Adrenal insufficiency: Diagnosis and treatment

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The article was professionally consulted by resident Doctor Le Thanh Tuan - Department of General Surgery - Vinmec Nha Trang International General Hospital. The doctor has extensive experience in examination, treatment and surgery of abdominal diseases.
Adrenal insufficiency is a condition in which the adrenal glands produce too little cortisol, disrupting metabolic processes in the body, seriously affecting human health.

1. Adrenal cortex physiology

The adrenal gland is a small endocrine gland located above the two kidneys. Each gland is composed of 2 parts, the marrow secretes catechamine hormones to maintain blood pressure and heart rate; The adrenal cortex secretes the hormone aldosterone. This is the main mineral corticosteroid secreted by the glomerulus, which is the outermost layer of the adrenal cortex. Aldosterone acts on the renal tubules to increase sodium reabsorption and potassium excretion, thereby providing protection in hypovolaemia and hyperkalemia.
1.1. Mechanism of secretion of adrenocortical hormone Decrease in blood volume causes indirect stimulation of aldosterone secretion. Decreased blood volume stimulates the paraglomerular cells to secrete renin; renin stimulates peripheral conversion of angiotensin I to angiotensin II; angiotensin II stimulates aldosterone secretion. Hyperkalemia directly stimulates aldosterone secretion. Atrial sodium-reducing factors and dopamine inhibit aldosterone secretion. Corticosteroids are the major glucocorticoids secreted by the medial and reticular layers of the adrenal cortex.
1.2. Effects of Cortisol Increases blood sugar by inhibiting insulin secretion and increasing gluconeogenesis from the liver. Inhibition of protein synthesis in muscle bundles creates a source of amino acids for that regeneration. Required for the production of angiotensin II, thus helping to maintain vascular tone. Inhibits production or activity of many inflammatory and immune mediators such as Interleukin-6 (IL-6), lymphokines, progstaglandins and histamine. Increases renal free water clearance Decreases serum calcium by inhibiting intestinal calcium absorption, tubular renal tubular calcium diffusion into cells. Cortisol is excreted in a circadian rhythm, with the highest at waking and lowest at bedtime. Normally, increased cortisol secretion during physical activity increases glucose and fatty acids needed for energy production. Cortisol secretion is increased in cases of acute trauma, infection or psychological trauma. Cortisol increases in these cases are protective, helping the body to prevent dangerous overreactions.
Androgens are produced in the adrenal cortex, most in the inner bundle. Aldosterones are the primary androgens whose function is to be secreted by the adrenal glands. The secretion of this hormone precedes the secretion of androgens by the gonads, stimulating the growth of the sex hair system during puberty.

2. Diagnosis of adrenal insufficiency

2.1. Essential points in the diagnosis Fatigue, abdominal pain, vomiting, nausea, diarrhea, fever, impaired consciousness. Low blood pressure, dehydration; skin pigmentation increases. High blood potassium, low blood sodium, high blood urea. Non-stimulating cosyntropin raises blood cortisol to normal levels. 2.2. Diagnostic measures of adrenocortical insufficiency To diagnose adrenocortical insufficiency, your doctor may initially use a measurement of the level of cortisol or adrenocorticotropic hormone (ACTH) in your blood. When the symptoms are partially controlled, tests will be carried out to diagnose whether the level of adrenocorticotropic hormone is normal or not, specific tests such as:
Check potassium levels through blood potassium tests bar; Check sodium levels through sodium test; Determination of blood sugar through a fasting blood glucose test; Testing cortisol levels; Adrenal cortex hormone test. 2.3. Subclinical diagnosis The number of eosinophils may increase, the number of red blood cells may decrease; hyperkalemia, decreased blood sugar. Blood cultures, sputum cultures, or urine cultures may be positive in cases of acute adrenocortical failure triggered by infection. Neutrophils are moderately reduced, lymphocytes are increased, and the number of eosinophils exceeds 300/ml of blood. In chronic adrenocortical insufficiency, hyponatremia accounts for 90%, while serum potassium is elevated (65%). In patients with diarrhea, blood potassium does not increase. Fasting blood sugar. Blood calcium may increase. The test measures the concentration of very long chain fatty acids in the blood plasma. Low plasma cortisol (< 5 mg/dl) at 8 am is diagnostic, especially with concomitant elevation of serum ACTH (usually > 200 μ/ml). The cosyntropin stimulation test was performed as described above. Anti-adrenal antibodies are found in serum in approximately 50% of cases of autoimmune Addison's disease. Anti-thyroid antibodies are 45% and antibodies to other tissues may also be present.

3. Treatment of adrenal insufficiency

3.1 General Measures When diagnosed with acute adrenocortical insufficiency, you should immediately and aggressively treat all infections, and increase the dose of hydrocortisone accordingly.
The dose of glucocorticoids is also increased in cases of trauma, surgery, stress, the maximum dose of hydrocortisone used in cases of severe stress is 50 mg every 6 hours intravenously or intramuscularly.
Lower dose given orally or parenterally for milder cases of stress. This dose will be gradually reduced to the normal dose once the stress has subsided.
Patients with adrenocortical white matter disorder are treated with diet and bone marrow transplantation.
3.2. Specific treatment Alternative therapy includes a combination of both glucocorticoids and mineralocorticoids. In mild cases, hydrocortisone alone may be sufficient.
Hydrocortisone is the drug of choice, most patients with adrenal insufficiency take it orally at a maintenance dose of 15-25 mg/day in 2 divided doses: 2/3 of the dose taken in the morning and 1/3 of the dose taken in the morning. my afternoon. Some cases respond better to prednisolone with doses of 3 mg in the morning and 2 mg in the evening. Many patients require additional fludrocortisone or salt intake because the salt-retaining effect of hydrocortisone is insufficient.
Fludrocortisone acetate has a strong salt-retaining effect. Oral dose 0.05 mg - 0.3 mg/day. If the patient has orthostatic hypotension, hyperkalemia or emaciation, the dose should be increased. In contrast, in cases of edema due to hypokalemia or hypertension, the dose should be reduced.
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