Adrenal Disease

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Adrenal Disease

• Normal Anatomy
• and
• Physiology

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Adrenal Disease

• Objectives
• 1. To increase students working knowledge of
  adrenal anatomy, physiology and pathology
• 2. To incorporate this working knowledge into
  patient assessment and clinical decision making

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Adrenal glands cortex medulla
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• Adrenal Normal Physiology
• Adrenal medulla
• - ganglion of the sympathetic nervous system
• - secretes catecholamines
• epinephrine and norepinephrine

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• Adrenal Normal Physiology
• Adrenal medulla
• Catecholamine (epinephrine and norepinephrine)
  secretion in response to sympathetic stimulation
  fight or flight response

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• Adrenal Normal Physiology
• Adrenal cortex secretes steroid based hormones
• a. sex steroids
• b. mineralocorticoids
• c. glucocorticoids

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• Adrenal Normal physiology
• Sex steroids (testosterone)
• supplemental to gonadal
• production not crucial to life

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Adrenal Normal physiology b.
Mineralocorticoids control of Na / K / H20
blood pressure renin / angiotensin /
aldosterone CRUCIAL TO LIFE
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• Adrenal Normal physiology
• Regulation of Renin / Angiotensin / Aldosterone
• Renin secreted by JGA in response to BP or
• chronic Na depletion
• Renin catalyses the production of angiotensin I
  (a
• decapeptide) from a circulating protein
• 3. Angiotensin converting enzyme (ACE) in the
  lungs
• cleaves off 2 more amino acids to form
• Angiotensin II (an octapeptide)

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• Adrenal Normal physiology
• Renin / Angiotensin / Aldosterone
• Angiotensin II
• is a potent vasoconstrictor and
• it stimulates the release of aldosterone by the
  
• adrenal cortex
• Aldosterone acts on the collecting tubule to
  increase
• the reabsorption of Na (and, therefore H2O)

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• Adrenal Normal physiology
• Glucocorticoids
• -control of CHO / protein / fat metabolism
• -maintenance of vascular reactivity
• -anti-inflammatory
• -maintenance of homeostasis in response
• to stress (surgery, infection, starvation, etc.)
• CRUCIAL TO LIFE

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• Adrenal Normal physiology
• Glucocorticoids control of
• CHO / protein / fat metabolism
• insulin antagonist ( serum glucose)
• hepatic glucose output
• initiates lipolysis and proteolysis
• gluconeogenesis

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• Adrenal Normal physiology
• Glucocorticoids
• maintenance of vascular reactivity
• primes blood vessels to respond
• to catecholamine driven
• vasoconstriction

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• Adrenal Normal physiology
• Glucocorticoids anti-inflammatory
• inhibits lysosome, prostaglandin,
• eicosanoid, and cytokine release
• inhibits endothelial cell adhesion

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• Adrenal Normal physiology
• Glucocorticoids
• maintenance of homeostasis in
• response to physiologic stress
• (surgery, infection, starvation, etc.)

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Adrenal Normal physiology Steroid hormone
mechanism of action

• 1. cell entry
• 2. cytoplasmic
• receptor binding
• 3. migration to
• nucleus
• 4. DNA transcription
• mRNA migration
• to cytoplasm
• 6. mRNA translation
• 7. regulation of
• receptor number
• or activity

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1
3
4
6
5
2
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• Adrenal Normal physiology
• Steroid mechanism of action
• requires multiple steps for effect
• therefore, requires time to have
• an effect 2 to 4 hours

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• Adrenal Normal physiology
• Glucocorticoids regulation
• Normal diurnal variation (highest in AM)
• Daily average of approximately 20 mg

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• Adrenal Normal physiology
• Glucocorticoids regulation
• Increased secretion in response to
• physiologic stress (up to 200 mg)
• Decreased secretion in response to
• exogenous steroids, eg Prednisone

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Adrenal Normal physiology c.
Glucocorticoids regulation
STRESS OR DECREASING CORTISOL
EXOGENOUS STEROID OR INCREASING CORTISOL
CRH corticotropin releasing hormone
hypothalamus
CRH
anterior pituitary
ACTH
cortisol
adrenal cortex
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Adrenal Disease Hyperadrenalism
Hypoadrenalism Patients taking or have taken
oral steroids Will have 50 in 2000 patient
practice
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Adrenal Disease (hyper) Hyperadrenalism
(Cushingoid) Cushings disease excess
of cortisol production (eg pituitary or
adrenal tumour) with signs and symptoms of
excess steroid
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Adrenal Disease (hyper) Hyperadrenalism
(Cushingoid) Cushings syndrome Signs and
symptoms of excess steroid secondary to
chronic use
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• Adrenal Disease (hyper)
• Cushingoid side effects from excess
• long term steroids
• adrenocortical suppression
• weight gain, moon face, buffalo hump
• abdominal striae, acne

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• Adrenal Disease (hyper)
• Cushingoid side effects from excess
• long term steroids
• hypertension, heart failure
• osteoporosis, growth suppression
• diabetes, impaired healing, peptic ulcers
• depression, psychosis

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• Adrenal Disease (hypo)
• Adrenal insufficiency
• Primary Addisons disease (loss of
• gt90 of adrenal cortex) due to
• autoimmune, hemorrhage,
• infection, tumour, surgery, etc.
• Cortisol and Aldosterone deficiency

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• Adrenal Disease (hypo)
• Adrenal insufficiency
• Secondary hypothalamic or pituitary
• disease or exogenous steroid causing
• suppression of the hypothalamic /
• pituitary axis leading to atrophy of the
• adrenal cortex
• Cortisol deficiency only

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• Adrenal Pharmacology
• b. Glucocorticoids steroids indicated
• for inflammatory conditions such as
• rheumatoid arthritis (RA)
• systemic lupus erythematosis (SLE)
• asthma
• inflammatory bowel disease (IBD)
• prevention of organ transplant rejection
• many others

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Adrenal Pharmacology b. Glucocorticoids
equivalents Cortisol 20 mg
Prednisone 5 mg Solumedrol 4 mg
Decadron .75 mg
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• Adrenal Disease (hypo)
• c. Secondary Adrenal insufficiency
• IS caused by chronic oral steroid use
• gt 5 mg of Prednisone / day (gt 20 mg of
• cortisol) for gt 2 wks within the last year
• IS NOT caused by inhaled, nasal or topical
• steroid use

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• Adrenal Disease (hypo)
• c. Secondary Adrenal insufficiency
• Strategies used to minimize suppression
• minimize oral dosage to 20 mg/day
• equivalent of cortisol or less
• every other day dosing
• tapering dosage to complete course

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• Adrenal Disease (hypo)
• d. Adrenal insufficiency Problems
• impaired CHO / protein / fat metabolism
• hypoglycemia
• hypovolemia / hyperkalemia / acidosis
• hypotension

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• Adrenal Disease (hypo)
• d. Adrenal insufficiency Signs and
• symptoms
• excess pigmentation
• postural hypotension (dizziness)
• muscular weakness
• nausea, anorexia, weight loss

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• Adrenal Disease (hypo)
• d. Adrenal insufficiency diagnosis
• Signs and symptoms
• Lab values difficult to do and interpret
• CRH stimulation
• ACTH stimulation
• 24 hour urine cortisol

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• Adrenal Disease (hypo)
• d. Adrenal insufficiency treatment
• Treat the cause (tumour / infection)
• Hormone replacement
• mineralocorticoid
• glucocorticoid

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• Adrenal Pharmacology
• d. For mineralocorticoid insufficiency
• fludrocortisone (Florinef)
• 0.05 to 0.1 mg daily

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• Adrenal Pharmacology
• d. For glucocorticoid insufficiency
• Cortisol 20 mg AM / 10 mg PM
• Prednisone 5 mg AM / 2.5 mg PM
• (divided doses to reflect normal diurnal
• cycle)

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• Adrenal Crisis
• e. Acute Adrenal insufficiency crisis
• medical emergency
• inability to tolerate physiologic stress
• acute refractory hypotension, diaphoresis
• dehydration, dyspnea, hypothermia,
• hypoglycemia, circulatory collapse, death
• less likely with secondary AI

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• Adrenal Crisis prevention
• e. Acute Adrenal crisis prevention
• 1. Recognition of patient at risk
• Addisons disease
• Has taken suppressive dose
• Is taking low suppressive dose
• (Prednisone 10 mg or less)

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Adrenal Crisis prevention e. Acute Adrenal
crisis prevention 2. Supplement day before /
day of / day after 100 mg cortisol 20 mg
Prednisone or double the existing dose if 10
mg of Prednisone or less
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• Adrenal Crisis treatment
• e. Acute Adrenal crisis treatment
• Hydrocortisone 100 mg IV bolus
• Hospital setting for fluid and electrolyte
• replacement
• Correction of hypoglycemia
• Continued IV steroid

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• Adrenal Dental concerns
• Assess compliance with steroids
• 2. Assess need for supplementation
• complexity of surgery versus
• degree of adrenal suppression
• 3. Discontinue Ketoconazole and
• barbiturates if possible

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Adrenal Dental concerns 4. AM procedures 5.
Anxiety reduction eg N2O / O2 6. Good intra-
and post-op pain control avoid NSAIDs (Peptic
ulcers) 7. Monitor blood pressure 8. Cushingoid
patients prone to fractures
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Questions????
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Thyroid Disease

• Normal Anatomy
• and
• Physiology

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Thyroid Disease

• Objectives
• 1. To increase students working knowledge of
  thyroid anatomy, physiology and pathology
• 2. To incorporate this working knowledge into
  patient assessment and clinical decision making

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Thyroid gland
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Thyroid Normal Physiology Thyroid gland
produces 3 hormones T3 triiodothyronine T4
thyroxine Calcitonin controls Calcium levels
in conjunction with parathyroid hormone and
Vitamin D
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Thyroid Normal Physiology T3
triiodothyronine more potent form of thyroid
hormone 20 formed by the thyroid, 80 by
deiodination in the periphery T4 thyroxine
produced in the thyroid Thyroid hormone
formation is iodine dependant
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The Great Lakes area is endemically deficient in
iodine, for this reason iodine is added to the
table salt.
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Thyroid Normal Physiology Thyroid hormone
distribution produced and stored (3 to 4 month
reserve) in the thyroid gland secreted and
transported bound to thyroid globulin
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Thyroid Normal Physiology Thyroid hormone
effects controls oxidative metabolism and basic
metabolic rate growth and maturation of
tissues
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Thyroid Normal physiology Thyroid hormone
mechanism of action

• 1. cell entry
• 2. cytoplasmic
• receptor binding
• 3. migration to
• nucleus
• 4. DNA transcription
• mRNA migration
• to cytoplasm
• 6. mRNA translation
• 7. regulation of
• receptor number
• or activity

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1
3
4
6
5
2
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• Thyroid Normal physiology
• Thyroid hormone regulation
• Increased secretion in response to
• physiologic stress (cold, illness, etc)
• Decreased secretion in response to
• increased thyroid hormone levels

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Thyroid Normal physiology Thyroid hormone
regulation
STRESS / COLD OR DECREASING THYROID HORMONE
INCREASING THYROID HORMONE
TRH thryroid releasing hormone
hypothalamus
TRH
anterior pituitary
TSH
Thyroxine
thyroid gland
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• Thyroid Assessment
• Serum TSH
• Elevated in hypothyroidism
• Decreased in hyperthyroidism
• Most commonly performed screening
• test

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Thyroid Disease Hyperthyroidism
Hypothyroidism Thyroid masses benign /
malignant
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• Hyperthyroidism (thyrotoxicosis)
• Causes
• autoimmune (Graves disease)
• multinodular goitre
• thyroid adenoma
• subacute thyroiditis
• ingestion of TH (OD / factitial / food)
• anterior pituitary disease

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Hyperthyroidism (thyrotoxicosis) Graves
disease autoimmune - stimulatory anti-TSH
receptor anti- bodies resulting in continual
stimulation of thyroid hormone
production - 71 female to male ratio
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• Hyperthyroidism (thyrotoxicosis)
• Signs and symptoms
• nervousness, irritability, tremour
• fatigue, heat intolerance,
• weight loss, rosy complexion
• tachycardia, palpitations, atrial
• fibrillation, angina

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• Hyperthyroidism (thyrotoxicosis)
• Signs and symptoms
• - myxedemared, raised, puffy areas
• dyspnea due to muscle weakness
• diarrhea
• wide stare, lid lag

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• Hyperthyroidism (thyrotoxicosis)
• Signs and symptoms
• Graves ophthalmopathy
• - edema and inflammation of the extra-
• ocular muscles
• - increase in orbital connective tissue
• and fat
• - may be persistent and lead to loss
• of vision

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• Hyperthyroidism (thyrotoxicosis)
• Treatment
• Medical propylthiouracil blocks
• hormone synthesis in the thyroid
• and conversion of T4 to T3 in
• the periphery
• - B-blocker (propranolol) to control
• adrenergic symptoms

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Hyperthyroidism (thyrotoxicosis) Treatment -
Radioiodine ablation - Surgery
thyroidectomy Radio ablation will and surgery
might make the patient hypothyroid
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• Thyrotoxic crisis (thyroid storm)
• Acute hyperthyroid crisis risk factors
• more likely in patients who have long
• standing or poorly treated disease and
• in patients with goiter and eye signs
• precipitated by trauma, infection
• or surgery

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• Thyrotoxic crisis (thyroid storm)
• Acute hyperthyroid crisis S S
• extreme restlessness
• nausea, vomiting, abdominal pain
• fever, diaphoresis
• tachycardia, arrythmia
• pulmonary edema, congestive
• heart failure
• stupor, coma, hypotension death

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• Thyrotoxic crisis (thyroid storm)
• Acute hyperthyroid crisis treatment
• propylthiouracil (Propyl-Thyracil)
• potassium iodide (Thyro-Block)
• propranolol (Inderal)
• glucorticoids
• IV glucose, Vitamin B complex
• wet packs, ice packs, fans

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Hyperthyroidism (thyrotoxicosis) Dental
concerns - be aware of signs and symptoms -
assess compliance with medications - in
poorly controlled or newly diagnosed - avoid
epinephrine
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Hyperthyroidism (thyrotoxicosis) Dental
concerns - refer to MD if concerns exist -
prevent and manage infection - be alert to
SS of thyroid storm - treat as normal if well
controlled
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• Hypothyroidism
• Causes
• congenital agenesis or hypoplastic
• autoimmune (Hashimotos thyroiditis)
• iodine deficiency with goitre
• iodine excess
• post-radio ablation
• post-surgical ablation
• anterior pituitary disease

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• Hypothyroidism
• Signs and symptoms
• Congenital Neonatal cretinism
• Slowing of mental and physical
• activity, weakness
• - Cold intolerance
• - Constipation, weight gain

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• Hypothyroidism
• Signs and symptoms
• Dry skin, dry and brittle hair
• Loss of outer 1/3 of the eybrows
• - Puffy eyelids
• - Hoarse voice
• - Myxedema

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• Hypothyroidism
• Treatment
• T4 (L-thyroxin, Synthroid)
• Titrated until patient has
• normal TSH

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• Hypothyroid crisis
• Myxedematous Coma risk factors
• Seen in untreated or non-compliant
• patients
• Precipitated by cold, trauma, surgery,
• infections and CNS depressants
• More common in winter

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• Hypothyroid crisis
• Myxedematous Coma S S
• severe myxedema
• bradycardia
• severe hypotension

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• Hypothyroid crisis
• Myxedematous Coma treatment
• IV T4
• Steroids
• CPR

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Hypothyroidism Dental Concerns - be aware of
signs and symptoms - assess compliance with
medications - in poorly controlled or newly
diagnosed - use CNS depressants (sedatives
and narcotics) with caution
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Hypothyroidism Dental Concerns - refer to MD
if concerns exist - prevent and manage
infection - be alert to SS of myxedematous
coma - treat as normal if well controlled
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Thyroid masses Benign - goitre due to iodine
deficiency - enlargement due to Graves
disease - thyroiditis - thyroglossal duct
cyst - benign adenoma
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Thyroid masses Malignant - follicular
carcinoma - papillary carcinoma - anaplastic
carcinoma - other carcinomas
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Thyroid masses Malignant increased risk for
cancer if nodule is found - in patients
of a young age - in a male - with a history
of radiation exposure - with concommitant
dysnea, dysphagia or dysphonia (hoarseness)
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Thyroid masses Malignant increased risk for
cancer if nodule is found to - be a hard
fixed lump - be a single nodule - have
demonstrated rapid growth
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Thyroid masses Assessment - history -
clinical examination - thyroid function
tests - thryroid scan - fine needle
aspiration biopsy
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Thyroid cancer Treatment - radio ablation
with 131I - thyroidectomy /- neck
dissection - external beam radiotherapy for
persistent disease Does not cause
osteoradionecrosis of the jaws
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Questions????