Hypercortisolism

medications

(medications control manifestations but do not effect a cure) 1. Mitotane 2. Aminoglutethimide 3. Ketoconazole 4. somatostatin analog (octreotide)

adrenalectomy: postoperative care

-V.S., I&O,monitor electrolytes especially 48hrs post-op. -bilateral adrenalectomy results in adrenal insufficiency. Addisonian crisis & hypovolemic shock may occur. cortisol given to replace inadequate levels post op. -assess: temp,WBC count, wound drainage.

adrenalectomy: preoperative care

-discuss diet high in vitamins, protein, and K if hypokalemic. ( excess glucocorticoid increases catabolism) -use medical and surgical asepsis -correct electrolyte and glucose imbalances -teach; turn cough and deep breath d/t high risk infection

causes

1. iatrogenic cushing's syndrome 2. pituitary form (cushing's disease) 3. ectopic form from ACTH-secreting tumors 4. adrenal form from cortisol- secreting adrenal tumor.

diagnostic tests

1. late night salivary cortisol test will be increased in cushing's 2. Abdominal CT scan (assess for tumors) 3. Abdominal MRI (assess for tumors) 4. BUN will be increased in addison's disease (adrenal hypofunction) 5. Sodium will be increased in cushing's (adrenal hyperfunction) 6. Potassium will be increased in cushing's 7. serum glucose will be increased in cushing's 8. urinary free cortisol (UFS) will be increased in cushing's

pituitary form (cushing's disease)

with ACTH hypersecretion by a benign tumor of the pituitary. most commonly caused by a small pituitary adenoma.

risk factors

women 30-50 years. taking long term steroids (e.g. treatment of arthritis,organ transplant, adjunct to chemotherapy).

assessment

health Hx: history of pituitary, adrenal,pancreatic, or pulmonary tumor. frequent infections, GI bleeding, stress fractures, pain, changes in weight distribution and height, fatigue, weakness, bruising, skin infections, menstrual history, sexual function. physical: V.S. behavior, appearance, fat distribution, face, skin, hair distribution, muscle size and strength and gait

cushings syndrome have increased risk for infection. elevated cortisol levels causes:

impaired immune response, infection, affects protein synthesis, delayed wound healing and inhibits collagen formation, epidermal atrophy, impaired blood flow to edematous tissue, altered cellular nutrition. teach importance of increased intake of protein, vitamin A and vitamin C to help support collagen formation.

cushings syndrome have increased risk for injury. excess cortisol levels causes:

increased calcium absorption, demineralization of bones, increased risk of fractures, weakness, fatigue and falls.

Aminoglutethimide and/or Ketoconazole

inhibits cortisol synthesis by the adrenal cortex. administered for ectopic ACTH-secreting tumors that can't be surgically removed.

manifestations

result from the ACTH or cortisol excess and manifests as exaggerated cortisol actions. obesity,fat redistribution, central obesity, buffalo hump, moon face, changes in protein metabolism,muscle weakness/ wasting in extremities, fibroblasts inhibited, loss of collagen and connective tissue, thinning of skin, abdominal striae, easy bruising,poor wound healing, frequent skin infections,altered glucose metabolism,DM, electrolyte imbalances, calcium malabsorption, osteoporosis, compression fractures,renal calculi, hypokalemia, hypertension (as K lost and Na retained), hirsutism, menses irregularities,

Iatrogenic form

results from long-term therapy with glucotorticoids

Somatostatin analog (octreotide)

Suppresses ACTH secretion in some patients

surgery

1. Adrenalectomy with one adrenal gland usually involved in an adrenal cortex tumor. 2. bilateral adrenalectomy when ACTH-producing ectopic tumor is involved. requires lifelong hormone replacement. 3. hypophysectomy (transsphenoidal route or by craniotomy) is removal of pituitary gland.

hypercortisolism (cushing's syndrome)

A CONDITION RESULTING FROM THE HYPERSECRETION OF GLUCOCORTICOIDS (circulating cortisol or ACTH) FROM THE ADRENAL CORTEX.

late night salivary cortisol test

First collect saliva specimen at 11pm then give dexamethasone 1mg PO (it will suppress ACTH) .Then collect serum cortisol at 8am the next morning.If extremely high dose of dexamethasone is needed to suppress ACTH, then the primary disorder is adrenal cortex hyperplasia. If ACTH is not suppressed, an adrenal tumor is suspected. pg 508

ectopic form

caused by ACTH-secreting tumors (small cell lung cancer). ACTH hypersecretion is greater than in the pituitary form (cushing's disease).

fluid volume excess

cushing's syndrome causes excess cortisol secretion, which then causes sodium and water reabsorption and volume excess. patient will have weight gain, edema, and hypertension. -1liter of fluid retention= 2lbs (0.9kg) of body weight -ECF excess is manifested by hypertension, bounding and rapid pulse, crackles, wheezes, dependent edema and/ or JVD. -restrict fluids

Mitotane

directly suppresses activity of adrenal cortex and decreases peripheral metabolism of corticosteroids. treats metastatic adrenal cancer.

complications

electrolyte imbalances (hyperglycemia, hypernatremia, hypokalemia), hypertension, and emotional disturbances, increased susceptibility to infections, disabilities from fractures, and acute deficit of cortisol (addison's crisis) from bilateral adrenalectomy.

adrenal form

excessive cortisol secretion by an adrenal tumor. excess secretion suppresses the pituitary ACTH production, resulting in atrophy of the uninvolved adrenal cortex.