Endocrinology

Adrenal Disorders

Clinical overview and exam mastery guide for cortisol excess/deficiency, adrenal crisis emergency care, and hyperaldosteronism treatment.

Cushing
Excess cortisol
Addison
Low cortisol plus low aldosterone
Adrenal Crisis
Immediate IV hydrocortisone
Conn Syndrome
Aldosterone excess

Adrenal Axis Snapshot

Cortex cortisol aldosterone Medulla epinephrine norepinephrine Exam focus cortisol and aldosterone disorders Clinical split: excess, deficiency, and emergency decompensation Replace deficiency, block excess synthesis/effect, and treat crises immediately

Endocrine emergencies require treatment before full diagnostic completion.

1. Adrenal Physiology (Foundation First)

Cortex

  • Cortisol (glucocorticoid)
  • Aldosterone (mineralocorticoid)
  • Androgens

Medulla

  • Epinephrine
  • Norepinephrine
Most exam questions focus on cortisol and aldosterone disorders.

2. Cushing Syndrome (Excess Cortisol)

Causes

  • Exogenous steroid exposure (most common overall)
  • Pituitary adenoma (Cushing disease)
  • Adrenal tumor
  • Ectopic ACTH production

Clinical Features

  • Central obesity, moon facies, buffalo hump
  • Purple striae, hypertension, hyperglycemia
  • Osteoporosis and proximal muscle weakness
First-line strategy is treating the source (often surgery for a resectable tumor).
Drug MOA Major Side Effects Contraindications / Notes
Ketoconazole Inhibits adrenal steroidogenic enzymes and lowers cortisol synthesis Hepatotoxicity, GI upset Contraindicated in significant liver disease
Metyrapone 11-beta-hydroxylase inhibition decreases cortisol production Hypertension, hypokalemia Mineralocorticoid precursor accumulation can worsen BP/electrolytes
Mifepristone Glucocorticoid receptor antagonist; blocks cortisol effect, not level Hypokalemia, endometrial thickening Useful in Cushing syndrome with hyperglycemia

3. Addison Disease (Primary Adrenal Insufficiency)

Etiology and Features

  • Adrenal destruction (autoimmune, TB, hemorrhage)
  • Fatigue, weight loss, hypotension
  • Hyperpigmentation, hyponatremia, hyperkalemia

Replacement Therapy

  • Hydrocortisone for glucocorticoid replacement
  • Fludrocortisone for mineralocorticoid replacement
Drug MOA Major Side Effects Notes
Hydrocortisone Replaces cortisol activity Weight gain, hyperglycemia, long-term bone loss Foundation of adrenal insufficiency treatment
Fludrocortisone Mineralocorticoid receptor agonist replacing aldosterone effect Hypertension, hypokalemia, edema Required in primary adrenal insufficiency

4. Adrenal Crisis (Emergency)

Triggers and Features

  • Triggers: infection, surgery, abrupt steroid withdrawal
  • Severe hypotension/shock, hypoglycemia, hyponatremia

Immediate Management

  • 1. IV hydrocortisone immediately
  • 2. IV fluids
  • 3. Electrolyte correction
Do not delay treatment while waiting for confirmatory laboratory results.

5. Secondary Adrenal Insufficiency

Usually due to pituitary dysfunction or chronic exogenous steroid suppression. Aldosterone is typically preserved.

Treatment generally requires glucocorticoid replacement without mineralocorticoid replacement.

6. Primary Hyperaldosteronism (Conn Syndrome)

Clinical Pattern

  • Hypertension
  • Hypokalemia
  • Metabolic alkalosis

Treatment Branches

  • Bilateral disease: medical therapy (spironolactone)
  • Unilateral adenoma: surgical adrenalectomy

Spironolactone

  • MOA: mineralocorticoid receptor blockade reduces sodium retention and preserves potassium
  • Side effects: hyperkalemia, gynecomastia
  • Contraindications/caution: significant hyperkalemia or severe renal dysfunction

Management Recap Drill

Cushing: surgery when possible, medical cortisol control when needed.
Addison: hydrocortisone plus fludrocortisone replacement.
Adrenal crisis: immediate IV hydrocortisone and fluids.
Hyperaldosteronism: spironolactone for bilateral disease or surgery for unilateral adenoma.

Visual Algorithm Placeholder

[Insert Adrenal Disorder Diagnostic and Treatment Flowchart Here During UI Integration]

Guideline References (Management)

Endocrine Society Clinical Practice Guidelines

https://www.endocrine.org

Guideline Scope

  • Cushing syndrome management
  • Adrenal insufficiency replacement
  • Hyperaldosteronism therapy options

7. Common Exam Traps

Exogenous steroid exposure is the most common overall cause of Cushing syndrome.
Primary adrenal insufficiency often shows hyperpigmentation with hyperkalemia.
Adrenal crisis treatment must start immediately.
Secondary adrenal insufficiency usually does not need mineralocorticoid replacement.
Spironolactone is first-line medical therapy for bilateral primary hyperaldosteronism.

8. Quick Revision Summary

Must Remember

  • Cushing equals cortisol excess
  • Addison equals cortisol deficiency with mineralocorticoid loss in primary disease
  • Adrenal crisis requires urgent steroid and fluid therapy
  • Aldosterone excess drives hypertension and hypokalemia
  • Gradual steroid taper helps prevent HPA-axis suppression complications

Practice Questions Placeholder

  • Topic: Adrenal Disorders
  • Subtopics: Cushing syndrome, Addison disease, adrenal crisis, hyperaldosteronism, steroid tapering