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Curriculum standards

Knowledge guides

LG 20: Adrenal disorders

Key presentations and conditions

Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.

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Less common or more complex presentations and conditions

Advanced Trainees will understand these presentations and conditions.

Advanced Trainees will understand the resources that should be used to help manage patients with these presentations and conditions.

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Epidemiology, pathophysiology, and clinical sciences

Advanced Trainees will have a comprehensive depth of knowledge of the principles of the foundational sciences.

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Investigations, procedures, and clinical assessment tools

Advanced Trainees will know the scientific foundation of each investigation and procedure, including relevant anatomy and physiology. They will be able to interpret the reported results of each investigation or procedure.

Advanced Trainees will know how to explain the investigation or procedure to patients, families, and carers, and be able to explain procedural risk and obtain informed consent where applicable.

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Important specific issues

Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management, and integrate these into care.

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Presentations
  • Cardiac arrythmia
  • Electrolyte disturbance
  • Fatigue
  • Fractures
  • Headache
  • Hirsutism
  • Hypertension:
    • constant
    • paroxysmal
  • Hypotension
  • Incidental adenoma
  • Menstrual disturbance
  • Metabolic syndrome
  • Pallor
  • Palpitations
  • Sweating
  • Weight gain/Obesity
  • Weight loss
Conditions
  • Adrenal cancer
  • Adrenal insufficiency/failure:
    • adrenoleukodystrophy
    • autoimmune:
      • Addison's disease
      • immunotherapy related
      • polyglandular autoimmune syndrome
    • haemorrhage
    • idiopathic
    • infarction
    • infection
  • Adrenal metastasis
  • Adrenal nodular disease:
    • functional:
      • Conns syndrome/ hyperaldosteronism
      • Cushings syndrome/ hypercortisolism
      • phaeochromocytoma/catecholamine-producing
    • non-functional
  • Congenital adrenal hyperplasia
  • Macronodular adrenal hyperplasia
  • Phaeochromocytoma
  • Primary adrenocortical

For each presentation and condition, Advanced Trainees will know how to:

Synthesise
  • recognise the clinical presentation
  • identify relevant epidemiology, prevalence, pathophysiology, and clinical science
  • take a comprehensive clinical history
  • conduct an appropriate examination
  • establish a differential diagnosis
  • plan and arrange appropriate investigations
  • consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
  • provide evidence-based management
  • prescribe therapies tailored to patients' needs and conditions
  • recognise potential complications of disease and its management, and initiate preventative strategies
  • involve multidisciplinary teams
Consider other factors
  • identify individual and social factors and the impact of these on diagnosis and management
Conditions
  • Inherited adrenal disorders:
    • congenital adrenal hypoplasia
    • MEN2A, MEN2B/3 VHL
    • micronodular adrenal disease/Carney complex
  • X-linked adrenal leukodystrophy

For each presentation and condition, Advanced Trainees will know how to:

Synthesise
  • recognise the clinical presentation
  • identify relevant epidemiology, prevalence, pathophysiology, and clinical science
  • take a comprehensive clinical history
  • conduct an appropriate examination
  • establish a differential diagnosis
  • plan and arrange appropriate investigations
  • consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
  • provide evidence-based management
  • prescribe therapies tailored to patients' needs and conditions
  • recognise potential complications of disease and its management, and initiate preventative strategies
  • involve multidisciplinary teams
Consider other factors
  • identify individual and social factors and the impact of these on diagnosis and management

Clinical science

  • Anatomy, physiology, and histopathology of the normal and the abnormal adrenal gland (cortex and medulla), hypothalamic-pituitary-adrenal axis and sympathetic/parasympathetic ganglia
  • Epidemiology and natural history of adrenal hormone excess disorders
  • Epidemiology of genetic predisposition to adrenal disease
  • Function and regulation of the adrenal gland

Diagnostic work up

  • Aetiology, pathology, and clinical manifestations of adreno-cortical hormone deficiency, primary and secondary
  • Aetiology, pathology, and clinical manifestations of adrenal hormone excess:
    • hyperaldosteronism
    • hypercortisolism
    • phaeochromocytoma
    • virilising tumours
  • History, physical examination, and diagnostic work up of patient suspected of presenting with adrenal disease
  • Limitations, indications, and interpretation of biochemical assays in the diagnostic work up of adrenal disorders:
    • complex diagnostic work up and pitfalls in Cushing syndrome
    • diagnostic work up and pitfalls in hyperaldosteronism
    • different genetic disorders affecting the adrenal gland
    • impact of medications on the assessment of hormone excess and deficiency

Medical management considerations

  • Emergency and long-term management of hypoadrenalism due to primary and secondary adrenal insufficiency:
    • prescribing and monitoring of glucocorticoid and/or mineralocorticoid
    • screening for associated disorders
  • Medical management of adrenal disorders of excess hormone production and monitoring of the underlying condition
  • Monitoring of treatment efficacy
  • Pharmacological principles of medications used in adrenal disorders:
    • alpha and beta-receptor antagonists
    • glucocorticoids
    • mineralocorticoid receptor antagonists
    • mineralocorticoids
    • steroid biosynthesis inhibitors, such as:
      • ketoconazole
      • metyrapone
Investigations
  • Biochemical investigation of adrenal disease, including the hypothalamic-pituitary-adrenal axis:
    • baseline testing
    • dynamic testing
  • Imaging:
    • CT adrenal protocol
    • MRI
    • PET scan
  • Interpretation of biochemical testing in the clinical context:
    • dynamic endocrine testing
    • specific understanding of indications (and contraindications):
      • investigation for suspected Cushing syndrome, such as:
        • dexamethasone suppression tests
        • salivary testing
        • urine testing
      • short synacthen test
  • Investigation for suspected Conn's syndrome:
    • fludrocortisone suppression test
    • seated saline suppression test
  • Laboratory biochemistry:
    • timing, patient preparation, and assay platforms suited for adrenal hormone testing
Procedures
  • Indications for adrenal vein sampling
  • Indications for adrenalectomy
  • Indications for chemotherapy for malignant adrenal lesions
  • Pre-, peri- and postoperative management of patients with adrenal disease, with particular emphasis on prevention of adrenal crisis and preoperative preparation and perioperative management of phaeochromocytoma

Evidence-based practice

  • Remain abreast of evidence for best practice and apply this using clinical judgement and individual circumstances in partnership with patients
  • Seek multidisciplinary care/review from centres of expertise wherever necessary

General management considerations

  • Impact of adrenal disease and/or genetic diagnoses on the patient, their partner and, where applicable, their family/carers
  • Incorporate environmentally sustainable practices in clinical care
  • Longitudinal and multidisciplinary care needs of people with adrenal disease
  • Mitigate clinical risk with sick day management plans when applicable, including use of medical alert bracelets or similar
  • Options for improving equitable access to comprehensive care for individuals, such as:
    • appropriate multicultural resources
    • multidisciplinary involvement
    • use of telehealth and other digital health tools
  • Pre-, peri- and postoperative management of patients with adrenal disease
  • Screening and genetic counselling of patients with inherited adrenal disease and referral of their family members if appropriate and with informed consent

Health needs of specific patient groups

  • Preconception counselling and pregnancy management of women with congenital adrenal hyperplasia
  • Multidisciplinary care of patients with adrenal cancer or malignant phaeochromocytoma/paraganglioma