Adrenal insufficiency is a deficit in the production of steroid hormones (glucocorticoids and mineralocorticoids) by the adrenal glands.
Glucocorticoids and mineralocorticoids are produced by the adrenal glands. This production of glucocorticoids is stimulated by another hormone called ACTH (adrenocorticotropic hormone) which is synthesized in the pituitary gland. In turn, the ACTH is stimulated by another hormone made by the hypothalamus. Mineralocorticoids regulate what substances like renin and angiotensin.
The cases of adrenal insufficiency can be divided into two groups: 1) those related to the inability of the adrenal glands themselves to manufacture these hormones in sufficient amount (Addison’s disease), and 2) secondary to insufficient ACTH production.
The most common cause of Addison’s disease is what is called autoimmune adrenalitis ie inflammation and destruction of the adrenal glands by antibodies against the adrenal glands that may appear occasionally accompanied by the involvement of other glands. Other causes of Addison’s disease are infections such as tuberculosis and others. There also causes bleeding in the case of Waterhouse-Friderichsen Syndrome or in cases associated with the use of anticoagulants. The metastatic tumors in other locations, the surgical removal of the adrenal or adrenal inhibitor therapy as mitotane, ketoconazole, aminoglutethimide or metyrapone stimulation may relate to primary adrenal insufficiency. At times there may be no destruction of the gland but the resistance to the action of ACTH by antibodies that block the action of ACTH so that the gland, although not synthesize or secrete healthy corticosteroids.
The causes of secondary adrenal insufficiency are due to threats of the pituitary or hypothalamus that present with lack of secretion of ACTH.
External Steroid treatment inhibits secretion of ACTH and secretion of corticosteroids by the adrenal glands.The same happens when a tumor of any other location that manufactures steroids. In these cases, when steroids are removed from the blood or because we no longer use the drug or because extirpate the tumor that will trigger a crisis produced adrenal glands as previously were inhibited.
In primary adrenal insufficiency will affect both glucocorticoids and mineralocorticoids, however in the case of secondary adrenal insufficiency only affect glucocoticoides.
The symptoms will result from glucocorticoid deficiency. Generally clinical manifestations usually appear gradually and include weakness, fatigue, weight loss, nausea, vomiting, abdominal pain usually mild diffuse character.
When the damage is also affected primary and mineralocorticoids. In this situation often added symptoms like craving for salt, and hypotension episodes of sickness especially when we get up after having spent time lying. These symptoms are due to sodium loss by mineralocorticoid deficiency.
In primary adrenal insufficiency usually be increased since the pituitary ACTH works well not detected in blood corticosteroids and ACTH production increases to stimulate production of corticosteroids. This produces an increase in the pigmentation of the skin in areas not exposed to sunlight.
Because the adrenal gland does not produce steroids in women may be missing pubic and underarm hair as they are the main source of androgens, unlike males where the main androgen is testosterone produced by the testes.
Other symptoms may also appear as calcifications in cartilage and joints.
Sometimes there may be an adrenal crises usually by a sharp fall in blood corticosteroids. It usually occurs when a patient is in drug treatment with steroids that inhibit the generation of corticosteroids by the adrenal gland and suddenly stop receiving such treatment, sometimes bleeding can occur by destruction of the adrenal glands or situations of excessive effort by the agency as serious infections, burns, etc.. In this case the symptoms include high fever, nausea, vomiting, severe hypotension and shock if not resolved.
Diagnosis is made by measuring the levels of cortisol in blood, which will be diminished. This is done after administration of Synthetic ACTH. Moreover, in case of primary insufficiency or Addison’s disease ACTH levels will be increased, but not in the case where the ACTH secondary failure is decreased.
Imaging tests such as abdominal ultrasound, and preferably CT or MRI of the abdomen may highlight morphological alterations of the gland.
Usually the treatment will be based on the substitution of corticoesteroideas hormones. In the case of primary failure or Addison’s disease is both glucocorticoid and mineralocorticoid adminsitrarán, while if it is secondary only be administered glucocorticoids. Generally the administration of glucocorticoids include pharmacological preparations based cortisone, hydrocortisone, prednisone or dexamethasone. Substitutes include fludrocortisone mineralocorticoids.
You must know that in times of stress such as surgery, trauma and others will require a dose increase so the patient should be trained to manage their medication.
In cases of secondary adrenal insufficiency generally glucocorticoid treatment are usually sufficient. Adrenal crisis is a medical emergency and requires high doses of intravenous cortisol and abundant hydration by sera in inpatient.
Prevention happens because individuals under prolonged corticosteroid treatment, they are not withdrawn abruptly, and the dose is increased under stress, such as infections, surgery, or trauma. In other cases, there is no possibility of disease prevention.
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