What is adrenal insufficiency?

Adrenal insufficiency means that there are not enough adrenal hormones.
Without the right levels of these hormones, your body cannot maintain
essential life functions.
Adrenal insufficiency may be permanent or temporary. When AI is
permanent, medication must be taken daily for the rest of the patient's life.

Causes of permanent AI include the following:

• Addison Disease
• Congenital adrenal hyperplasia
(CAH) discovered in childhood
• complete surgical removal of the
pituitary gland
• surgical removal of the adrenals.

Temporary adrenal insufficiency is brought on by physical stress, infection,

surgery, or when the proper medication is not taken.

Causes of temporary AI include the following:

• transsphenoidal surgery for Cushing
disease that removes a tumor from
the pituitary gland
• removal of a tumor that has been
causing the adrenal glands to make
too much cortisol
• medical treatment for Cushing
Syndrome with drugs that lower
cortisol levels.
• medical treatment with steroids for
prolonged periods of time

Signs and Symptoms

• unusual tiredness and weakness

• dizziness when standing up
• nausea, vomiting, diarrhea
• loss of appetite
• stomach ache.
• weight loss
 • darkened skin
• craving for salt

Cushing's Syndrome
Cushing’s disease is a condition in which the pituitary gland releases too
much adrenocorticotropic hormone (ATCH). The pituitary gland is an organ
of the endocrine system.
Cushing's disease is a form of Cushing syndrome.
Causes
Cushing's disease is caused by a tumor or excess growth (hyperplasia) of
the pituitary gland. This gland is located at the base of the brain.
People with Cushing's disease have too much ACTH. ACTH stimulates the
production and release of cortisol, a stress hormone. Too much ACTH
means too much cortisol.
Cortisol is normally released during stressful situations. It controls the
body's use of carbohydrates, fats, and proteins and also helps reduce the
immune system's response to swelling (inflammation).
Symptoms
Symptoms usually include:
• Upper body obesity (above the waist) and thin arms and legs
• Round, red, full face (moon face)
• Slow growth rate in children
Skin changes that are often seen:
• Acne or skin infections
• Purple marks (1/2 inch or more wide) called striae on the skin of the
abdomen, thighs, and breasts
• Thin skin with easy bruising
Muscle and bone changes include:
• Backache, which occurs with routine activities
• Bone pain or tenderness
• Collection of fat between the shoulders (buffalo hump)
• Thinning of the bones, which leads to rib and spine fractures
• Weak muscles
Women often have:
 • Excess hair growth on the face, neck, chest, abdomen, and thighs
• Menstrual cycle becomes irregular or stops
Men may have:
• Decreased fertility
• Decreased or no desire for sex
• Impotence
Other symptoms that may occur include:
• Mental changes, such as depression, anxiety, or changes in behavior
• Fatigue
• Headache
• High blood pressure
• Increased thirst and urination
Exams and Tests:
• Blood ACTH level
• Brain MRI
• Corticotropin-releasing hormone test, which acts on the pituitary
gland to cause the release of ACTH
• Dexamethasone suppression test (high dose)
• Petrosal sinus sampling - measures ACTH levels in the veins that
drain the pituitary gland

Treatment:
Treatment involves surgery to remove the pituitary tumor, if possible. After
surgery, the pituitary may slowly start to work again and return to normal.
During the recovery process, you may need cortisol replacement
treatments. Radiation treatment of the pituitary gland may also be used.
If the tumor does not respond to surgery or radiation, you may get
medications to stop your body from making cortisol.
If these treatments are not successful, the adrenal glands may need to be
removed to stop the high levels of cortisol from being produced.
Outlook (Prognosis)
Untreated, Cushing's disease can cause severe illness, even death.
Removal of the tumor may lead to full recovery, but the tumor can grow
back.
Possible Complications:
• Compression fractures
• Diabetes
• High blood pressure
• Infections
• Kidney stones
• Psychosis

ADRENAL INSUFFICIENCY
Addison’s disease
is a disorder that occurs when the adrenal glands do not produce
enough of their hormones.

Causes:
The adrenal glands are small hormone-secreting organs located on top of
each kidney. They consist of the outer portion (called the cortex) and the
inner portion (called the medulla).
The cortex produces 3 types of hormones:
• The glucocorticoid hormones (such as cortisol) maintain sugar
(glucose) control, decrease (suppress) immune response, and help
the body respond to stress.
 • The mineralocorticoid hormones (such as aldosterone) regulate
sodium and potassium balance.
• The sex hormones, androgens (male) and estrogens (female), affect
sexual development and sex drive.
Addison's disease results from damage to the adrenal cortex. The damage
causes the cortex to produce less of its hormones.
This damage may be caused by the following:
• The immune system mistakenly attacking the gland (autoimmune
disease)
• Infections such as tuberculosis, HIV, or fungal infections
• Hemorrhage, blood loss
• Tumors
• Use of blood-thinning drugs (anticoagulants)

Symptoms:
• Changes in blood pressure or heart rate
• Chronic diarrhea
• Darkening of the skin - patchy skin color
• Unnaturally dark color in some places
• Paleness
• Extreme weakness
• Fatigue
• Loss of appetite
• Mouth lesions on the inside of a cheek (buccal mucosa)
• Nausea and vomiting
• Salt craving
• Slow, sluggish movement
• Unintentional weight loss
Exams and Tests:
• Increased potassium
 • Low blood pressure
• Low cortisol level
• Low serum sodium
• Normal sex hormone levels
Other tests may include:
• Abdominal x-ray
• Abdominal CT scan
Treatment:
Treatment with replacement corticosteroids will control the symptoms of
this disease. However, you will usually need to take these drugs for life.
People often receive a combination of glucocorticoids (cortisone or
hydrocortisone) and mineralocorticoids (fludrocortisone).

Possible Complications:
Complications also may result from the following related illnesses:
• Diabetes
• Hashimoto's thyroiditis (chronic thyroiditis)
• Hypoparathyroidism
• Ovarian hypofunction or testicular failure
• Pernicious anemia
• Thyrotoxicosis
Pheochromocytoma
Tumors of the adrenal medulla secrets increased amount of
catecholamines
A small tumor in the adrenal gland that secretes large amounts of
epinephrine and norepinephrine.
Sing and Symptoms:

 hyperglycemia
 cardiac arrhythmia and CHF

Diagnostic test :
 vanillymandalic (VMA) in 24hrs urine

 End product of catecholamine metabolism

 Drugs and food to be with held 24hrs before the test:
 Coffee and tea

banana
vanilla

chocolates
Management:

 surgery
Nursing Care:

 monitor BPin supine and standing

 monitor for glucose and acetone

Primary aldosteronism

A condition which the body’s adrenal glands produce too much

aldosterone, causing loss potassium and sodium retention. The excess
sodium in turn holds onto water, increasing blood volume and blood
pressure.

Signs and Symptoms:

• hypokalemia
• increases neuromuscular
• irritability and produces muscle weakness
• fatigue
• Headaches
• Paresthesia
• flaccid paralysis
• elevated BP
Causes:
Common conditions causing the overproduction of aldosterone include:
• A benign growth (aldosteronoma) in an adrenal gland — a condition
also known as Conn's syndrome
• Overactivity of both adrenal glands (bilateral adrenal hyperplasia)
In rare cases, primary aldosteronism may be caused by:
• Cancerous (malignant) growths in the outer layer (cortex) of the
adrenal gland
• Genetic mutations
• A rare type of primary aldosteronism called glucocorticoid-remediable
aldosteronism (GRA) that runs in families and causes high blood
pressure in children and young adults

Complications:
The most serious complication of primary aldosteronism is high blood
pressure. Untreated high blood pressure can lead to:
• Heart attack
• Heart failure
• Left ventricular hypertrophy — enlargement of the muscle that makes
up the wall of the left ventricle, your heart's main pumping chamber
• Stroke
• Kidney disease or kidney failure
• Premature death

Tests and Diagnosis:

• Oral salt loading. You'll follow a high-sodium diet for three days
before your doctor measures aldosterone and sodium levels in your
urine.
• Saline loading. Your aldosterone levels are tested after sodium mixed
with water (saline) is infused into your bloodstream for several hours.
• Fludrocortisone suppression test (FST). After you've followed a high-
sodium diet and taken fludrocortisone — which mimics the action of
 aldosterone — for three days, aldosterone levels in your blood are
measured.
• Abdominal computerized tomography (CT) scan. A CT scan can help
identify a tumor on your adrenal gland or an enlargement that
suggests overactivity.
• Adrenal vein sampling. This is the most reliable test for determining
the cause of primary aldosteronismLifestyle and home remedies,
Management:
• Follow a healthy diet. Limit the sodium in your diet by focusing on
fresh foods and reduced-sodium products, avoiding condiments, and
removing salt from recipes. Diets that also emphasize a healthy
variety of foods — including grains, fruits, vegetables and low-fat
dairy products — can promote weight loss and help to lower blood
pressure. Try the Dietary Approaches to Stop Hypertension (DASH)
diet — it has proven benefits for your heart.
• Achieve a healthy weight. If your body mass index (BMI) is 25 or
more, losing as few as 10 pounds may reduce your blood pressure.
• Exercise. Regular aerobic exercise seems to lower blood pressure in
some people, even without weight loss. You don't have to hit the gym
— taking vigorous walks most days of the week can significantly
improve your health. Try walking with a friend at lunch instead of
dining out.
• Don't smoke. If you smoke, stop. Nicotine in tobacco makes your
heart work harder by temporarily constricting your blood vessels and
increasing your heart rate and blood pressure. Talk to your doctor
about medications that can help you stop smoking.
• Limit alcohol and caffeine. Both substances can raise your blood
pressure, and alcohol can interfere with the effectiveness of some
blood pressure medications. Ask your doctor whether moderate
alcohol consumption is safe for you.
Glossary Terms
abdomen:
Also referred to as the belly. It is the part of the body that contains all of the internal structures
between the chest and the pelvis.

adrenal:
Glands that reside above the kidneys composed of an inner medulla and an outer cortex.

adrenal cortex:
The outer layer of the adrenal gland.

adrenal gland:
One of a pair of small glands, each of which sits on top of one of the kidneys. These glands
produce hormones that help control heart rate, blood pressure, the way the body uses food and
other vital functions.

adrenal medulla:
Inner portion of the adrenal gland.

adrenaline:
Also known as epinephrine. Hormone secreted in the adrenal gland that raises blood pressure,
produces a rapid heartbeat and acts a neurotransmitter when the body is subjected to stress or
danger.

aldosterone:
An adrenal hormone critical for salt (sodium) balance. Produced by the outer part of the
adrenal cortex, its action causes a reabsorption of sodium and secretion of potassium and is
critical for the maintenance of blood pressure.

alpha-adrenergic blockers:
 Also known as alpha-blockers. Drugs used to treat high blood pressure and other conditions
like an enlarged prostate or stress urinary incontinence.

anesthesia:
Loss of sensation in any part of the body induced by a numbing or paralyzing agent. Often
used during surgery to put a person to sleep.

anxiety:
A feeling of apprehension, often characterized by feelings of stress.

benign:
Not malignant; not cancerous.

cancer:
An abnormal growth that can invade nearby structures and spread to other parts of the body
and may be a threat to life.

catecholamine:
Type of organic compound.

cortex:
The outer layer of an organ.

cortisone:
A hormone secreted by the adrenal gland and used to treat rheumatoid arthritis and allergies.

CT scan:
Also known as computerized tomography, computerized axial tomography or CT scan. A
diagnostic imaging procedure that uses a combination of X-rays and computer technology to
produce cross-sectional images of the body. Shows detailed images of any part of the body,
including bones, muscles, fat and organs. CT scans are more detailed than general X-rays.

degradation products:
Something made to decline to a lower condition, quality or level.

diagnosis:
The process by which a doctor determines what disease or condition a patient has by studying
the patient's symptoms and medical history, and analyzing any tests performed (e.g., blood tets,
urine tests, brain scans, etc.).

endocrine:
Relating to glands that secrete hormones internally directly into the lymph nodes or
bloodstream.
endocrine glands:
Any gland of the body that secretes hormones directly into the lymph nodes or bloodstream.

epinephrine:
Also known as adrenaline. Hormone secreted in the adrenal gland that raises blood pressure,
produces a rapid heartbeat and acts as a neurotransmitter when the body is subjected to stress
or danger.

gland:
A mass of cells or an organ that removes substances from the bloodstream and excretes them
or secretes them back into the blood with a specific physiological purpose.

glucagons:
A hormone responsible for helping maintain proper blood sugar levels.

high blood pressure:

Medical term is hypertension.

histamine:
A hormone transmitter involved in local immune response regulating stomach acid production
and in allergic reactions.

hormone:
A natural chemical produced in one part of the body and released into the blood to trigger or
regulate particular functions of the body. Antidiuretic hormone tells the kidneys to slow down
urine production.

hypertension:
High blood pressure, which can be caused either by too much fluid in the blood vessels or by
the narrowing of blood vessels.

hypertensive:
Having high blood pressure.

incision:
Surgical cut for entering the body to perform an operation.

invasive:
Having or showing a tendency to spread from the point of origin to adjacent tissue, as some
cancers do. Involving cutting or puncturing the skin or inserting instruments into the body.

ions:
Electrically charged atoms.
kidney:
One of two bean-shaped organs that filter wastes from the blood and discharge these waste
products in urine. The kidneys are located on either side at the level of the 12th ribs toward the
back. The kidneys send urine to the bladder through tubes called ureters.

kidneys:
One of two bean-shaped organs that filter wastes from the blood and discharge these waste
products in urine. The kidneys are located on either side at the level of the 12th ribs toward the
back. The kidneys send urine to the bladder through tubes called ureters.

laparoscope:
An instrument in the shape of a tube that is inserted through the abdominal wall to give an
examining doctor a view of the internal organs.

laparotomy:
An operation in which the abdominal cavity is opened and inspected directly.

medulla:
The innermost area of an organ.

meta-iodobenzylguanidine:
A radioisotope.

metastatic:
Cancer that has metastasized, in other words, spread to other parts of the body.

MRI:
Also referred to a magnetic resonance imaging. A diagnostic procedure that uses a
combination of large magnets, radiofrequencies and a computer to produce detailed images of
organs and structures within the body.

pharmacologic:
Reaction to drugs.

pheochromocytoma:
A tumor of the adrenal gland, which is typically benign (non-cancerous).

renal:
Pertaining to the kidneys.

thyroid:
An endocrine gland located in the neck that secretes the hormones responsible for controlling
metabolism and growth.
tumor:
An abnormal mass of tissue or growth of cells.

tyramine:
Normal substance in the body that helps support blood pressure.

urge:
Strong desire to urinate.

urine:
Liquid waste product filtered from the blood by the kidneys, stored in the bladder and expelled
from the body through the urethra by the act of urinating (voiding). About 96 percent of which
is water and the rest waste products.

urologist:
A doctor who specializes in diseases of the male and female urinary systems and the male
reproductive system.

Addison disease
An illness caused by the failure of the
adrenal glands to secrete enough adrenal
hormones.

Adrenal glands
Two glands, each located above a kidney,
that secrete cortisol and other
essential hormones.

Aldosterone
A hormone made by the adrenal glands
that regulates salt, potassium, and water
in the body.

Congenital Adrenal Hyperplasia (CAH)

A deficiency of adrenal hormones that is
present from birth.
Cortisol
A hormone secreted by the adrenal
glands that regulates carbohydrate and
protein metabolism.

Cushing disease
A pituitary tumor that makes too much
ACTH and causes Cushing syndrome
Cushing syndrome
An illness caused when too much cortisol
is made by the adrenal glands.

Glucocorticoid
A hormone that is produced by the adrenal
cortex that is involved in carbohydrate,
protein, and fat metabolism and
has anti-inflammatory properties

Hydrocortisone
A form of cortisol. This is the drug used
to replace cortisol in the body.

Transsphenoidal surgery
Highly specialized neurosurgery in which
tumors are removed from the pituitary
gland.