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Endocrine surgery
Published in Alexander Trevatt, Richard Boulton, Daren Francis, Nishanthan Mahesan, Take Charge! General Surgery and Urology, 2020
Ross M. Warner, Richard Boulton
Conn's syndrome = primary hyperaldosteronism.Aetiology: The most common cause is an adrenal adenoma.Signs and symptoms: Tiredness, weakness, thirst, polyuria, cramps, headaches and hypertension. It should be suspected in patients with hypertension (especially patients <40 years old with resistant hypertension – on three or more agents) and hypokalaemia.Investigations: Blood tests typically show hypokalaemia and hypernatraemia, with possible metabolic alkalosis. The diagnosis is confirmed with elevated aldosterone and suppressed renin levels (samples taken off medication). Imaging (CT or MRI) can sometimes identify the site of adenoma, although frequently adrenal venous sampling (AVS) is necessary for localisation.Management: Blood pressure control; spironolactone (aldosterone antagonist), adrenalectomy if lateralisation demonstrated on CT adrenal imaging and/or AVS.
Endocrinology
Published in John D Firth, Professor Ian Gilmore, MRCP Part 1 Self-Assessment, 2017
John D Firth, Professor Ian Gilmore
Patients with Cushing’s syndrome may have different presentations and features depending upon the cause. Most patients will have features that are more or less typical of Cushing’s, but those with ectopic ACTH from a malignant tumour or a malignant adrenal tumour may present rapidly with weight loss, hypertension, hypokalaemia, obvious tumour and features of its spread, and not much in the way of Cushingoid features. Patients with an adrenal adenoma do not have features of hyperandrogenaemia like hirsutism because benign adrenal tumours produce cortisol but not androgens. Absence of hirsutism and virilisation in a patient with other features of Cushing’s syndrome favours adrenal adenoma but needs further investigation. A normal MRI scan of the pituitary does not differentiate between different non-pituitary dependent causes of Cushing’s syndrome.
Endocrine tumours
Published in Brice Antao, S Irish Michael, Anthony Lander, S Rothenberg MD Steven, Succeeding in Paediatric Surgery Examinations, 2017
Michael Skinner, Eduardo Perez
The treatment of a functional adrenal adenoma is excision. The mortality rate from operative removal is generally less than 1%, with a cure rate of 75%. Laparoscopic adrenalectomy is now the preferred approach for benign functioning adrenal tumours. Treatment of patients with bilateral adrenal hyperplasia is with spironolactone.
Adrenocortical carcinoma arising from the colonic mesentery
Published in Baylor University Medical Center Proceedings, 2022
Samuel Z. See, Sinan Ali Bana, Nuvaira Ather, Amy Haberman
Clinical presentation depends on whether the tumors are functioning or nonfunctioning. Patients with functioning tumors typically present with symptoms of the Cushing syndrome and/or virilization.8 Many nonfunctioning tumors are detected incidentally on radiographic studies performed for another reason. Imaging generally shows an inhomogeneous hypervascular tumor with irregular margins with or without necrosis and hemorrhage.9,10 Biopsy and subsequent histopathologic evaluation are required for diagnosis. Immunohistochemistry findings of positive alpha-inhibin, Melanin-A, and SF-1 can confirm the primary adrenal origin.11 The Modified Weiss Criteria use histopathologic characteristics to differentiate an adrenal adenoma from carcinoma. These characteristics include a mitotic rate >5 per 50 high-power fields, clear cytoplasm compromising ≤25% of the tumor, abnormal mitoses, necrosis, and capsular invasion, with each criterion receiving a score of 0 when absent and 1 when present. Using the formula 2× mitotic rate criterion + 2× clear cytoplasm criterion + abnormal mitoses + necrosis + capsular invasion, a score of 3 or more suggests malignancy.12
Clinical characteristics of concurrent primary aldosteronism and renal artery stenosis: A retrospective case–control study
Published in Clinical and Experimental Hypertension, 2021
Xu Meng, Yan-Kun Yang, Yue-Hua Li, Peng Fan, Ying Zhang, Kun-Qi Yang, Hai-Ying Wu, Xiong-Jing Jiang, Jun Cai, Xian-Liang Zhou
In the PA with RAS group, RAG or CT renal angiography confirmed that the degree of RAS was greater than 70% in at least one lesion. Six lesions were present in left renal arteries and four in right renal arteries. The most frequently involved vessel was the ostial renal artery (n = 7). Two other lesions were present in proximal renal arteries, and diffuse involvement of the entire artery was noted in one patient. Analysis of the radiological findings for the lesions showed that peripheral atherosclerosis was diagnosed in eight patients and was the most common cause among the 10 patients. The remaining two patients received diagnoses of Takayasu arteritis and fibromuscular dysplasia (n = 1, each). Adrenal adenoma and adrenal hyperplasia were the most common types of adrenal mass diagnosed by at least two experienced radiologists. Eight lesions were present on the left side and three on the right side (one patient had bilateral adrenal hyperplasia). AVS was performed in five patients, four of which had positive results that met the surgical indications for unilateral adrenalectomy. The remaining five patients declined to undergo AVS. The results of RAG and CT renal angiography are shown in Table 2.
Adrenal disorders in pregnancy, labour and postpartum – an overview
Published in Journal of Obstetrics and Gynaecology, 2020
Madhavi Manoharan, Prabha Sinha, Shabnum Sibtain
Treatment of adrenal adenoma includes medical or surgical (unilateral adrenalectomy) therapy after delivery. Surgery is ideally carried out during the second and rarely in the third trimester. The perioperative complication of adrenalectomy varies between 1.7% and 30.7% (Aporowicz et al. 2018). Bilateral adrenelectomy is also associated with a higher complication rate. Left and right adrenelectomy is associated with different risks, due to asymmetry of the abdomen. Left adrenelectomy is associated with injury to surrounding vascular structures like inferior venacava, spleen, splenic vessels and colon. There is an increased risk of metabolic complications and respiratory insufficiency. These women are also at increased risk of wound infection; poor wound healing, deep vein thrombosis and pulmonary embolism due to anti-inflammatory and immune suppressive effects of cortisol. Surgical treatment reduces maternal and fetal morbidity with live births close to 87%; however, it does not reduce the incidence of preterm birth or growth restriction (Choi et al. 2011; Lekarev and New 2011; Toutounchi et al. 2011; Tomaszewski and Dewailly 2012; Sammour et al. 2012; Nassi et al. 2015).