10-Adrenal gland disorders .pdf

Adrenal gland disorders Dr. Ali Adnan Adrenal gland disorders what is secreted by the adrenal gland? The adrenal glands are small endocrine glands located bilaterally at the superior pole of each kidney The adrenal medulla functions as a sympathetic ganglion and secretes epinephrine. The adrenal cor...

Adrenal gland disorders Dr. Ali Adnan Adrenal gland disorders what is secreted by the adrenal gland? The adrenal glands are small endocrine glands located bilaterally at the superior pole of each kidney The adrenal medulla functions as a sympathetic ganglion and secretes epinephrine. The adrenal cortex secretes several steroid hormones with multiple actions Cortisol acts as an insulin antagonist increasing blood levels and peripheral use of mineralocorticoid glucocorticoid cortisol and inflammation Its antiinflammatory action is modulated by its inhibitory action on (1) lysosome release (2) prostaglandin production (3) eicosanoid and cytokine release (4) endothelial cell expression of intracellular and extracellular adhesion molecules (ICAMs and ECAMs, respectively) that attract neutrophils (5) leukocyte function. cortisol and stress Cortisol secretion is pulsatile and normally regulated by hypothalamus-pituitary-adrenal axis Peak levels of plasma cortisol occur around the time of waking in the morning and are lowest in the evening and night The normal secretion rate of cortisol over a 24-hour period is approximately 20 mg. During periods of stress, the HPA axis is stimulated surgery itself is one of the most potent activators of the HPA. Disorders of the adrenal glands Hyperadrenalism is characterized by excessive secretion of adrenal cortisol, mineralocorticoids, androgens, or estrogen in isolation or combination. The most common type of overproduction is due to glucocorticoid excess. When this is caused by pathophysiologic processes, the condition is known as Cushing disease. The term Cushing syndrome is a generalized state caused by excessive cortisol in the body, regardless of the cause. Disorders of the adrenal glands Adrenal insufficiency is divided into three categories: primary, secondary, and tertiary. Primary adrenocortical insufficiency, also known as Addison disease, occurs when the adrenal cortex is destroyed or the gland is removed. Secondary adrenocortical insufficiency is the consequence of pituitary disease or a lack of responsiveness of the adrenal glands to ACTH (corticotrophin) or caused by critical illness. Tertiary adrenal insufficiency results from processes that impair function of the hypothalamus, which is most commonly caused by chronic use of corticosteroids. Because abnormal adrenal function can be life threatening, these conditions are of significant concern in clinical practice. EPIDEMIOLOGY A dental practice serving 2000 adults can expect to encounter 50 patients who use corticosteroids or who have potential adrenal abnormalities. PATHOPHYSIOLOGY AND COMPLICATIONS Hypoadrenalism: Deficiencies of adrenocortical hormones produce signs and symptoms that are often nonspecific, or any symptoms unless the patient is significantly stressed and does not have adequate circulating cortisol during times surrounding stress. In this event, an adrenal crisis is possible. However, an adrenal crisis in a patient with secondary or tertiary adrenal suppression is rare and tends not to be as severe as that seen with primary adrenal insufficiency because aldosterone secretion is normal. Thus, hypotension, dehydration, and shock are seldom encountered. PATHOPHYSIOLOGY AND COMPLICATIONS Hyperadrenalism. Adrenal hyperfunction can produce four syndromes that are dependent on the adrenal product that is in excess—androgen, estrogen, mineralocorticoid, and cortisol. Androgen-related disorders are rare and primarily affect the reproductive organs. Mineralocorticoid excess (primary aldosteronism) is associated with hypertension, hypokalemia, and dependent edema. The most common form of hyperadrenalism is caused by glucocorticoid excess (endogenous or exogenous), and it leads to a syndrome known as Cushing syndrome. This syndrome classically produces weight gain, a broad and round face (“moon facies”) (Fig. 15.7), a “buffalo hump” on the upper back, abdominal striae, hypertension, hirsut- ism, and acne. PATHOPHYSIOLOGY AND COMPLICATIONS Cushing syndrome classically produces weight gain, a broad and round face (“moon facies”), a “buffalo hump” on the upper back, abdominal striae, hypertension, hirsutism, and acne. PATHOPHYSIOLOGY AND COMPLICATIONS Other findings may include glucose intolerance (e.g., diabetes mellitus), heart failure, osteoporosis and bone fractures, impaired healing, and psychiatric disorders (mental depression, mania, anxiety disorders, cognitive dysfunction, and psychosis). Longterm steroid use also may increase risks for insomnia, peptic ulceration, cataract formation, glaucoma, growth suppression, and delayed wound healing. dental management Patient assessment type of adrenal disorder Hyperadrenalism: Blood glucose levels should be determined and invasive procedures should be per- formed during periods of good glucose control. Follow-up appointments should be arranged to assess proper wound healing. Because of the risk of peptic ulceration, postoperative analgesics for longterm steroid users should not include aspirin and other nonsteroidal antiinflammatory drugs. Dental management of patients taking steroids The need for additional (i.e., supplemental) corticoster-oids for patients taking daily or alternate-day steroids to prevent adrenal crisis during and after surgery has been a concern ever since Fraser and colleagues reported in 1952 that a patient who had taken cortisone for 8 months experienced refractory hypotension at the end of a routine surgical procedure and died 3 hours later. A similar case was reported a year later. The general consensus for several decades was that “at-risk” patients who take corticosteroids should be provided supplemental steroids during periods of stress, trauma, or illnes Dental management of patients taking steroids Dental management of patients taking steroids Assess which type of insufficiency Bleeding is not an issue unless anticoagulant is taken Blood Pressure should be monitored patient follow-up Avoid phenobarbital use because it increases the metabolism of cortisol and reduces blood levels of cortisol. Also, discontinue use of phenytoin, rifampicin, troglitazone ketoconazole, fluconazole, etomidate, metyrapone, and aminoglutethimide (inhibitors of corticosteroid production) at least 24 hours before surgery, with the consent of the patient’s physician. Adrenal crisis blood pressure very low, below 100/60 mm hg occurs in adrenal insufficiency Immediate treatment during an adrenal crisis requires proper patient positioning (i.e., head lower than feet) fluid replacement administration of vasopressors administration of 100 mg of hydrocortisone or 4 mg of dexamethasone IV, and immediate transportation to a medical facility.