Adrenal insufficiency

Adrenal insufficiency is a syndrome caused by a primary adrenal cortex disorder (Addison's disease) or secondary changes due to decreased secretion of ACTH; Is manifested by symptoms of decreased production of adrenal cortex hormones. Distinguish chronic and acute adrenal insufficiency.

Etiology, pathogenesis. Primary adrenal insufficiency is caused by tuberculosis (in 40% of cases) or atrophy of the adrenal cortex caused by autoimmune processes (in 50% of cases), less often by bilateral adrenalectomy, adrenal thrombosis or embolism. The cause of secondary insufficiency may be postnatal necrosis of the pituitary (Shikhen syndrome), pituitary tumors, hypophysectomy, craniopharyngiomas.

Pathogenesis: decreased secretion of cortisol, aldosterone and corticosterone. Symptoms, course. Primary chronic insufficiency is characterized by constant muscle weakness, which increases after exercise, weight loss, hyperpigmentation of the skin of the face, neck, palmar folds, axillary areas, perineum. Pigmented spots on the mucous membranes (the inner surface of the cheeks, tongue, hard palate, gums, vagina, rectum) are bluish-black in color. BP is usually lowered, sometimes normal, can be increased when combined with hypertension. Almost always expressed gastrointestinal disorders (decreased appetite, nausea, vomiting, abdominal pain, loose stools); Protein (reduced protein synthesis), carbohydrate (low sugar on an empty stomach, flat curve after loading with glucose) and water-salt (hyperkalemia, hyponatremia) metabolism are violated. Excretion in the urine of sodium is increased, potassium - reduced. Characterized by a decrease in the level of 17-ACS in plasma and urine, the absence or reduction of the reserves of hormone secretion by the adrenal cortex when stimulating ACTH. Secondary adrenal insufficiency, accompanied by the loss of only the secretion of ACTH by the pituitary, is extremely rare. The combination with a deficiency of thyroid-stimulating, somatotropic, gonadotropic hormones is more often observed, characterized by the corresponding symptoms (interstitial-pituitary insufficiency).

The diagnosis is based on a decrease in the baseline level of 17-ACS in urine and plasma and a preserved response to ACTH. Isolated insufficiency of ACTH occurs in patients taking synthetic corticosteroids for the treatment of non-endocrine diseases (bronchial asthma, skin and kidney diseases).

Acute adrenal insufficiency, or addisonic crisis, is an acute coma that occurs in patients with chronic adrenal insufficiency, usually when infection, trauma, surgery and other extreme conditions are attached. Occurs with acute hemorrhage in the adrenal gland or the development of a heart attack in them. For the addisonian crisis are characterized by: cardiovascular failure, a fall in blood pressure, gastrointestinal disorders (indomitable vomiting, multiple multiple stools), neuropsychiatric disorders, increased pigmentation. From the laboratory data, a decrease in the sodium content in the blood to 130 mmol / l and lower, an increase in the potassium content to 6-8 mmol / l, the presence of low blood sugar, eosinophilia, and lymphocytosis are characteristic.

Treatment of primary and secondary adrenal insufficiency is the introduction of hormones of the adrenal cortex. Apply prednisolone (prednisone) to 5-10 mg or cortisone for 25-50 mg per day; Combinations of prednisolone and cortisone are recommended; 2 / d dose of hormones taken inside the morning and 1/3 - in the afternoon (after eating). If the blood pressure is not normalized, add 5 mg of desoxycorticosterone acetate in the oily solution in / m daily, every other day or twice a week, or in tablets 5 mg 1-3 times a day under the tongue. Treatment is performed under the control of blood pressure (if it is above 130/80 mm Hg, the dose is reduced, achieving normalization of blood pressure), body weight (rapid increase also indicates an overdose of glucocorticoids), general well-being of the patient (disappearance of anorexia, dyspepsia, muscle weakness) . Synthetic drugs (dexamethasone, triamcinolone, etc.) should not be used for a long time to compensate for chronic adrenal insufficiency. The diet should contain a sufficient number of proteins, fats, carbohydrates and vitamins; Additionally prescribed table salt (up to 10 g per day), with a sharp decrease in body weight, anabolic steroids are recommended (courses 3-4 times a year). Ascorbic acid is prescribed for 1-2 grams per day permanently. With tuberculous etiology of the disease, anti-tuberculosis treatment is carried out together with a phthisiatrician. In acute adrenal insufficiency hydrocortisone is administered in / m (50-100 mg4-6 times a day) and IV (special solution for intravenous administration of cortisone and hydrocortisone -100-200 mg struyno, 200-400 mg by drop method in isotonic chloride solution Sodium or 5% glucose solution - 300 ml for 4-5 hours together with cardiovascular drugs).

You can inject a solution of prednisolone for IV infusion in a jet or drip in doses of 30-90 mg. Deoxycorticosterone acetate is injected 5-10 mg / m daily until blood pressure normalization. With concomitant inflammatory processes, antibacterial therapy is used. The prognosis is favorable with timely and adequate replacement therapy.