the kidneys (i.e., renin and angiotensin). 3.Aldosterone regulates physiologic levels of sodium and potassium; these two electrolytes are important for control of intravascular volume and blood pressure.  THERAPEUTIC USE OF GLUCOCORTICOIDS Equivalent doses of 5 mg prednisolone are: 1. Hydrocortisone 20 mg. 2.Dexamethasone 0.5 mg. Glucocorticoids and Their Relative Potency 1.Short-Acting (36 Hours): Betamethasone and Dexamethasone Inhaled: Beclomethasone CONDITIONS WITH EVIDENCE-BASED BENEFITS OF STEROIDS Asthma ,Croup, Crohn's disease, Ulcerative colitis, Giant cell arteritis (temporal arteritis), Polymyalgia rheumatica , Rheumatoid arthritis , Systemic lupus erythematosus , Polyarteritis nodosa, Wegener's granulomatosis, Sarcoidosis, Eczema , Otitis externa, Pemphigus, Dermatomyositis, Minimal change glomerulonephritis, Acute leukemia , Acquired hemolytic anemia , Idiopathic thrombocytopenic purpura, Cerebral edema, Cluster headache , Congenital adrenal hyperplasia , Anaphylaxisand allergic reactions   Adverse effects of glucocorticoids Adverse effect of glucocoticoid (steroid) are related to dose and duration of therapy. 1. Diabetes mellitus can be worsened. 2. Mood disturbance, either depression or mania, and insomnia. 3. Fracture risk is greater in glucocorticoid-induced osteoporosis than in post- menopausal osteoporosis, so when systemic glucocorticoids are prescribed for > 3 months, bone- protective therapy should be considered. 4. The patient may show no febrile response to an infection. 5. Glucocorticoids act synergistically with NSAIDs, including aspirin, to increase the risk of gastric erosions and ulceration. 6. Latent TB may be re-activated 7. patients on corticosteroids should be advised to avoid contact with varicella zoster virus 8. Cushing syndrome  Management of glucocorticoid withdrawal  All glucocorticoid therapy can suppress the HPA axis; however,  a crisis due to adrenal insufficiency on withdrawal of glucocorticoids occurs only after  prolonged (>3 weeks) or  repeated courses,  or doses of prednisolone > 7.5 mg/day.  In these circumstances, steroid withdrawal must be slow (tapering) as the HPA axis may take months to recover.  Patients must avoid sudden withdrawal.  ADRENOCORTICAL INSUFFICIENCY 1.Primary adrenocortical insufficiency,  also known as Addison's disease, is characterized by the destruction of the adrenal cortex with resulting deficiency of all of the adrenocortical hormones. 2.,secondary adrenocortical insufficiency,  The more common form may be the consequence of hypothalamic or pituitary disease or the administration of exogenous corticosteroids. 1.Primary adrenocortical insufficiency (Addison's disease)  Addison's disease (Adrenocortical Insufficiency) is the hypofunction of the adrenal cortex.  There is a decrease in adrenal steroids which are: 1.glucocorticoids, 2.mineralcorticoids, and 3. androgen.  The adrenal cortex function is inadequate to meet the patient's need for steroids. ).  CAUSES 1. Autoimmune or idiopathic atrophy of the adrenal glands which is responsible for 80% to 90% of cases. 2. Surgical removal of both adrenal glands. 3. Infection of the adrenal glands (Tuberculosis and histoplasmosis are the most common infections that destroy adrenal gland tissue  Signs and Symptoms  Tiredness,  weakness,  loss of appetite,  weight loss,  dizziness when standing,  muscle aches,  abnormal hair distribution,  patches of darkened skin or unexplained tanning,  depression and gastrointestinal disturbances. Oral Complications and Manifestations  In primary adrenal insufficiency,  diffuse or focal brown macular pigmentation of the oral mucous membranes is a common finding.  Pigmentation of sun-exposed skin often  follows the appearance of oral pigmentation.  Diagnosis of Addison`s disease  Early stages difficult to diagnose  Cortisol levels  ACTH Stimulation Test  CRH Stimulation Test  Patients with this disease exhibit  low levels of plasma cortisol  high levels of ACTH.  The increase in ACTH levels represents a vain attempt by the pituitary to stimulate hormone production in the unresponsive adrenal cortex.  Treatment of Addison`s disese  Hormone replacement therapy;  depending on which hormone is low.  ADDISONIAN CRISIS  Symptoms include  sudden penetrating pain in lower back, abdomen or legs,  severe vomiting, diarrhea followed by  dehydration,  low blood pressure and  loss of consciousness  TREATMENT OF ADDISON`S CRISES  Immediately inject 100mg hydrocortisone i.v. or i.m.  followed by rapid rehydration with i.v. administration of 0.9% saline solution (or equivalent)  Secondary Adrenal Insufficiency Much more common than primary adrenal insufficiency cause by 1. exogenous use of steroid 2.Pitutary adenoma 3.Infction 4.Surgical removal of pituitary gland tumorB Diagnosis by 1.Law cortisol 2.Law ACTH Treatent Remove the cause L.8  Hyperadrenalism Definition ;-hyperactivity of adrenal gland which lead to excessive secretion of  adrenal cortisol,  mineralocorticoids,  androgens  in isolation or combination.  The most common type of overproduction is known as Cushing's disease  Cushing's syndrome  Cushing'ssyndrome is result from excessive secretion of glucocorticoid Causes of Cushing syndrome  Endogenous  exogenous the most common cause is iatrogenic, due to prolonged administration of synthetic glucocorticoids such as prednisolone (exogenous Cushing's syndrome). Classification of endogenous Cushing's syndrome  ACTH-dependent - 80%  Pituitary adenoma secreting ACTH  Non-ACTH-dependent - 20%  Adrenal adenoma  Adrenal carcinoma  (pseudo-Cushing's(  Alcohol excess  Depression  Obesity  Symptoms of Cushing's syndrome 1.Cardiovascular (hypertension and heart failure), 2.obesity, 3.moon face, 4.buffalo hump, 5.hyperglycemia, 6.peptic ulcers, 7.muscle weakness, 8. mood alterations, 9.impaired wound healing, 10. increased susceptibility to infections and 11. decreased inflammatory response.  MOON FACE ABDOMENAL STRIA  Investigations  24-hour urinary cortisol  Increase serum cortisol  ACTH  Increase in pituitary adenoma  Decrease in - adrenal adenoma and - adrenal carcinoma  Additional tests include plasma electrolytes and glucose  CT/MRI detects most adrenal adenomas  Because of the negative feedback mechanism of the HPA axis, 1. 1.the patient's cortisol levels are high and 2. 2.the ACTH levels are low.  DIAGNOSIS  History of chronic use of cortisol .symptom of fatigue and tirede  Sign of truncal obesity ,moon face ,abdominal strai ,buffalo hump  Increase s. cortisol  Increase ACTH in pitutiry adenoma  Decrease ACTH IN adrenal adenoma  And adrenal carcinoma  Increase urinary cortisol.  TREATMENT OF CUSHING SYNDROM  Treatments for Cushing syndrome are designed to lower the amount of cortisol in the body.  The best treatment for you depends on the cause of the syndrome. Options include:  Reducing glucocorticoid use.  If Cushing syndrome is caused by taking glucocorticoid medicine for a long time, by lowering medicine you take. . Stopping these medicines too quickly can cause you to have too little cortisol in your body.  Slowly tapering off the medicine allows your body to make a healthy amount of cortisol.  SURGERY  If Cushing syndrome is caused by a tumor recommend removing the tumor with surgery.  Pituitary tumors are often removed by a neurosurgeon, . ACTH-producing tumors in other parts of the body may be removed with regular surgery  If an ACTH-producing tumor isn't found, or if one can't be fully removed and Cushing syndrome continues, r may recommend removing the adrenal glands. This is called a bilateral adrenalectomy.  After both adrenal glands are removed, you may need to take medicines to replace cortisol and another adrenal hormone called aldosterone for the rest of your life.  This process can take from six months to a year or more. Sometimes, people with Cushing syndrome need lifelong replacement medicine. RADIATION THERAPY  If the surgeon can't totally remove a pituitary tumor, radiation therapy may be needed along with surgery.  Radiation also may be used for people who can't have surgery.  Radiation can be given  in small doses over six weeks, or  with a single, high dose of radiation. MEDICAL TREATMENT  Medicines can be used to control cortisol levels when surgery and radiation don't work or aren't an option.  Medicines also might be used before surgery in people who are very sick with Cushing syndrome.  This can improve symptoms of the disease and reduce the risks of surgery.  Medical therapy for Cushing syndrome is not a cure and may not completely improve all of the symptoms of too much cortisol. MEDICINES TO CONTROL CORTISOL PRODUCTION AT THE ADRENAL GLAND INCLUDE  ketoconazole,  osilodrostat (Isturisa),  mitotane (Lysodren),  levoketoconazole (Recorlev),  metyrapone (Metopirone).  Mifepristone (Korlym, Mifeprex) is approved for people with Cushing syndrome who have type 2 diabetes or high blood sugar.  Mifepristone does not lower the amount of cortisol the body makes, but it blocks the effect of cortisol on tissues.  Pasireotide (Signifor) is given as a shot two times a day. It works by lowering the amount of ACTH from the tumor, which lowers cortisol levels SIDE EFFECTS FROM THESE MEDICINES  may include  tiredness,  upset stomach,  vomiting,  headaches,  muscle aches,  high blood pressure, low potassium  swelling.  Some have more-serious side effects, such as brain and nervous system side effects and liver damage.  Sometimes, the tumor or its treatment causes the pituitary or adrenal gland to make too little of other hormones. If this happens, your health care provider can recommend hormone replacement  Dental Considerations in patient with addissonin disease To avoid an adrenal crisis in dental patients , the dental clinician should 1.ensure that the usual corticosteroid dose is taken before surgical procedures and 2.will need to monitor the patient closely during the post-surgical phase of care. 3.Generally, however, most routine dental procedures do not require the administration of supplemental steroids. 4.Minor surgical stress 25 mg hydrocortisone equivalent preoperatively. 5.Moderate surgical stress 50-75 mg hydrocortisone equivalent on the day of surgery and up to one day after. 6. Major surgical stress 100-150 mg hydrocortisone equivalent per day given for 2 to 3 days preoperatively. Postoperatively, 50 mg hydrocortisone IV every 8 hours for the first 48 to 72 hours after surgery  NOT  Surgical procedures lasting longer than 1 hour are more stressful than shorter procedures and are considered major surgery  Patients who take corticosteroids for prolonged periods have an increased likelihood of having  hypertension,  diabetes,  delayed wound healing,  osteoporosis, and  peptic ulcer To minimize the risk of an adverse outcome:in dental patient with aadernal indufficiendy 1 1.Surgery should be scheduled in the morning when cortisol levels are highest. 2. Proper stress reduction should be provided because fear and anxiety increase cortisol demand 3.Because of the risk of peptic ulceration, postoperative analgesics should not include aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs. 4.pressure should be taken at baseline and monitored during dental appointments.. 5.Blood glucose levels should be determined. 6.Follow-up appointments should be arranged to assess proper wound healing. 7. Because osteoporosis has a relationship with periodontal bone loss, implant placement and bone fracture, periodic measures of periodontal bone loss are indicated, 8.Blood and fluid volume loss exacerbate hypotension, thereby increasing the risk for development of adrenal insufficiency-like symptoms. 9.A fasting state can contribute to hypoglycemia which can mimic features of an adrenal crisis but does not require glucocorticoids for resolution.  Emergencies Treatment Acute adrenal crisis  Acute adrenal crisis is a medical emergency. 1. Apply wet/ice packs, 2. 2.assess and monitor vital signs, 3. 3.start intravenous saline solution, 4. 4. administration of 100 mg of hydrocortisone or 4 mg of dexamethasone IV, 5. 5.start an intravenous infusion of glucose solution and transport patient to an emergency medical facility. Thankyou for lissing