adrenal hypertension

8/14/2019 Adrenal Hypertension

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ADRENAL AND EXTRA-ADRENAL

HORMONE SECRETING TUMOURS

A SEVEN YEARS EXPERIENCE AT RGH

Dr.Nadir Mehmood

Assistant ProfessorSurgery

Rawalpindi Medical College

Rawalpindi


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INTRODUCTION

Small in size but powerful in influence , the Adrenal glands and theirhormones are necessary to sustain life and maintain homeostasis.

Adrenal glands were overlooked by early anatomist and were firstaccurately described in 1563 by Bartholomeos Eustachius.

More than 300 years passed before there was some understandingof the functions of these glands.

Adrenal and extra adrenal tumors are rare and often present laterwhen physiological derangement is well established .


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INTRODUCTION

Despite the rarity of such tumors there have beensignificant advances in the understanding andmanagement of these tumors in the recent years.

Disorders of Adrenals and the related structure maypresent in a variety of ways depending on the effects ofhormones they produce.

Even such tumors may produce mass effect or be an

incidental finding in the course of investigating some

other problem. So such findings do not always warrant treatment.


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PHYSIOLOGY

Hyperfunction of adrenal gland is divided into threecategories depending upon the main hormone ofsecretion

1: Hypercotisolism

Cushing syndrome ( primary adrenal pathology

Cushings disease (secondary to raised ACTH)

2: Hyperaldosteronsim

Conns syndrome ( primary adrenal pathology)

Secondary hyperaldosteronism ( chronic renalfailure

3: Hypercathecholaminemia

Adrenal glands tumors

Extra adrenal chromoffin tissue tumors


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PHSYIOLOGY

As these adrenal hormones regulate a wide range ofphysiological functions,it is not surprising that hyperplastic orneoplastic conditions of adrenal and extra-adrenal tissues cancause excessive secretion of various hormones resulting in avariety of clinical syndrome

The presentation and diagnosis of adrenal and extra-adrenaltumors secreting hormones is complex and the discriminatingfactors for each are necessary to minimize the time and costin diagnosis.

Because of the rarity of such tumors, most of the studies in

the literature are retrospective in nature.


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PURPOSE OF THE STUDY

To evaluate a broad range of features ,including

Clinical Features

Evolution of disease/syndrome

Hormone secretion

Imaging technique

Problems during anesthesia

Approaches to the exposure of the related

structures Technique used

Intra and postoperative morbidity and mortality

Histopathological diagnosis


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METHOD

A detailed history, especially pertaining to headache,sweating,palpitation,flushing,mass or pain abdomen,uncontrolled hypertension, breathlessness, episodicweakness of limbs or tremors in hand, nausea,vomiting or diarrhea and weight loss/gain wasrecorded on data sheets.

History of any medical treatment for the presentingsymptoms/complaints and their efficacy in relievingthe complaints was recorded.

Previous medical and surgical history,family H/O anydisease like hypertension,diabetes or obesity or tumorof any site was recorded.


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METHOD

A detailed clinical examination of each patient includingweight and height, vital signs, skin, face, neck, hairdistribution, extremities and abdomen was performed.

A record of blood pressure was analyzed, especiallyafter the abdominal examination/palpitation in patientswith pheochrmocytoma.

Patients with visual complains and headaches weretested for visual acuity and in patients with severe

uncontrolled hypertension, fundoscopy was alsoperformed.


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INVESTIGATIONSRoutine investigations on all patients

C.P. E.S.R

R/E urine

B.S.R

Urea and creatinine

Serum electrolyte Blood grouping

E.C.G

Chest X-ray P.A view

Special tests were selectively performed including,

L.F.Ts

I.V.U

Echocardiography

Serum hormones level - cortisol, aldosterone, renin andurinary VMA


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INVESTIGATIONS

Routine imaging included

- Ultrasound examination

- C.T scan on all patients Results of all these investigations

were listed in tabulated form and

the findings of ultrasound, C.T scanand operative findings werecomparatively analyzed.


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OPERATIONS A total 14 operations were performed in 13 patients. One patient with bilateral adrenal pheochromocytoma was operated

twice , once at a time.

2 patients were not operated, one with incidentaloma, and the otherwith right adrenal pheochromcytoma with multiple metastasis in theliver ( Pt.refused operation )

Preoperative blood pressure was controlled using a combination ofdrugs which included

- Diovan(Valsartan)

- Prazocin

- Nifidipine

- Atenolol

- Frusemide

for patients with pheochromocytoma and Cushing syndrome and- Spinolactone for patients with Conns synd.


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TECHNIQUE

Antibiotic prophylaxis as 1 gm of 1st generationCephalosporin I/V was given to all the patientsfollowed by two doses postoperatively.

General anesthesia by a senior anesthetist. Posterolateral approach through the bed of 12th rib

in 11patients.

Anterior midline in 2 patients with paraganglionoma

and pheochromocytoma of organ Zukerkandle.


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Peroperative tachyarrhthmia during themanipulation of pheochromocytoma wascontrolled by infusion of lignocaine, and rise inB.P was controlled by nitrocine infusion.

Postoperative hypotension of varying degreeoccurred in almost all patients withpheochromocytoma, even the one with bilateraladrenal pheochromocytoma which wascontrolled by infusion of:

0.9% N/Saline

Gelafundin

Blood transfusion

Infusion of dopamine


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Replacement of fluid ranged from 3.5 litres to 7 litres

Average 5.25 litres as

-N/saline 2000ml

-Gelafundin 100ml

-5% D/W 1000ml-2 units of blood.

Coticosteriod replacement was given to all patientsafter surgery for Cushings syndrome and after secondoperation on patient with bilateral pheochromocytoma.

The patients were followed up for an average of 2.5years, ranging from 12 months to 5 years


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PRESENTATION /CLINICAL

FEATURES

PHEOCHROMOCYTOMA

Recurrent episodes of severe headache,sweating palpitation and flushing ( face, handsand chest) 7

Triad of headache, palpitation and sweating withmass in Rt.H.C and Rt.L.R 1

Pain in Rt.L.R and Rt.H.C.associated with triad1

PARAGANGIONOMA

Mass in Rt.H.C 1

Hypertension not controlled by ordinary dosageof antihypertensive drugs


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PRESENTATION /CLINICAL

FEATURES

CONN SYNDROME

Episodic weakness of limbs and tremors in the hand 3

Adding headache,palpitation and breathlessness 1

Other symptoms of nausea, vomiting and diarrhea 1

CUSHING DISEASE

Obesity,breathlessness on exertion, mood changes and easybruisibility. 2

Off and on complain of backache, joint pain, increased appetite, weightgain, sweating, vertigo and headache


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Age

Most of the patients were young

Age Range 15 - 45 years

Average age 31.066 years


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ON CLINICAL EXAMINATION

Pulse rate Range 80-96/min

Av 80/min

B.P Systolic range 140-240mmhg

Av 196

Diastolic range 95-150mmHg

Av 128.57mmHg

R/R Range 18-28/min

Av 20/ min

Weight 125kg=2 with cushing Incident 130kg

Ht 5 . 1, 5 . 2 and 5 . 4

Range 46-96kg with pheo and conn Av 62.09kg

Height 4 . 10 - 5 . 8Av 5 . 2


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ABDOMINAL EXAMINATION

Mass abdomen in3 cases - all pheo (20% of all cases )

Visible bulge and palpable mass that was ballotable andmoved with respiration.

After completing the abdominal examination patientstypically experienced episodes of headache, sweatingand flushing -- all pheo cases

So medical students and junior residents were refrainedfrom examination of patients with suspectedpheochromocytoma.

Striae distentie on abdomen, chest and limb in boththe cases of Cushings and incedendaloma.


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INVESTIGATIONS

H.b Range 9.6 - 15gm

Av. 11.6533gm

T.L.C Range 4400-8900

Av. 6200

E.S.R Range 10-90mn

Av. 23.6mn

Urine R/E Albumin +/++3 cases

B.S.R

S.Urea/ creatinine

L.F.Ts Select

H.B.V and C Screen all


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INVESTIGATIONS

S.Electrolytes

Na Range N Av N

K Range 1.3-2.6 Av 2(conns only)

Cl Range N Av N

Ca Range N Av N

S.Renin Range 0.6-2.62

Av 1.32666

S.Aldosterone Range 35.9-130

Av 91.8666

S.Prolactin 789.2 (N-61-512.m.I.u/ml)


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Three measurements of 24-hr urinary VMA

in 10 patients of pheochromocytoma and

incidentaloma

Range 4 - 15.6mg / 24hr

Average9.1972mg / 24hr

Normal upto 8 mg / 24 hrNo relation with the size of the tumor


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Tumor N Male Female Rt Lt B/L

Total 15 5 10 7 5 1

Adrenal 13 5 8 7 5 0

Pheo 7 4 3 4 2 1

Conn 3 1 2 2 1 0

Cush 2 0 2 1 1 0

Incid 1 0 1 0 1 0

Pheo OrgZ 1 0 1 0 0 0

Paragang 1 0 1 0 0 0


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PREOP-PREPARATION Patients were admitted on an average of 5 days preoperatively B.P control with

Cap Diovan ( Valsartan) 80mg OD

Tab minipres ( prazocin ) 1 mg - 2mg T.D.S

Cap Adalet ( nifidipine) 10 mg-20 mg T.D.S

Tab Atenolol 50mg-100mg O.D/ B.D

Tab Frusemide 20mg-40mg O.D or B.DTab Spinoloctone 100mg TDS

Tab Voltaral( diclfenac) 50mg BD for pain

Correction of iron deficiency with hematanics

Fluids

C.V.P was passed in Rt.Subclavian vein via infraclavicular route in O.T.

preoperativly.


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DURATION OF SURGERY

Range 1.75 hrs - 5.5hrs

Average 2.5 hours

Postoperative stay

Range 7 - 15 days Average 9.3 days


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MORBIDITY

No wound infection

Chest infection in 1 patient


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MORTALITY

One patient with paraganglianoma

suffered from cardiac arrestperoperatively.

Died on 3rd postoperative day due toC.V.A. and respiratroy distress.


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FOLLOW UP

After two months of follow up all the

patients were symptomatically improvedwithout any antihypertensive therapy.

Serum electrolyte and other laboratory

data became normal after the first week ofoperation.


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S. No. U/S C.T Scan V.M.A Perop Finding

1. 83 X 68mm 80 X60mm 4.7mg/ 24hr 100 X 90mm2. Normal 30 X 20mm 7.5mg/ 24hr 30 X 20mm3. 40 X 16mm 24 X 25mm 9.5mg/ 24hr Not operated4. Normal 6.0mg/ 24hr 5. 55 X 52 X 40mm 45 X 38 X 48mm 15.6mg/ 24hr 45 X 35 X 45mm6. 120 X 80 X 50mm 150 X 90X 60mm 13.2mg/ 24hr 150 X 90 X 60mm7. (Rt) 35 X 39mm

(Lt) 36 X 24mm41.27 X 35.63

36 X 24mm40 X 50mm30 X 40mm

8. 65 X 80mm 58 X 75mm 9.5mg/ 24hr 55 X 75mm9. 30 X 38mm 35 X 40mm 11.2mg/ 24hr 35X 40mm10. 40 X 29mm 40 X 33mm 9.0mg/ 24hr 40 X 30mm11. Huge mass>150mm Huge mass>150mm 7.5mg/ 24hr Not operated12. 15 X 12mm 15 X 12mm 15 X 10mm13. 35 X 40mm 35 X 40mm 7.6mg/ 24hr 35 X 40mm14. 25 X 30mm 26 X 32mm 25 X 30mm15. 50 X 40mm 51 X 40mm 9.5mg/ 24hr 50 X 40mm


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ConclusionYoung hypertensive patients should be

investigated thoroughly.

Pre-op preparation is essential to succesful

management of such patients.

Comparing theresult of U/S, C.T. and operativefindings, U/S had a sensitivity of 86.6% in

diagnosing tumors compared with 100%

sensitivity of C.T. scan.Urinary VMA excretion was not related to size of

the tumor.

Over-night dexamethasone test has good

diagnostic yield in hypercathecholaminia.


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Cortical sparing adrenalectomy is

a good option in patients with

bilateral tumors.

Sequential operation is better

choice to simultaneous surgery in

patients with bilateral tumors.

adrenal hypertension

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