Adrenal Glands

The adrenal glands are paired organs that are located above the kidneys. They are under the control of the pituitary gland via adrenocorticotropic hormone (ACTH).

The adrenal glands are composed of two layers: the outer cortex, and the inner medulla. The cortical cells produce the hormones cortisol, DHEA, aldosterone, and the sex steroids testosterone and estradiol. The medullary cells produce epinephrine and norepinephrine.

Diseases of the adrenal glands

Hyperaldosteronism (Conn’s Syndrome)
Usually the cause is a benign tumor in the adrenal gland that secretes aldosterone. Excess aldosterone causes the symptoms of hypertension and hypokalemia. Bilateral adrenal hyperplasia (BAH) can also cause this syndrome. Cancer is uncommon.
Hypercortisolism (Cushing’s Syndrome)
Excess cortisol can be caused by taking steroid medications, excess secretion of cortisol from the adrenal glands, or an extra-adrenal cause such as an ACTH secreting pituitary tumor (Cushing’s disease) or rarely, a neuroendocrine tumor of the pancreas, lung, or bronchus. Adrenal causes include a benign adenoma, hyperplasia, and adrenocortical cancer. The symptoms include weight gain, muscle weakness, fragile skin, striae, fat deposits in the posterior neck, shoulder, and abdomen, new onset diabetes, mood disturbances. The diagnostic tests for this syndrome may be extensive.
Pheochromocytoma
These tumors secrete the catecholamines epinephrine, norepinephrine, and dopamine. Some may be part of an inherited syndrome, such as MEN or Von Hippel-Lindau.The excess catecholamines are usually secreted in bursts, causing symptoms such as spells of hypertension, dizziness, rapid and/or pounding heart beats, and in severe cases, could cause stroke and heart attacks. Most pheochromocytomas are benign, but around 10% are malignant. Prior to surgery, the effects of the catecholamines must be blocked with drugs such as phenoxybenzamine, and/or calcium channel blockers. Beta blockers may also be used if a rapid heart rate is present.
Adrenal Incidentalomas
With the increasing use of body imaging techniques such as CT and MRI scans, increasing numbers of adrenal masses are found incidentally. Most of these masses are benign and do not require any treatment. However, some may be producing hormones, or rarely, be small adrenocortical cancers. These must be removed surgically. Therefore, patients with adrenal masses should undergo screening tests for hormone production. If the mass is 4 cm or greater, surgery may be considered even if it is not producing any hormones.
Adrenocortical Carcinoma
Adrenocortical carcinoma is very rare. They may or may not produce hormones. If the cancer has not spread to other organs, the best treatment is surgery. Chemotherapy and mitotane may also be given.

Adrenal surgery

Adrenalectomy
This is a surgical procedure to remove the adrenal gland(s). Most small adrenal masses can be removed laparoscopically. However, larger masses and those that are suspicious for cancer are removed via open surgery.

Care preparation for adrenalectomy

  • Patients with pheochromocytoma will need to have their catecholamine production adequately blocked with medications such as phenoxybenzamine, and/or calcium channel and beta blockers prior to surgery.
  • Patients with hyperaldosteronism will need to have their blood pressure and potassium levels under optimal control prior to surgery.
  • Patients with severe hypercortisolism will sometimes be placed on medications to block steroid production such as metatyrapone, aminoglutethimide, or mitotane, prior to surgery.

Care after adrenalectomy

Patients who have undergone bilateral adrenalectomy will need to have replacement of adrenal function with cortisol and mineralocorticoid. They are at risk for developing adrenal insufficiency with stress, and may need cortisol injections at those times.