Heal your Adrenals with this Easy Program

Adrenal Fatigue Recovery Workbook

This valuable book gives you all of the tools that you need in order to identify, manage, and treat the symptoms of adrenal fatigue syndrome. AFS is a medical problem that most doctors don't really know how to diagnose. The symptoms are often seen as being too vague to mean anything to medical professionals, and therefore people who suffer from this debilitating condition often suffer alone, and without medication. And those that DO get medicated often get put on something useless for this condition such as antidepressants or sleeping pills, which just add issues on to what you are already experiencing. If you are feeling down, tired, or depressed for no reason, there is a good chance that you are suffering from Adrenal Fatigue Syndrome There is no need for you to bear that alone! Why would you want to do that when you have a valuable resource in your hands? This book has everything you need to get help!

Adrenal Fatigue Recovery Workbook Summary


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A104 Adrenocorticotrophic hormone and the adrenal gland

The adrenal glands are located on the top of each kidney (see Figure A12). Each adrenal gland consists of a central medulla and an outer cortex. Decreased activity of the adrenal gland leads to Addison's disease. This was common following tuberculosis affecting the adrenal gland when both the medulla and cortex were affected. In Addison's disease, sodium and water are lost from the body and this causes a lowering of blood pressure, muscle weakness, nausea, and vomiting. The production of

Modalities for Imaging the Adrenal Gland

Evaluation of a patient with an adrenal gland mass is founded on a thorough history and physical examination, followed by appropriate biochemical tests. After the diagnosis has been established, imaging procedures are used for localization and presurgical planning. Improvements of functional and anatomic imaging procedures allow reliable preoperative evaluation of virtually all adrenal masses. Computed tomography (CT) and magnetic resonance imaging (MRI) are the main modalities used to localize adrenal tumors. The best radiologic imaging test is CT scanning, and it is usually the only imaging study required. In this chapter, we review adrenal imaging techniques and discuss their indications and limitations. We also present flowcharts showing how the most prevalent adrenal diseases, including incidentaloma of the adrenal gland, should be approached. CT is the modality most commonly used to evaluate a patient suspected of having an adrenal mass.1 CT accurately delineates the location,...

Incidentalomas of the Adrenal Gland and Adrenocortical Carcinoma

Pheochromocytoma Mri

The frequent use of imaging procedures, especially ultrasonography and CT, results in the discovery of unsuspected adrenal masses. So-called incidentalomas or adrenalomas are the most common reason the clinician becomes concerned about the adrenal gland. Incidentalomas have been found in 0.6 to 4.3 of patients or at autopsy.4243 The major concern when evaluating a patient with an inciden-taloma is whether the tumor is functioning and whether it is benign or malignant (Fig. 66-9). The most common cause of nonfunctioning adrenal masses is cortical adenomas, followed by metastases to the adrenals, myelolipomas, ganglioneuromas, adrenal cysts, and a multitude of other rare findings, some of which have specific CT and MRI characteristics. Of all incidentally discovered masses, 6.5 are pheochromocytomas45 and FIGURE 66-8. The flowchart shows the diagnostic procedures used in imaging the adrenal glands for a suspected pheochromocytoma. FDG 2-fluorine-18-fluoro-2-deoxy-D-glucose MIBG...

Incision of Gerotas Fascia Between the Upper Pole of the Kidney and the Adrenal Gland

Gerota Fascia Located

The posterior aspect of Gerota's fascia is incised transversely at the level of the upper pole of the kidney (Fig. 6). The aim of the ensuing dissection is to circumferentially mobilize the upper pole and mid-region of the kidney and the covering Gerota's fascia. The upper pole is now dropped posteriorly onto the psoas muscle away from the adrenal gland. This dissection proceeds immediately adjacent to the parenchyma of the upper pole of the kidney. Care must be taken not to injure any accessory vessel entering the upper pole of the kidney. At this juncture, the unmobilized adrenal gland is still located in its normal position, attached anteriorly to the parietal peritoneum. Careful blunt and sharp dissection is performed toward the renal hilum, between the upper pole of the kidney posterolaterally and the adrenal anteromedially. The caudal limit of this dissection is the renal hilar vessels, usually, the superior branch of the renal artery. Multiple small renal hilar vessels...

Physiology anatomy and biochemistry of the adrenal gland

Adrenal Glands Anatomy

The adrenal gland is located on the upper segment of the kidney (Fig. 45-1).1 It consists of an outer cortex and an inner medulla. The adrenal medulla secretes the catecholamines epinephrine (also called adrenaline) and norepinephrine (also called noradrenaline), which are involved in the regulation of the sympathetic nervous system. The adrenal cortex consists of three histologically distinct zones the zona glom-erulosa, zona fasciculata, and an innermost layer called the zona reticularis. Each zone is responsible for production of different hormones (Fig. 45-2). FIGURE 45-1. Anatomy of the adrenal gland. (From Ref. 23.) FIGURE 45-1. Anatomy of the adrenal gland. (From Ref. 23.) The zona reticularis produces the androgens andro-stenedione, dehydroepiandros-terone (DHEA), and the sulfated form of dehydroepiandrosterone (DHEA-S). Only a small amount of testosterone and estrogen are produced in the adrenal glands. Androstenedione and DHEA are converted in the periphery, largely to...

Adrenal Glands

The adrenal (suprarenal) glands consist of a cortex (secretes mineralocorticoids, glucocorticoids, and androgens) and a medulla (secretes adrenalin). The adrenal glands lie at the T12 vertebral level, on the superior pole of each kidney, and are separated from the kidneys by the renal capsule. The left adrenal gland is positioned more medially than the right adrenal gland (Figure 11-5). Vascular supply. Each gland receives an arterial supply from three arteries superior adrenal artery (branch of the inferior phrenic artery), middle adrenal artery (branch of the aorta), and inferior adrenal artery (branch of the renal artery). Venous drainage of the right adrenal gland empties directly into the inferior vena cava, whereas that of the left adrenal gland empties into the left renal vein. Innervation. Sympathetic nerves innervate the adrenal medulla. The least splanchnic nerve, through the aorticore-nal ganglion, provides innervation. However, unlike other organs innervated by the...

Should I or My Child Receive Sedative Medication Before Surgery

Whatever the reasons for your own anxiety, the adverse physiological and psychological consequences of stress and anxiety are well known. Anxiety can activate the fight-or-flight reaction, mediated by the sympathetic nervous system. Activation of the sympathetic nervous system results in adrenaline secretion by the adrenal glands, increased heart rate, increased blood pressure, increased anxiety, and often a sense of doom.

Chemical transmission

One fairly early source of biologically active material was the adrenal glands (glands as conspicuous and highly coloured as these were obvious targets for extraction). A difference between the cortex and the medulla was apparent, and it was soon shown that extracts of the adrenal medulla mimicked to a considerable extent the effects of sympathetic nerves on their target organs. The adrenal extracts were rich enough to allow the early identification of adrenaline as the active principle, and in 1904, after comparing the effect of nerve stimulation to that of application of adrenaline, Elliott proposed that it was released from the sympathetic nerves. Other important sources of biological materials were the poisonous fungi - such as fly agaric, Amanita muscaria (the red and white spotted toadstool). When applied to organs innervated by the parasympathetic nervous system, extracts of fly agaric were shown to mimic the effects of activating these nerves. The active

The neural tube the first steps to thought

By day twenty-eight, the neural tube is completely closed. The hollow centre will become the spinal canal and ventricles of the brain. As the neural crest sealed, some of the excess cells pinched off to lie on either side. These migrate through the embryo to form the peripheral and autonomic nervous systems, some hormone releasing glands, such as the thyroid and adrenals, and the pigment producing cells of the skin (melanocytes).

Cipkip Structure And Function

P27Kip1 is an inhibitor of cell division. An increase in levels of p27Kip1 causes proliferating cells to exit from the cell cycle, and a decrease in p27Kip1 is necessary for quiescent cells to resume division. Deletion of Kipl in mice results in hyperplasia in several organs, including endocrine tissues (adrenals, gonads, and pituitary gland), the retina, and the thymus (Fero et al. 1996 Kiyokawa et al. 1996 Nakayama et al. 1996). Thymic hyperplasia is associated with increased T-cell proliferation, and the absence of Kipl in the spleen selectively enhances proliferation of hematopoietic progenitor cells. These findings suggested at the time that p27Kip1 is an essential component of the signaling pathway that connects mitogenic signals to the cell cycle at the G1 restriction point. These findings have subsequently been confirmed in studies of the cardiovascular system as well.

Intrauterine Growth Restriction

Growth restriction has also been described as asymmetric and symmetric. Asymmetric or head-sparing IUGR occurs because of fetal autoregulation of blood flow. The initial response to lack of adequate delivery of oxygen and nutrients to the fetus results in shunting of blood flow to important organs such as the brain and adrenal glands. Muscle and other viscera such as kidneys are somewhat underperfused, resulting in smaller body than head, smaller muscle mass, and oligohydramnios due to underperfusion of the fetal kidneys and decreased fetal urine output. If inadequate delivery of oxygen and nutrients is early, persistent, or profound, all organs and tissues of the body will be affected and symmetric IUGR ensues. IUGR from fetal infection or genetic disorder is often symmetric as well because all the tissues of the body are often affected.

Adrenalectomy For Solitary Metastasis

Metastases to the adrenal gland are more common than primary adrenocortical carcinoma. Such metastases tend to originate from pulmonary, renal, mammary, and gastrointestinal carcinomas (3). Adrenal metastasis has been noted in 10 to 27 of autopsies of patients with known malignancy (4,5). Patients with metastasis to the adrenal gland commonly have disseminated cancer. Rarely does the clinician diagnose a patient suspected of harboring an isolated adrenal metastasis. The management of such a patient presents a challenging dilemma. Having already undergone definitive treatment for the primary malignancy, the physician is faced with counseling the patient on the best treatment strategy for the presumed metastasis. Unfortunately, the treatment of such lesions is controversial. Although some reports support the surgical treatment of isolated adrenal metastases with long-term survivors, identifying the most suitable surgical candidate is less clear. The ideal study would involve a...

Neurogenesis in the adult hippocampus

Hippocampal neurogenesis occurs throughout adulthood, but declines with age (Kuhn et al., 1996). Understanding what causes this age-related decrease in neurogenesis may be important in assessing the possible utility of potential future neuronal replacement therapies based on manipulation of endogenous precursors. Although aged rats have dramatically lower levels of neurogenesis than young rats, adrenalectomized aged rats have levels of neurogenesis very similar to those of young adrenalectomized rats (Cameron and McKay, 1999 Montaron et al., 1999). These results suggest that it is at least partially increased corticosteroids, which are produced by the adrenal glands, and not a decrease in the number of multipotent precursors, that leads to age-related decreases in neurogenesis.

Possible Role Of Egvegf In Pathological Conditions

We are currently assessing the expression of EG-VEGF and VEGF in a series of adrenal gland tumor specimens (our unpublished observations). Again, the expression pattern of EG-VEGF is rather distinct from that exhibited by VEGF. In adrenal-medulla-derived tumors (pheochromocytomas), VEGF is highly expressed throughout, whereas EG-VEGF is undetectable. In contrast, carcinomas of cortical origin express both VEGF and EG-VEGF. These data exemplify the concept that therapies to affect therapeutic angiogenesis or antiangio-genesis may require knowledge of the tissue-specific molecules that regulate and maintain the distinct vascular beds. Currently, we are examining the expression and potential role of EG-VEGF in other endocrine disease states, including pathologies of the placenta. The therapeutic values of EG-VEGF neutralizing reagents, and of EG-VEGF receptor-specific agonists or antagonists, remain to be demonstrated.

Illustrative Case

A 50-year-old white male developed headache and experienced a grand mal seizure 1 year after resection and radiation therapy for a right superior sulcus tumor. CT scan of the brain demonstrated a brain metastasis 3 cm in maximal diameter in the left temporal lobe. He was given anticonvulsants and steroids and offered the option of SRS or surgical resection. He opted for surgical resection. He received WBRT to 30 Gy in 10 fractions after surgery. He developed widespread metastases to the adrenal gland, bone, and lungs, and died 11 months later despite aggressive chemotherapy in a clinical trial.

Brain Metastases Renal Cell Carcinoma

There are approximately 31,000 new cases of renal cell carcinoma (RCC) in the United States each year. Of these, 30 to 40 will eventually become metastatic. The most common sites for metastatic dissemination are the lungs (65 ), bone (40 ), liver (14 ), adrenals (8 ), peritoneum (8 ), and brain (5 ). Most often, brain metastases occur at advanced stages of the disease however, 12 of patients will have the brain as their first metastatic site, and half of these metastases will be solitary lesions.4

Metachromatic Leukodystrophies

The metachromatic leukodystrophies (see TabJe.,.30-6 ), also known as sulfatide lipidoses, are a group of lysosomal storage disorders recognized by the accumulation of excessive amounts of sulfatide. The term metachromatic, as a description of the diseases, derives from the staining properties of the stored lipid sulfatides, which develop a brown or gold hue with toluidine blue rather than the usual blue of myelin. The enzymatic defect involves arylsulfatase-A or cerebroside sulfatase-A. A heat-stable nonenzymatic protein activator is also necessary for the hydrolysis of the sulfatide. The sulfatide is stored in lysosomes of neuronal white matter as well as in other somatic tissues, giving rise not only to signs of the disease in the central and peripheral nervous systems but also to disease in other organs and tissues such as the kidneys, pancreas, adrenal glands, liver, and gallbladder. y

Miscellaneous Techniques

Mental activities, including sleep, temperature, nocturnal and diurnal rhythms, growth, sexuality, and blood pressure. Regarded as a master gland, its stimulatory and inhibitory hormones control the functions of secondary glands such as the thyroid, adrenals, ovaries, and testes. Despite its importance, damage or removal of the pituitary gland by disease, tumor, surgery, and radiation is well tolerated as long as hormone supplementation is provided afterward.

Brief History of Social Stress Research

Social stress research traces its origins to the foundational works of W.B. Cannon, Adolf Meyer, and Hans Selye. Cannon (1929), a neurologist and physiologist, reviewed laboratory research on animals and case studies of medical patients to argue that emotionally provocative experiences (e.g., fear, pain) produce increases in levels of physiological activity that help animals cope with the experience (e.g., heightened adrenal gland activity). While often adaptive, these increases may promote disease if not relieved. Meyer, a psychiatrist, extended Cannon's work by asserting that normative changes, such as graduating from school or the birth of a child, also have the potential to affect physical and mental health. Selye (1956), a physician and endocrinologist, conducted extensive animal experiments which demonstrated that a variety of physical stressors (e.g., cold, pain) elicited that same syndrome of physiological reactions, which he called the General Adaptation Syndrome. The...

In Neuronal Transmission and in Multiple Behaviors

Of Adrenal Gland Catecholamine Release Although the a -AR contributes to the regulation of catecholamine release in some tissues, it serves as the main autoregulator in other organs (Table 1). In particular, the a -AR regulates epinephrine secretion from the chromaffin cells of the adrenal gland (92). Plasma epinephrine levels (adrenal chromaffin cells represent the primary source of epinephrine, whereas sympathetic neurons release circulating norepinephrine) (93) are selectively elevated in a -AR - mice (92). In line with this observation, Northern blot analysis demonstrated that a2C-AR mRNA (and not mRNA encoding a2A-AR or a -AR) is found in isolated mouse adrenal chromaffin cells further, a2C-AR mRNA predominates in the human adrenal gland (94,95). In an autocrine fashion analogous to sympathetic neuronal activation, the a2C-AR found on chromaffin cells inhibits stimulated epinephrine release (92). Collectively, these data reinforce the role that this receptor subtype plays in...

Management of Clinically Inapparent Adrenal Masses Surgery Versus FollowUp

Traditionally, surgical approaches to the adrenals have been anterior transperitoneal, posterior extraperitoneal, and thoracoabdominal (for large tumors).56 The application of laparoscopic techniques in the surgery of the adrenal glands has essentially replaced all traditional open approaches in the same manner as laparoscopic cholecystectomy has replaced traditional open cholecystectomy. Because there are so many benefits associated with the laparoscopic approach, open adrenalectomy should be reserved for very large adrenal carcinomas invading the surrounding tissue. We have compared the anterior, posterior, and laparoscopic approach in 165 patients who underwent adrenalectomy between 1984 and 1994.57 Although in this study we included our early cases and learning experience, the advantages of the laparoscopic approach were clearly shown in terms of morbidity (12.2 in the anterior approach, 8.1 in the posterior approach, and 0 in the laparoscopic approach), mean operating time, mean...

Disturbances in Calcium and Phosphate

Calcium homeostasis is a delicate balance among a number of organ systems and functions. These include kidneys, thyroid, parathyroid, bone, adrenal glands, gastrointestinal tract, nutrition, infectious disease, and medication. Malfunction in any of these modalities can result in hypercalcemia or hypocalcemia with the potential for serious morbidity and mortality. Total body calcium is balanced between plasma and the bony skeleton in a state of dynamic equilibrium. Approximately 1 of total calcium is in circulation, and the remaining 99 is stored in bone. In plasma, circulating calcium is approximately 40 protein (albumin) bound 45 exists in an ionized state (Ca++) and about 15 is found as various salts (calcium citrate, calcium lactate, calcium phosphate, calcium sulfate). Bony calcium exists in an active state with constant deposition and resorption under the influence of parathyroid hormone (PTH, parathormone), calcitonin, osteoclastic and osteoblastic activity, and neoplastic...

Mycobacterium tuberculosis

The combination of an unrelenting headache (+ - low grade fever) with malaise and anorexia and a CSF lymphocytic pleocytosis with a mild decrease in the glucose concentration is suggestive of tuberculous meningitis. The initiation of therapy should not await bacteriological proof of tubercle bacilli by smear or culture. The development of hydrocephalus and the clinical scenario just described is additional strong evidence for tuberculous meningitis. The absence of radiographical evidence of pulmonary tuberculosis and or a negative tuberculin skin test does not exclude the possibility of tuberculous meningitis. The classic Ghon complex refers to Anton Ghon's observation from autopsy specimens that the primary lesion of tuberculosis is in the lung with secondary infection in the tracheobronchial lymph nodes.y In addition to the primary complex, chest radiographic abnormalities suggestive of pulmonary tuberculosis are hilar adenopathy, a miliary pattern, upper lobe...

Primary Insufficiency

AIDS patients are at risk for adrenal insufficiency from multiple causes. AIDS patients' adrenal glands may be infiltrated by multiple infections and malignant processes, including cytomegalovirus, Mycobacterium tuberculosis or M. avium-intracellulare, Pneumocystis carinii, toxoplasmosis, histoplasmosis, Kaposi's sarcoma, and lymphoma. The human immunodeficiency virus may invade the adrenal. The adrenal is the preferred site of cytomegalovirus in the AIDS patient.9 Autoimmune adrenalitis also occurs. Drugs used in the treatment of AIDS-related diseases such as ketocona-zole, corticosteroids, rifampin, and phenytoin may also contribute to impaired adrenal function. Thrombocytopenia may lead to acute adrenal hemorrhage. The severe hypocho-lesterolemia seen in some AIDS patients may lead to impaired corticosteroid production.10

Do androgens have physiologic relevance in women

Is significant androgen receptor expression in male and female non-reproductive tissues, including kidney, thyroid, breast, colon, lung and adrenal glands. There is also significant expression in female reproductive tissues including endometrium, ovary, uterus, fallopian tube and myometrium.

Effects on the central nervous system

The effect of DHEA on libido and sexuality is most likely a consequence of increased androgenic activity derived from DHEA by peripheral bioconversion. In recent years it has become increasingly clear that androgens play a keyrole for female sexuality (Arlt 2003 Shifren et al. 2000). In fact, the adrenals are a major source of female androgens (Labrie et al. 2003) and their fundamental role for female sexuality (Waxenberg et al. 1959) has been rediscovered by studies on the therapeutic potential of DHEA. The available evidence and the superior pharmacokinetic properties make DHEA a highly attractive tool for treatment of impaired sexuality in women. However, firm conclusions must await the results of further trials.

Endocrine Pancreas and Hypoglycemia

An important physiologic role of the endocrine pancreas is protecting the body against hypoglycemia, which is undertaken by the release of glucagon to counteract the fall in glucose. A large number of studies have been directed at establishing the mechanisms underlying the glucagon response to hypoglycemia, and it has been demonstrated that it is caused by an increase in both parasympathetic and sympathetic neural activity and by elevated levels of epinephrine secreted by the adrenal medulla.162 The importance of the neural effects for this response has been demonstrated in humans, in whom infusion of a ganglionic blocker has been found to inhibit the glucagon response to hypoglycemia.163 A similar response is that seen during neuroglycopenia, when a local reduction of glucose in the brain cells initiates activation of the autonomic nervous system to increase the secretion of glucagon and, in some species, also insulin.64164 Neuroglycopenia is induced experimentally by an intravenous...

Endocrine Pancreas and Stress

Accompanied by a 50 inhibition of glucose-stimulated insulin secretion.168 It was subsequently shown that both chemical sympathectomy and adrenalectomy prevented the impaired glucose-stimulated insulin secretion that occurred during swimming,169 which shows that both the sympathetic nerves and the adrenals are of importance in this response. Thus, it might be assumed that stress stimulates the sympathetic nervous system, which inhibits insulin secretion through local release of norepinephrine as well as through arterially borne epinephrine. It has also been demonstrated that galanin immunoneutralization prevents the inhibition of glucose-stimulated insulin secretion that accompanies swimming,170 which indicates that the neuropeptide galanin, occurring in pancreatic adrenergic nerve terminals (see prior discussion), contributes, along with norepinephrine, to the islet response to swimming stress. In any case, the neural influences on islet function are of great importance for the...

Influencing memory by hormonal activation associated with emotional arousal

These hormones have a variety of effects associated with the flight or fight response, including increased heart rate and blood pressure, diversion of blood flow to the brain and muscles, and mobilization of energy stores. There is now a wealth of evidence that another effect of this activation is to improve memory storage for experiences surrounding stress activation, and that the amygdala is critical to this influence on memory.

Cetin Ozturk Nahida Akel and Anthony A Killeen 1 Introduction

Apo E plays an important role in the metabolism of these lipoproteins by binding to the low-density lipoprotein (LDL) receptor in hepatic and extrahe-patic tissues and a putative apo E receptor or LDL receptor-related protein. Apo E is synthesized predominantly in the liver and intestine but is also expressed in significant amounts in the brain, where apo E is the major mediator of cholesterol and lipid transport and plays an important role in membrane maintenance and repair. Apo E is the primary apolipoprotein in the brain, produced by astrocytes and oligodendrocytes. It is also produced in the adrenal gland and kidney.

Acute Adrenal Insufficiency Related to Bilateral Adrenal Hemorrhage

Veins Fragile Adrenal

The pathophysiology of adrenal hemorrhage remains unclear. Excessive anticoagulant does not seem to be responsible because transient prothrombin time abnormalities occur in only half of the patients.23 Heparin-induced thrombocytopenia may play a role.34 The fragile blood supply may contribute to the hemorrhage. The adrenal is supplied by 50 to 60 small arterial branches from three suprarenal arteries. These arteries feed a subcapsular plexus, which drains through a few venules into medullary sinusoids. Vasoconstriction or hypervascularity could raise adrenal venous pressure, causing hemorrhage.35 The single central vein and its thick longitudinal muscle bundles may make it vulnerable to formation of platelet thrombi, stasis, and thrombosis.36 Stress elevates corticotropin levels, which increase oxygen uptake by the adrenals and increase adrenal perfusion.37 Focal necrosis may increase the vulnerability to hemorrhage. Hemorrhagic cortical necrosis is the most common pathologic finding...

Thoracoscopic Transdiaphragmatic Adrenalectomy Patient Selection

Transperitoneal Laparoscopy

Although a history of major open abdominal surgery is no longer a contraindication to transabdominal laparoscopic adrenalectomy, significant technical difficulty may be encountered in patients with such a history. In fact, the presence of extensive adhesions might preclude transperitoneal laparoscopy in these patients. In these cases, the virgin retroperitoneal space may be directly and successfully accessed using retroperitoneal laparoscopy (6,21). Nevertheless, neither the transperitoneal nor the retroperitoneal laparoscopic approach may be confidently employed in the occasional patient who has had both the transperitoneal and the retroperitoneal spaces already violated by open surgery. An ipsilateral radical, total or partial nephrectomy through an extraperitoneal 11th rib incision, followed by a subsequent staged contralateral renal or adrenal procedure through a transperitoneal Chevron incision for bilateral renal carcinoma or benign end-stage disease, may result in the clinical...

Mecanism Of Centripetal Lipid Accumulation Supraclavicular Fat And Face

Hypocortisolemia can be primary, in which there is a defect intrinsic to the adrenal gland, or secondary, when pituitary or hypothalamic dysfunction causes decreased secretion of CRH or ACTH. Primary adrenal insufficiency was described by Thomas Addison in 1855 and is most commonly associated with destruction of the adrenal glands, either by tuberculosis, acquired immunodeficiency syndrome (AIDS), autoimmune disorder, adrenal hemorrhage, or tumor. In such cases, ACTH levels are high in response to the low plasma levels of gluco-corticoids. Secondary adrenal insufficiency is most often caused by suppression of the hypothalamic-pituitary axis by exogenous glucocorticoid therapy. Endogenous causes are a result of pituitary destruction by large tumors, apoplexy (hemorrhage into a pituitary adenoma), pituitary infarction (Sheehan's syndrome), inflammatory process (lymphocytic hypophysitis, Langerhans cell histiocytosis), or granulomatous disease (sarcoidosis). In almost all cases, loss of...

Androgen dynamics in women

The three sources from which androgens in women arise from are the adrenal cortex, the ovarian theca (and to a lesser degree, ovarian stromal cells), and by peripheral bioconversion of circulating androgenic prohormones. The adrenal gland produces about 95 of circulating serum dehydroepiandrosterone (DHEAS, the production rate of which is 19 mg day in young women) and 50 of dehydroepiandrosterone (DHEA, the production rate of which is 16 mg day). The rest of circulating DHEA is produced by peripheral conversion of DHEAS (30 ) in addition to a small ovarian contribution (20 ) (Burger 2002). DHEAS circulates unbound to protein, has virtually no androgenic action, and has a half-life of 10 hours it serves as a circulating prohormone for production of DHEA and the more potent downstream androgens both in the circulation and in peripheral tissues. Twenty-eight percent of DHEA comes from hydrolysis of DHEAS, and about 31 of DHEA is sulfated to DHEAS (Haning etal. 1989 Bird etal. 1978). The...

Operative Technique

Laparoscopy Lateral Decubitus

Several laparoscopic approaches to the adrenal glands are recognized, including the following Although the retroperitoneal approach is advocated by some authors,14 17 the technique of choice by most surgeons performing laparoscopic adrenalectomy is the transabdominal lateral approach, originally described by us in 1992.118 Positioning of the patient in the lateral decubitus position uses gravity to help retract the surrounding organs (including the bowel), and effectively exposes the adrenal gland for laparoscopic intervention. As a result, there is reduced dissection and minimal retraction of the vena cava and other adjacent structures. move the colon from the inferior pole of the adrenal and expose the lienorenal ligament (Fig. 74-3). This mobilization allows instruments to be inserted more easily and helps prevent inadvertent trauma to the colon or spleen during instrument insertion. Then, the lienorenal ligament is incised inferosuperiorly approximately 1 cm from the spleen (Fig....

Abdominal And Pelvic Surgery

Abdominal procedures constitute the bulk of general surgery. These procedures include operations on the abdominal wall for hernias, infections, tumors, and trauma, as well as intra-abdominal operations including gastric, intestinal, liver, pancreas, spleen, and adrenal gland surgery. General surgical procedures involving the perineum include operations for fissure, hemorrhoidectomy, anal fistula, abdominoperineal proctectomy, ischiorectal abscess, and pilonidal sinus and abscess drainage.

Primary Hyperaldosteronism

Contrast-enhanced CT scan of a patient with primary hyperaldosteronism identifies a 1.5-cm-diameter, well-marginated, rounded adenoma adjacent to the right adrenal gland. The aldosteronoma is isodense with adjacent adrenal tissue. Notice the normal size and appearance (lambda shape) of the left adrenal gland. FIGURE 66-5. The flowchart shows the diagnostic modalities used in imaging the adrenal glands for a suspected case of hyperaldosteronism. NP-59 131I-6P-iodo-methyl 19-norcholesterol.

Hormonal Regulation Prostate

Hormone Found The Prostate Gland

Ous dissemination. ' Lymph node metastases are more common in patients with large, undifferentiated tumors that invade the seminal vesicles. The pelvic and abdominal lymph node groups are the most common sites of lymph node involvement (Fig. 92-1). Skeletal metastases from hematogenous spread are the most common sites of distant spread. Typically, the bone lesions are osteoblastic or a combination of os-teoblastic and osteolytic. The most common site of bone involvement is the lumbar spine. Other sites of bone involvement include the proximal femurs, pelvis, thoracic spine, ribs, sternum, skull, and humerus. The lung, liver, brain, and adrenal glands are the most common sites of visceral involvement, although these organs usually are not involved initially. About 25 to 35 of patients will have evidence of lymphangitic or nodular pulmonary infiltrates at autopsy. The prostate is rarely a site for metastatic involvement from other solid tumors. Normal growth and differentiation of the...

Addisons Disease and Acute Adrenal Hemorrhage

Adrenal insufficiency was first recognized in 1855, when Thomas Addison1 published the monograph, On the Constitutional and Local Effects of Disease of the Supraadrenal Capsules. He described 11 patients with general languor and debility, remarkable feebleness of the heart's action, irritability of the stomach, and a peculiar change of the color of the skin. The primary cause historically was adrenal destruction from tuberculosis. By the turn of the 20th century, surgery of the adrenal glands was being performed. Death after adrenalectomy was thought to be due to the accumulation of toxic products they were believed to remove. In 1927, the development of an adrenal extract named cortin improved the management of adrenalec-tomized patients.2 In 1937, deoxycortone was synthesized in 1948, cortisone was isolated and between 1952 and 1955, aldosterone was isolated and synthesized. Availability of these steroids and the understanding of their physiologic role dramatically altered the...

What happens when hormone therapy fails

Ketoconazole is a medication that decreases androgen production from both the testicles and the adrenal glands and also works directly on the prostate cancer cells. In patients who have not responded to first-line hormone therapy (LHRH analogue or antagonist plus antiandrogen), Ketoconazole plus hydrocortisone decreases the PSA in about 15 of patients. In those who have not Corticosteroids (e.g., prednisone) can also decrease the production of androgens by the adrenal gland. They also have beneficial effects on appetite and energy level. Decreases in PSA have occurred in 20 to 29 of patients with hormone-refractory prostate cancer who are taking corticosteroids. Other corticosteroids, such as dexametha-sone and megestrol acetate, may also improve symptoms.

Anatomy of the Pancreas

Pancreatic Lymph Nodes

Usually crossing the second lumbar vertebra. It is intimately associated with the left adrenal gland, left kidney, and splenic artery and vein, which course along its superior aspect. Because of its relationship to the vertebral bodies, the body of the pancreas is the segment where transection secondary to blunt trauma most commonly occurs. Small venous tributaries from the body of the pancreas empty into the splenic vein and are a potential source of troublesome bleeding when preservation of the spleen is attempted in patients undergoing distal pancreatectomy. Anteriorly, the body of the pancreas is covered by peritoneum separating the stomach from the pancreas. It is also the site for attachment of the transverse mesocolon. The middle colic artery originates from the superior mesenteric artery from beneath the body of the pancreas and emerges from between the peritoneal leaves of the transverse mesocolon.

Familial Amyloid Polyneuropathy

This disorder has many features in common with FAP type l. Upper and lower extremities are affected, but usually there is no associated carpal tunnel syndrome. Peripheral neuropathy can be severe, but the autonomic neuropathy is less prominent. Peptic ulceration may occur, and renal involvement results in hypertension and uremia. Amyloid deposition also occurs in the liver, adrenal glands, and testes. This type of FAP is associated with apolipoprotein Al-derived amyloid, and a substitution of arginine for glycine has been found in nucleotide 26 of the gene.

Concomitant Adrenalectomy

Incidence of adrenal involvement from renal cell carcinoma is 1-2 (70). Candidates for nephron-sparing surgery for an upper pole tumor may present with contiguous involvement of the adrenal gland (pT3a tumor) or hematogenous involvement of the gland (Mi tumors) (71). In such cases, partial or radical nephrectomy with concomitant adrenalectomy is indicated. Ramani et al. (72) reported concomitant ipsilateral adrenalectomy during laparoscopic partial nephrectomy in four patients with an upper pole renal tumor and suspected adrenal involvement. Preoperative three-dimensional computed tomograpgy scan revealed renal tumor abutting the adrenal gland in three patients, and a 4-cm adrenal mass in one patient. Using a transperitoneal approach, en bloc adrenalectomy was performed first, followed by laparoscopic partial nephrectomy. The adrenal gland was maintained en bloc with the partial nephrectomy specimen. No intraoperative complication occurred, and open conversion was not necessary in any...

Are there different types of hormone therapy Do I need to have my testicles removed

Hormone therapy is a form of prostate cancer treatment designed to eliminate the male hormones (androgens) from the body. The most common androgen is testosterone. Androgens are primarily produced by the testicles, under control of various parts of the brain. A small number of androgens are produced by the adrenal glands, which are small glands located above the kidneys and produce many important chemicals. Prostate cancer cells may be hormone sensitive, hormone insensitive, or hormone resistant. Cancer cells that are hormone sensitive require androgens for growth. Thus, elimination of the andro-gens would prevent the growth of such cells and cause them to shrink. Normal prostate cells are also hormone sensitive and also shrink in response to hormone therapy. Prostate cancer cells that are hormone resistant continue to grow despite hormone therapy. Antiandrogens are receptor blockers they prevent the attachment of the androgens, both those produced by the testicles and those produced...

Robotic Adrenalectomy

Adrenalectomy has historically been a significantly morbid procedure due to the deep location of the adrenal glands in the retroperitoneum. Laparoscopy has significantly decreased the morbidity associated with this operation, and laparoscopic adrenalec-tomy is now the recommended gold standard for the majority of adrenal disorders requiring surgery. Despite this transition to minimally invasive surgery, the incidence of disease processes requiring laparoscopic adrenalectomy is quite low and can potentially limit acquisition of skills necessary to perform the procedure. Laparoscopic adrenalectomy requires a delicate dissection of the adrenal gland as well as the adrenal veins and arteries. Given the somewhat restricted location of the adrenal gland and the careful dissection needed for successful removal, techniques of robot-assisted laparoscopic adrenalectomy have been reported in experimental models and clinically.

Pharmacologic Systemic Therapy Endocrine Therapy

Over the past decade, new information has been published regarding the use of a new generation of aromatase inhibitors. These data have changed the way we treat metastatic breast cancer, as well as early-stage breast cancer (as noted previously). In postmenopausal and castrated women, the main source of estrogen is derived from the peripheral conversion of androstenedione, produced by the adrenal gland, to estrone and estradiol. This conversion requires the enzyme aromatase. Aromatase also catalyzes the conversion of androgens to estrogens in the ovary in premenopausal women and in extraglandular tissue, including the breast itself, in postmenopausal women. Therefore, aromatase inhibitors (e.g., anastrozole, letrozole, and exemestane) effectively reduce the level of circulating estrogens, as well as estrogens in the target organ. Their toxicity profile consists mainly of nausea, hot flashes, arthralgias myalgias, and mild fatigue. Anastrozole and letrozole are nonsteroidal compounds...

Thoracoabdominal Lateral Transthoracic Approach

Right Thoracoabdominal Incision

The thoracoabdominal lateral transthoracic approach requires a large incision and opening of both the thoracic and peritoneal cavities. Because it provides only unilateral adrenal gland exposure, it is generally reserved for the following highly specific surgical circumstances 1. For very large tumors with substantial involvement of surrounding structures (especially the pancreas, spleen, and diaphragm on the left side and the liver, IVC, and diaphragm on the right), this approach affords the widest exposure of the adrenal gland and surrounding structures. For a right-sided approach, the incision begins over the right 10th rib near the lateral border of the sacrospinal muscle (Fig. 73-3). It is carried over the rib along the anterior abdominal wall across the costal cartilage and then down onto the anterior abdominal wall toward the midline rectus muscle. The rib and abdominal muscles are exposed and the 10th rib is resected subperiosteally as far back as its angle. The pleural cavity...

Secondary Adrenal Insufficiency Related to Exogenous Steroid Usage

A study of intensive care unit patients performed by Rivers and coworkers again raises the question of critical illness increasing the probability of adrenal insufficiency. They studied 104 patients with severe sepsis or septic shock. They described a group with functional hypoadrenalism, who exhibited any hypoadrenal laboratory values. They found an improvement in vasopressor-dependent refractory hypotension, even in the group with normal adrenal function. This study suggests that we need to reconsider our assessment of adrenal insufficiency and our use of corticosteroids in the severely ill. They recommended considering hydrocortisone treatment in patients older than 55 years in the presence of continued need for vasopressors after adequate volume resuscitation.19

Normal Sexual Development

Uterus and proliferation of endometrium. In addition, estra-diol enhances development of, and increase in, the ducts of the breast and body fat. Estrogen in low levels enhances linear growth, and high levels increase the rate of fusion of epiphy-ses. Testosterone is responsible for the increase in muscle mass, sebaceous glands, and voice changes seen in pubertal males and is a linear growth accelerator. In females, testosterone accelerates linear growth and stimulates pubic and axillary hair development. Progesterone in females is responsible for development of a secretory endometrium and plays a role in breast development. Linear growth and pubic hair development in both males and females are caused by androgens from the adrenal gland. Figures 35-5 and 35-6 show normal pubertal developmental stages of Marshall and Tanner.

Initial Investigations

Imaging may be required to evaluate local, regional, or distant disease. Ultrasonography provides noninvasive screening of the abdomen, including the liver, kidneys, and adrenals, but delineation of retroperitoneal and paraspinal disease is limited and requires cross-sectional imaging using CT or MRI

Localization Studies

Although the CT-based diagnosis of adenoma is reliable with acceptable certainty, it is worth noting that the CT-based diagnosis of hyperplasia is unreliable.52 The presence of non-aldosterone-secreting nodules in the ipsilateral or contralateral adrenal gland associated with an adenoma may result in a misdiagnosis as hyperplasia. In addition, hyperplasia may be associated with a unilateral macronodule and cause an erroneous diagnosis of an adenoma. Therefore, all patients with unilateral adenomas as small as 1 cm or bilateral nodules on CT and those with bilateral normal glands require further localization studies using isotope adrenal scanning or selective adrenal venous sampling for aldosterone and Cortisol levels, or both. Adrenal scanning with I3lI-6P-iodomethyl-19-norcholes-terol (NP-59) during dexamethasone suppression is considered the next choice for locating a hyperfunctioning adrenal gland if CT scan results are not definitive.53'54 Problems with adrenal scintigraphy...

Surgical Applications

Because of their fairly central position in the abdominal cavity, the adrenal glands cannot be felt, and few tumors grow large enough to be palpated. Approaches to the gland can be made through the posterior, lateral, and anterior surfaces. Laparoscopic adrenalectomy has become in recent years the technique of choice for most adrenal tumors. Surgical techniques are described in greater detail in other chapters of this book. The anatomic landmarks are mentioned here as an introduction. During right adrenalectomy, the dissection plane encounters the costopleural sinus, which can be reflected superiorly rarely, it might be necessary to incise the pleura and diaphragm. After incision of Gerota's fascia, dissection between the right kidney and the vena cava allows identification of the adrenal gland. Posteriorly and laterally, dissection can proceed quickly because few major vessels cross this space. When dissecting on the medial aspect, it must be remembered that there is usually only one...

The Bodys Response to Stress

Dangers Stress

Hypothalamus, and pituitary gland are activated. The amygdala and hypothalamus are parts of the brain associated with fear, stress, and the integration of bodily functions. The pituitary gland, which is controlled by the hypothalamus, is located just beneath the brain and releases hormones needed by the body. As part of the stress response, ACTH, a hormone released from the pituitary gland activates the adrenal glands, which in turn release the stress hormones, epineph-rine and cortisol (see Figure 9-1). These hormones act throughout the body to prepare us for responsive action. Epinephrine increases heart rate and blood pressure to help the body meet the new demands. Cortisol increases blood sugar (glucose) to provide more fuel for the energy needed to deal with the stressor, and it does this by promoting the synthesis of glucose and by assisting in the metabolism of fat, protein, and carbohydrates that produce additional glucose. Chronic stress can affect many organ systems and...

Controversy About The Role Of Laparoscopy For Malignancy

Although the role of laparoscopy for benign adrenal disease is currently defined, laparoscopic excision of malignant renal tumors of the adrenal gland remains controversial. The concern about laparoscopy for adrenal malignancy stems from seven individual case reports published in the last several years (Table 2) (26-32). These single case reports challenge the adequacy of adrenal resection for adrenal glands with a primary adrenal malignancy or solitary metastatic site. In each case report, the authors describe local recurrence or peritoneal carcinomatosis shortly after (4-14 months) routine laparo-scopic adrenalectomy. Two of the case reports consist of metastatic lung cancer to the adrenal gland. The other five case reports describe an initial adrenal mass thought to be benign after initial histopathologic analysis and only later diagnosed as malignancy when clinical recurrence was noted.

Adrenalectomy For Adrenocortical Carcinoma

Adrenocortical carcinoma is a rare disease with estimated 75 to 115 new cases a year in the United States (21). The staging system commonly used for adrenocortical carcinoma is shown in Table 1 (22). In this staging system, stages I and II include tumors localized to the adrenal gland, while stages, III and IV include tumors with local or distant spread, respectively. In a review of 602 patients from seven institutions, Ng and Libertino (23) found five-year survival based on stage as stage I, 30 to 45 stage II, 12.5 to 57 stage III, 5 to 18 and stage IV, 0 . Median survival was shorter in patients with unresectable tumors (3-9 months) as compared to those with complete surgical resection (13-28 months). Although the role of laparoscopy for benign adrenal disease is currently defined, laparoscopic excision of malignant renal tumors of the adrenal gland remains controversial.

Steroids or Corticosteroids

Steroids are one of the body's fundamental hormones, and prescribed hormones are not foreign substances but serve to boost the effects of steroids produced constantly by the adrenal glands. Steroid therapy has many potentially useful roles in the treatment of patients with cancer, such as being very potent in reducing inflammation and its related swelling, and is used in some chemotherapy treatments to shrink tumors, to reduce excessive levels of calcium that are sometimes caused by tumors, and to forestall nausea. They may improve mood and appetite, thus helping to promote weight gain.

Genetics vs Lifestyle

Rare defects in melanocortin receptors in the adrenals have also been associated with obesity. Most often, a person must be homozygous for the abnormal gene for the trait to be expressed. A defect in the melanocortin-4 receptor is the most common single-gene mutation associated with severe obesity but still accounts for only about 5 of this population. Other single-gene mutations have been found in animal models as well as humans, but all are extremely rare. Recently identified genes include the FTO (fat mass and obesity-associated) gene. Each of these genes seems to be associated with a modest increase in weight.

The Goal of Evaluation

Subclinical Cushing

Depending on the amount of glucocorticoids secreted, the clinical significance of subclinical Cushing's syndrome ranges from slightly attenuated diurnal Cortisol rhythm to atrophy of the contralateral adrenal gland, a dangerous condition after unilateral adrenalectomy if appropriate therapeutic measures are not taken early enough.37

Physiologic Effects of Corticosteroids

The physiologic effects of DHEA-S, DHEA, and androstene-dione are relatively weak, and they undergo conversion to testosterone in peripheral tissue. In females, androgens produced by the adrenal glands sustain normal pubic and axillary hair growth, and after menopause the adrenal glands are a major source of estradiol. However, in males, the high amount of androgens produced by the testis exceeds that produced by the adrenal glands.1

Adrenal Cortex And Medulla

Polypeptide Chain Cortex

The adrenal glands are situated at the superior poles of each kidney and may be thought of as two separate glands an outer cortex and the inner medulla. Medullary tissue may also be found at extra-adrenal sites along the course of the abdominal aorta. In keeping with all the other endocrine glands, the adrenals are richly vascularized. The adrenal gland derives its blood supply from three blood vessels a direct branch from the aorta, one from a branch of the phrenic artery and one from the renal artery. These arteries form a plexus on the capsule of the gland and blood flows through sinusoids to the medulla. Blood is drained through a single adrenal vein that leaves at the hilum of the gland to join the inferior vena cava. Preganglionic sympathetic nerve fibres that release acetylcholine richly innervate the adrenal medulla. Cholesterol is the precursor for all steroid hormones. Some cholesterol is made within the adrenal gland from acetate, but the majority comes from the circulating...

Nonpharmacologic Therapy

The treatment of choice in patients with adrenal adenomas is unilateral laparoscop-ic adrenalectomy. These patients require glucocorticoid supplementation during and after surgery due to atrophy of the contralateral adrenal gland and suppression of the HPA axis. Glucocorticoid therapy is continued until recovery of the remaining adrenal gland is achieved. Patients with adrenal carcinomas have a poor prognosis, with a 5-year survival of 20 to 58 , due to the advanced nature of the condition (metastatic disease). Surgical resection to reduce tumor burden and size, pharmacologic therapy, or bilateral laparoscopic adrenalectomy are the treatment options commonly utilized to manage this condition.1,22

Regional and General Anesthesia and Surgical Stress

Of certain stress hormones, like adrenaline and Cortisol, by the adrenal gland. These hormones can be detrimental to the body in a great number of ways when they persist for extended periods. The release of adrenaline alone increases heart rate, blood pressure, and oxygen demands on the heart, which may be harmful or fatal in the patient with advanced heart disease. It also causes elevated blood glucose levels and can impair the immune response, increasing susceptibility to infection.

Circadian Dysregulation

Previously considered a specific marker of depressive illness. It is now recognized as an abnormality in only some subsets of depressed patients, notably psychotic depressives. Also reported is blunted adrenocorticotrophic hormone (ACTH) response to exogenous CRH. More sensitive to detect HPA dysregulation is the combined use of the DST and the CRH stimulation test. In the setting of an abnormal HPA axis test, clinical response appears to best correlate with normalization of the neuroendocrine abnormality. Elevated plasma cortisol following dexamethasone (DEX) predicts a protracted clinical course. The combined DEX CRH test appears to be a useful predictor of increased relapse risk. Recent reports of alterations in cortisol regulation in women with a history of early life trauma or abuse further suggest that HPA axis dysregulation may be an important marker of vulnerability to various types of affective disorders in later life, paralleling studies in rodents and primates (Heim et al.,...

Hypercortisolemia Corticotroph Adenomas and Cushings Disease

The first step in diagnosing a patient with hypercortisolemia (Cushing's syndrome) is to find the etiology. In the subset of causes of Cushing's syndrome in the pediatric population, 85 of cases resulted from Cushing's disease.8 Patients diagnosed with Cushing's disease, thus having ACTH-releasing corti-cotroph adenomas, exhibit cushingoid features. Most often, these features in children are short stature, rapid weight gain, menstrual irregularities, skin striae, and mental status changes.9 To demonstrate that hypersecretion of cortisol is present, tests such as the 24-hour urinary free cortisol, 17-hydroxycorticosteroid, and creatinine excretion tests are performed.8 The normal diurnal variation in secretion of cortisol is also lost in Cushing's disease. The high- and low-dose dexamethasone suppression tests are also administered, with the dose of dexamethasone given according to body weight, and these tests have important diagnostic implications. These dynamic tests measure cortisol...

Visceral Pain Pathways For The Upper Abdomen

Visceral nociceptive afferent fibers travel from the visceral organs back to the spinal cord along the course of the sympathetic and parasympathetic efferent nerves. The celiac plexus is involved in nociceptive transmission from the upper abdominal viscera, including the pancreas, stomach, liver, biliary tract, spleen, kidneys, adrenals, omentum, small bowel, and large bowel to the splenic flexure. The greater (T5-T9), lesser (T10-T11), and least (T12) splanchnic nerves are primarily composed of preganglionic sympathetic nerve fibers. These splanchnic nerves traverse the posterior mediastinum and enter the abdomen through the diaphragmatic crus to synapse at the right and left celiac ganglia, forming the celiac plexus. Although there is anatomic variability, the celiac plexus is typically located anterolateral to the aorta immediately caudal to the celiac artery's origin, at the cephalad border of the L1 vertebral body.162 From the celiac ganglia, the postganglionic fibers then...

In puberty and adulthood

Increasing androgenic steroid secretion from the adrenals is defined as adrenarche and precedes puberty. Adrenarche is associated with increased growth of pubic and axillary hair independent of gonadal androgen secretion. Adrenal androgens include mainly dehydroepiandrostendione, its sulfate, and androstendione, but also other adrenal steroids have androgenic potential. Adrenocorticotropic hormone (ACTH) is a potent stimulator of adrenal androgen secretion however, its potency relative to cortisol secretion is much less. Also, substances other than ACTH may modulate adrenal androgen secretion. These include estrogens, prolactin, growth hormone, gonadotropins and lipotropin. None of these appear to be the usual physiological

In foetal sexual differentiation

Another gene involved in the development of the bipotential gonad and the kidneys is the recently cloned LIMl-gene. Homozygous deletions in this gene in mice lead to developmental failure of both gonads and kidneys. To date, no human mutations have been described in this gene, although a phenotype of renal and gonadal developmental defects in association with brain abnormalities might be anticipated. The role of the steroidogenic factor 1 (SF1) in the formation of the gonad is not yet clear. SF1 is the product of the FTZl-Fl-gene and is believed to be a nuclear orphan hormone receptor due to the presence of two zinc fingers and a ligand binding domain in its molecular structure. FTZ1-F1 mRNA is expressed in the urogenital ridge which forms both gonads and adrenals, and is also found in developing brain regions. Mice lacking SF1 fail to develop gonads, adrenals, and the hypothalamus. However, SF1 is probably also involved in other aspects of sexual development, as it regulates the...

Reninangiotensin System

Renin acts on a plasma protein, angiotensinogen, and splits off a decapeptide, angiotensin I. A converting enzyme found in both plasma and various tissues of the body, including lung, converts angiotensin I to angiotensin II. This agent has many actions. It is a potent vasopressor which acts on the glomerular arterioles and thereby contributes to glomerulotubular balance. It also has a direct action on the brain, stimulating the thirst centre. Of most importance is its effect of stimulating secretion of aldosterone from the zona glomerulosa of the adrenal gland. Plasma aldosterone levels are also affected by the plasma potassium concentration, an increase in potassium reducing the aldosterone concentration. The converse occurs with plasma sodium concentration, i.e. a decrease in plasma sodium increases aldosterone. The main action of aldosterone is to increase sodium reabsorption in the distal tubule. Potassium and or hydrogen ions are then secreted into the tubule in exchange for...

Mechanism of action

The infusion of relatively low concentrations of dopamine activates postsynaptic DAj receptors in blood vessels and the renal tubules. Stimulation leads to vasodilatation and improves some measures of renal function, such as cortical renal blood flow, glomerular filtration rate (GFR), sodium excretion and urine output. There is also an increase in mesenteric flow. Activation of presynaptic DA2 receptors decreases intrarenal norepinephrine release, which leads to vasodilatation. It also causes inhibition of aldosterone secretion from the adrenal glands and a consequent decrease in sodium reabsorption. Theoretically, this should decrease renal oxygen consumption and improve the renal oxygen supply demand relationship.

History And Examination

Thoracic patients often exhibit the respiratory symptoms of cough, sputum, haemoptysis, breathlessness, wheeze and chest pain, or oesophageal symptoms of dysphagia, pain and weight loss. Other common chest features are hoarseness, superior vena cava obstruction, pain in the chest wall or arm, Horner's syndrome, cyanosis and pleural effusion. Lung tumours may cause extratho-racic symptoms by metastatic spread, principally to brain, bone, liver, adrenals and kidneys, or by endocrine effects such as finger clubbing, hypertrophic pulmonary osteoarthropathy, Cushing's syndrome, hypercalcaemia, myopathies (e.g. Eaton-Lambert syndrome), scleroderma, acanthosis and thrombophlebitis.

Embolization procedures

The use of angiographic embolization continues to grow and become more sophisticated. It is undertaken for vascular malformations and fistulae, aneurysms, tumours, acute haemorrhage and ablation of function of an organ. Venous embolization is used to treat gastro-oesophageal varices, testicular varices and ablation of adrenal gland function. It may be performed as an alternative to surgery, particularly if the patient is unfit and the operation carries a high risk. Its use before surgery can help to reduce intraoperative blood loss.

Conduct of anaesthesia

And severe hypotension may occur after ligation of the venous drainage of the tumour, particularly if preoperative preparation has been inadequate. Marked fluctuations in arterial pressure may also occur during induction of anaesthesia and tracheal intubation. Sedative and anxiolytic premedication is useful agents used for induction and maintenance should be selected on the basis of cardiovascular stability, and drugs which have the ability to provoke histamine (and hence catecholamine) release are best avoided (Table 55.4). Monitoring of ECG, CVP and direct arterial pressure must be commenced before induction of anaesthesia. The exact choice of individual anaesthetic drugs is less important than careful conduct of anaesthesia, which may be induced by slow administration of thiopental or etomidate and maintained with nitrous oxide in oxygen, supplemented by either enflurane or isotlurane. The use of moderate doses of opioids (e.g. fentanyl 7-10 pg kg-l) may aid cardiovascular...

Epidemiology and etiology

Adrenal insufficiency generally refers to the inability of the adrenal glands to produce adequate amounts of cortisol for normal physiologic functioning or in times of stress. The condition is usually classified as primary, secondary, or tertiary, depending on the etiology (Table 45-1)2,4-8 The estimated prevalences of primary adrenal insufficiency and secondary adrenal insufficiency are approximately 60 to 143 and 150 to 280 cases per one million persons, respectively. Primary adrenal insufficiency is usually diagnosed in the third to fifth decade of life, whereas secondary adrenal insufficiency is commonly detected during the sixth decade.2,9 Adrenal insufficiency is more prevalent in women than in men, with a ratio of 2.6 12 Chronic adrenal insufficiency is rare.

History and Geography

From the initial description in the mid-nineteenth century to 1959, a large number of etiologic hypotheses were advanced for the syndrome, including maternal syphilis, familial tuberculosis, familial incidence of epilepsy, insanity, instability, and mental retardation. Once the increased incidence of congenital heart disease in the syndrome was recognized by John Thomson and A. E. Garrod in 1898, a cause in early fetal existence was sought. Among theories advanced were maternal alcoholism, fetal hyperthyroidism, maternal dysthyroidism, hypoplasia of the adrenals, dysfunction of the pituitary, abnormality of the thymus, chemical contraceptives, curettage, faulty implantation, degeneration of the ovum, and emotional shock in early pregnancy.

Thoracoscopic Transdiaphragmatic Adrenalectomy

Initially described by Pompeo et al. in a porcine model (89), this approach was further developed and the initial clinical series described by Gill et al. (12). In this series, the procedure was performed initially on four cadavers to develop the technique and then on three patients, all of who had significant abdominal scarring and prior ipsilateral renal surgery. After the placement of a double-lumen endotracheal tube, the patient is placed prone and a four-port transthoracic approach without pneumoinsufflation is used. Real-time laparoscopic ultrasound is used to identify the adrenal gland transdiaphragmatically. The diaphragm is incised, and the adrenal gland dissected. There were no intraoperative or postoperative complications, operative times ranged from 2.5 to 6.5 hours, and blood loss ranged from 50 to 500 mL (12).

Step 4 Dissection of the Upper Pole of the Kidney

An area of Gerota's fascia cephalad to the renal hilum is incised sharply along the anterior aspect of the upper pole, exposing the renal capsule. The surgeon then places his her left-handed instrument (suction irrigator or Debakey forceps) next to the capsule and retracts medially. This will develop the plane to dissect the adrenal gland from the upper pole of the kidney. The harmonic scalpel is used here, because it easily coagulates small, friable perforating vessels that may be traveling to the adrenal gland.

Step 11 Inspection of the Renal Bed Closure

The anterior rectus fascia is immediately closed with a running 0-polyglactin suture. Pneumoperitoneum is reestablished, and the renal bed is inspected at a low insufflation pressure. The renal artery and vein stumps are closely inspected. In addition, the splenic capsule, colon, and its associated mesentery, pancreas, and adrenal gland are examined for injury and to ensure meticulous hemostasis. Small sites of bleeding can be controlled

Relevant Anatomic Details

The arterial supply of adrenal gland is derived from three sources, namely the inferior phrenic artery, the aorta, and the renal artery. Adrenal vessels subdivide into minute branches prior to entering the adrenal cortex, where they further branch into capillaries ending in venous plexii within the adrenal medulla (9). On the right side, a single right adrenal vein emerges from the right adrenal apex and drains into the inferior vena cava. On the left side, a single left adrenal vein emerges from the middle portion of the gland and drains into the left renal vein. The left inferior phrenic vein, usually not easy to identify and typically communicating, can be injured during the dissection along the medial edge of the left gland due to its medial course. Hence, delicate dissection is essential to preserve the periadrenal vascular plexus, and the fibro-areolar tissue attachment of the remaining portion of adrenal gland.

Posterior Retroperitoneal Technique

Gerota's fascia is incised along its medial aspect along quadratus lumborum and the crus of the diaphragm. The incision is continued transversely over the adrenal gland. The middle adrenal arteries are controlled as they emerge from the crus. The renal pedicle is then identified. On the right side, the inferior vena cava is observed below the level of the adrenal arteries along the crus of the diaphragm. The right adrenal vein runs in a retrocaval direction and therefore is easily dissected from the dorsal side. The vein is clipped and transected, Gerota's fascia is incised transversely, and the inferior aspect of the adrenal is mobilized from the upper pole of the kidney and the inferior adrenal vessels are controlled. The dissection then continues laterally and superiorly, and the superior vessels are controlled. Siperstein et al. describe a similar approach but state that the position of the adrenal gland and kidney relative to the 12th rib is variable and therefore utilize...

Patient Selection Indications And Contraindications Indications

In contrast to primary adrenocortical carcinomas, metastatic lesions are generally small and confined to the adrenal gland, and thus amenable to laparoscopic resection (8). Laparoscopic adrenalectomy for metastatic disease may be indicated provided that the primary cancer is controlled or controllable, other metastatic diseases, if present, are resectable, and the patient is fit enough to tolerate general anesthesia (8,40).

Other Techniques And Modifications Direct Supragastric Left Sided Adrenalectomy

Vereczkei et al. described a similar approach wherein initial access to the adrenal gland is afforded by incising the leinodiaphragmatic ligament laterally from the left diaphragmatic crus, allowing the spleen to be retracted inferiorly and laterally. Both of these approaches aim to minimize visceral mobilization and allow direct access to the adrenal gland however, because the adrenal vein is accessed only after dissection of a large part of the tumor, these approaches are not suitable for removal of pheochromocytomas (5).

Mobilization of the Upper Pole

After ligation of the renal artery and vein, dissection is carried along the medial aspect of the kidney, maintaining a safe distance from the renal hilum. At the upper pole, the anterior layer of Gerota's fascia is entered and dissection continued close to the kidney to preserve the adrenal gland. The upper pole can be dissected using a combination of sharp and blunt dissection. The use of clips, harmonic scalpel, or endo-gastrointestinal anastomosis is encouraged, as capsular vessels are common at the upper pole. Dissection is then carried to the lateral aspect of the kidney, where blunt dissection is usually sufficient to free the kidney of all attachments except for the ureter.

Introduction And Background

Laparoscopic adrenalectomy has become the standard surgical approach for most surgically correctable benign disorders of the adrenal gland. Laparoscopic approaches to the adrenal gland may be performed via either transperitoneal or retroperitoneal routes and may be either unilateral or bilateral. Initially, the transperitoneal route was used, predominantly because of the familiarity of this approach with open surgery (9,10). However, following the development of retroperitoneal techniques by Gaur in 1992, lateral and posterior retroperitoneal approaches have also been adopted (11).

Instrument Modifications

A variety of instrument modifications that aid in dissection of the adrenal gland have been described. The harmonic scalpel may be of particular use in reducing operative time (58,78). Laparoscopic ultrasound probes with frequencies in the order of 5 to 7.5 MHz may be useful in identifying the adrenal gland and vein, confirming the presence or absence of an abnormality on the affected and contralateral sides, determining the resectability of large masses, facilitating partial resection, and identifying pathology in adjacent organs (6,64-66). However, data pertaining to the usefulness of this modality has been conflicting. Lucas et al. found laparoscopic ultrasound particularly useful in identifying the adrenal vein on the left when it is obscured by large amounts of retroperitoneal fat (66) in contrast, Brunt et al. found that laparoscopic ultrasound identified the vein in only 21 of cases (65). Laparoscopic ultrasound may be of particular benefit in retroperitoneal approaches where...

Increased Intra Abdominal Pressure

Increased intra-abdominal pressure compresses the splanchnic circulation (Fig. 1) (18), in both capillaries and capacitance vessels, and in both the venous and arterial systems (14,15,19-22). An intra-abdominal pressure of 20 mmHg or more diminishes blood flow to all abdominal and retroperitoneal organs except the adrenal gland (18,23-25).

Hand Assisted Laparoscopic Adrenalectomy

This technique, described by Bennett and Ray, is reported to be associated with short operative times and has the advantage of introducing tactile feedback in locating the adrenal gland. This technique utilizes the Handport f, which is placed in the upper midline for left-sided lesions and via an oblique right lower subcostal incision for right-sided procedures. The procedure then follows the same dissection as for open surgery with Kocherization of the duodenum on the right prior to control of the adrenal vein, whereas on the left, the greater omentum is divided, and the adrenal gland and vein accessed through the lesser sac (15).

Computed Tomography Protocol For Laparoscopic Surgical Planning

The first scan phase is a noncontrast computed tomography scanning of the abdomen, including the adrenal glands and both kidneys. This is essential not only to plan the contrast study, but because it provides baseline attenuation value for all renal masses and detects calcifications in the urinary tract and renal lesions.

Circumferential Specimen Mobilization

After control of the adrenal vasculature has been secured, sequential blunt and sharp dissection of the remaining attachments frees up the adrenal gland. Inferior phrenic vessels are often encountered along the undersurface of the diaphragm. During specimen mobilization, one should be careful not to create an unintentional perito-neotomy. Although a peritoneotomy does not significantly compromise operative FIGURE 8 Retroperitoneoscopic right adrenalectomy. Dissection between adrenal gland and inferior vena cava reveals short, horizontal main right adrenal vein, which is controlled and transected. Remainder of mobilization of right adrenal gland is similar to that on left side.

Anterior Transperitoneal Technique

As discussed previously, this approach has been largely superseded by the lateral transperitoneal approach. Typically, the patient is placed in either the supine or the semilateral position (9,58,88). Ports are generally placed in a subcostal arrangement (9,58,88). On the right side, the liver is retracted superiorly, and the paracaval posterior peritoneum is incised to achieve direct access to the inferior vena cava and therefore the adrenal vein (9,58,88). Once the vein has been divided, the adrenal is then mobilized (9,58,88). On the left side, the splenic flexure is mobilized medially and access to the adrenal achieved by reflecting the stomach and pancreatic tail medially (9,88). The adrenal vein is identified and divided, and the adrenal gland is then mobilized and removed (9,58,88).

Location of Distant Metastases

The lungs are the most common site of distant metastases in differentiated thyroid cancer, followed by the skeleton. Both lung and bone metastases also occur in about one third of patients with distant metastases. Other less common sites of metastases are the brain, the liver, the skin, and, rarely, the omentum and adrenal glands.9 These rare sites of metastatic disease are found more frequently in patients with lung and bone metastases.

Localizing Procedures

And magnetic resonance imaging (MRI) scanning. Radiocholesterol scintigraphy is very useful in patients with Cushing's syndrome because it evaluates both adrenals simultaneously.8 9 In patients with adrenocortical hyperplasia resulting from a corticotropin-dependent syndrome, scintigraphy shows bilateral uptake (Fig. 70-4A). In the presence of a cortisol-secreting adenoma, focal uptake is observed, and scintigraphy accurately depicts the suppression of the contralateral adrenal gland (Fig. 70-4B). When an adrenal tumor is present, either CT or MRI scanning localizes the tumor and documents the size of the mass and its relationship to the surrounding structures (Fig. 70-4C and D). In selected patients with a unilateral adrenal mass, image-guided fine-needle aspiration cytology may be performed when requested for surgical planning.10

Laparoscopic Ultrasound

We used laparoscopic ultrasonography in 15 selected cases. In 1 patient it showed the location of a 0.7-cm aldosteronoma in an adrenal gland after open surgery failed to find the organ. In 2 patients, no adenoma was found, necessitating only biopsy and closure rather than adrenalectomy. In 2 patients with large masses (10 and 12 cm), no extra-adrenal or lymph node involvement was found. The masses were completely removed laparoscopically and proved to be histologically benign. In 1 patient, vascular invasion of an adrenal adenocarcinoma was found, leading to conversion to successful open resection. In 1 patient with metastatic cancer, the invasion of periadrenal fat was demonstrated, and the lesion was removed with negative margins. In an additional 2 cases, it helped identify the right adrenal vein, which facilitated dissection and control. Finally, bilateral hyperplasia was found in another case, requiring bilateral adrenalectomy. Other groups reported similar results using...

Historical Background

The adrenal glands were first described in 1552 by Bartholomaeus Eustachius in his Opuscula Anat mica1 as glandulae renis incumbentes (glands lying on the kidney). His work was printed again in 1722 by Lancisus, long after Galen, da Vinci, and Vesalius failed to recognize their existence.2 In 1629, Jean Riolan of Paris introduced the term capsulae suprarenales, which persisted for many years.2 Their function remained controversial for the next 300 years. In 1716, the Academie des Sciences de Bordeaux offered a prize for the answer to the question What is the purpose of the suprarenal glands but no progress was achieved. In the 18th century, Edward Home thought that they form a reservoir in which some other substance is laid up in store, till wanted. 3 In 1805, Cuvier defined the anatomic division into a cortex and a medulla4 without suggesting any functional role of the adrenals. In 1855, Thomas Addison of Guy's Hospital5 published his clinicopathologic observations of 11 patients...

Adrenocortical Carcinoma in Childhood

The biochemical profile in children is similar to that in adults. Surgery is the only means offering cure. The role of adjuvant therapy is unproved. Average survival is 24 months but can reach up to 8 years. It should also be kept in mind that 40 of neuroblastomas are located in the adrenals and are now commonly diagnosed by antenatal ultrasonography.

Ovarian and Testicular Disorders

Sexual development in both males and females is driven by the hypothalamic-pituitary axis. The normal process is the result of pulsatile release of GnRH from the hypothalamus, which stimulates the pituitary to release FSH and LH (GHRH and GH also play a role). Release of FSH and LH activates the ovary and testis to produce estrogen and testosterone and is responsible for stimulation of gametogenesis. This process is assisted by conversion of adrenal androgens from the adrenal cortex into androstenedione and subsequently into potent androgens (testosterone) or estrogens (estradiol) in the peripheral tissues (see Adrenal Glands). Errors can occur along this complex pathway, resulting in early sexual development (precocity), delayed sexual development (delayed menarche), errors of translation (male feminization syndrome), early loss of reproductive function (premature menopause), and inappropriate response to stimuli (polycystic ovary syndrome).

Outcome Risk Factors for Postoperative Persistent Hypertension

Removal of the hyperfunctioning adrenal gland normalizes the renin-aldosterone system and corrects the hypokalemia. We have had a 98 success rate with unilateral adrenalectomy Identification of patients who are likely to have persistent hypertension after an adrenal operation is clinically important. Several authors have investigated various discriminant factors of persistent hypertension after removal of an adrenal lesion. We previously reported that age, gender, and the pathologic features of the resected adrenal gland are statistically significant prognostic factors of persistent hypertension after unilateral adrenalectomy in patients with primary hyperaldosteronism.13 In the present expanded series, univariate analysis showed that several variables, including age, gender, duration of known history of hypertension, and preoperative ratio of PAC to PRA, had a significant effect on postoperative hypertension (Table 68-2).

During Swallowing

Adrenal glands The adrenal glands lie on top of the kidneys. Each gland has a cortex (outer layer) and a medulla (core). The cortex produces corticosteroid hormones, whose roles include helping to regulate blood levels of salt and glucose, and tiny amounts of male sex hormones, which promote Adrenal gland Adrenal gland


There are three control studies in which surgery was performed on patients in the hypothyroid state.88 91-92 Problems and complications during and after surgery were then compared with those of euthyroid patients. On the basis of these studies, we have established guidelines for the care of patients in a hypothyroid state who may have to undergo surgery (Table 6-3). Before surgery, all surgical patients in a hypothyroid state should have glucocorticoid administered because hypothyroidism can be of central origin, and even primary hypothyroid patients may experience adrenal insufficiency during surgery.92 93 It is appropriate to administer 50 to 100 mg hydrocortisone every 8 hours during the preoperative period. The normal adrenal gland produces as much as 300 mg hydrocortisone a day thus, 100 mg of hydrocortisone given every 8 hours should be sufficient to cover all surgical stress. The dose of preoperative medications, such as sedatives, should be reduced or avoided. During...

Hormonal changes

Parturition is the expulsion of the fetus and its membranes from the uterus. It involves interaction between the hormonal and nervous system control mechanisms. It is thought to be initiated by the fetuses within the uterus. As they grow larger they outgrow the available space, which results in distress and the secretion of cortisol from the fetal adrenal glands. Cortisol causes the corpus luteum within the ovary to degenerate and the levels of progesterone secreted by it throughout pregnancy to fall. At the same time oestrogen levels begin to rise and the uterine muscles, which were relaxed under the influence of progesterone, regain their ability to contract and are described as being 'sensitized'.

Technique Options

The primary approaches to the adrenal gland are via either the transperitoneal or retroperitoneal route (Table 3). The transperitoneal route may be anterior, with the patient in a supine or semilateral position, or lateral, with the patient in the lateral decu-bitus position. The retroperitoneal approach may also utilize the lateral decubitus position or alternatively, the patient may be placed in the prone jack-knife position and the adrenal gland approached from the posterior aspect. More recently, a transthoracic approach has also been described (12). The advantages and disadvantages of each of the transperitoneal and retroperitoneal routes have been extensively addressed in the literature and are summarized below in Table 3. In this approach, the lateral decubitus position allows the viscera to fall medially with gravity, facilitating access to the adrenal gland (45). This contrasts the anterior approach in which the adrenal lies in the most dependent part of the operative field...