Insufficiency of the adrenal glands.

Insufficiency of the adrenal glands. Chronic primary insufficiency of the adrenal cortex (addison's disease, bronze disease) is a disease caused by bilateral defeat of the adrenal cortex. At the heart of the disease is complete cessation or significant reduction in the formation of hormones synthesized in it, especially glucocorticoids (cortisone, hydrocortisone) regulating carbohydrate, protein and fat metabolism, as well as mineralocorticoids (deoxycorticosterone, aldosterone) regulating water and salt metabolism. A decrease in the production of mineralocorticoids leads to loss of large amounts of sodium and water by the body, dehydration, a decrease in the mass of circulating blood and a drop in blood pressure, hyperpigmentation, impaired glucocorticoid production, to severe disturbances in carbohydrate metabolism, a fall in blood sugar levels, and also to the development of vascular insufficiency. The disease is equally common in adult men and women; In children is rare. The causes of primary adrenal insufficiency are processes that destroy the adrenal cortex (tuberculosis, syphilis , hemorrhages or embolisms in the adrenal glands, bilateral primary or metastatic adrenal tumors , amyloidosis , lymphogranulomatosis, AIDS, etc.).

Secondary adrenal insufficiency develops as a result of a disturbance in the function of the hypothalamic-pituitary system and a decrease in the production of ACTH (eg, in a tumor , postnatal necrosis of the pituitary or hypophysectomy); With secondary adrenal insufficiency there is no aldosterone deficiency, which determines the features of its clinical picture (absence of hyperpigmentation).

Clinical picture . Initial signs of chronic insufficiency of the adrenal cortex can be rapid fatigue, attacks of unmotivated weakness, lethargy. Characteristic for primary adrenal insufficiency, bronze skin coloration can occur long before the appearance of other manifestations of the disease. It is revealed primarily in open areas of the body, on flexural surfaces (especially on palmar folds), in places of natural pigmentation (nipples), in places rubbing clothes. Hypotension is observed (especially systolic blood pressure decreases), decreased appetite, nausea , vomiting , abdominal pain, muscles and joints, headaches are often noted, memory loss, rapid mental exhaustion. With a severe form of addison's disease, menstrual cycle is broken in men, impotence develops in men.

Acute adrenal cortex function or sharp exacerbation of chronic adrenal insufficiency (adrenal crisis) can lead to the development of a coma - adrenal coma. An immediate cause of acute adrenal insufficiency with addison's disease can be surgery, intercurrent infection, physical overstrain, eating disorders with insufficient sodium intake from food, sometimes even small doses of insulin. It can develop in persons with a latently flowing, latent, previously compensated form of addison's disease. Development of adrenal crises is possible in patients who previously received large doses of steroid hormones ( cortisone , prednisolone, triamcinolone) for a long time , especially after withdrawal of these drugs or with inadequate hormone replacement therapy. Finally, acute adrenal insufficiency can occur with hemorrhages in both adrenal glands in individuals with vascular pathology, hemorrhagic diathesis, septic diseases, especially meningococcal sepsis, and also with anticoagulant or fibrinolytic therapy.

For the adrenal crisis, the most characteristic are the collapoid state and pronounced abdominal disorders. Patients experiencing a sharp weakness, lethargy; Develop adynamy, a state of complete indifference and prostration, and sometimes delirium and convulsive seizures. Abdominal disorders (nausea, abdominal pain, vomiting , propensity to diarrhea) often precede the development of the crisis, and sometimes so dominate the clinical picture of acute adrenal insufficiency that patients are referred to surgical departments with suspected acute surgical abdominal pathology. On examination, a frequent small pulse is detected (tachycardia persists even after replenishment of fluid deficiency), low blood pressure (systolic often does not exceed 50 mm Hg), cold extremities, cyanotic; Quickly signs of dehydration of the body, there is a smell of acetone from the mouth. In patients with chronic adrenal insufficiency, dark pigmentation of the skin is often determined.

The diagnosis of chronic insufficiency of the adrenal cortex is established on the basis of a characteristic clinical picture and the results of additional studies that allow to detect an increase in the level of potassium and a decrease in the level of sodium, chlorine and glucose in the serum, as well as a low content of corticosteroids in the blood.

Diagnosis of the adrenal crisis is always difficult; The possibility of acute adrenal insufficiency should be considered in cases when a persistent, unexplained collapse and tachycardia are combined with abdominal pain, vomiting, diarrhea, severe weakness, adynamia and impaired consciousness in a patient with hyperpigmentation.

Treatment of chronic adrenal insufficiency implies an individually selected replacement hormone therapy, including glucocorticoids (hydrocortisone, prednisolone) and mineralocorticoids; Prevention is the timely and proper treatment of diseases that contribute to the emergence of adrenal cortex insufficiency.

In the treatment of acute adrenal insufficiency, the use of large doses of hormones in the adrenal cortex - glucocorticoids in combination with parenteral administration of glucose and sodium chloride solutions is of primary importance. Treatment should begin with intravenous administration of 125 mg hydrocortisone. At the same time, in order to fill the deficiency of extracellular fluid, intravenously drip isotonic sodium chloride solution and 5% glucose solution. For a day, drip up to 3 - 4 liters of fluid. With a significant persistent decrease in blood pressure, vasopressors (norepinephrine) are used. A patient with suspicion of acute adrenal insufficiency is immediately hospitalized in a therapeutic hospital, it should be transported on stretchers.

Prevention of adrenal crises consists in the active detection and dispensary registration of patients with addison's disease and those who receive long-term corticosteroids for various chronic diseases.