General Surgery
Adrenal Glands
MBBS surgery notes on the adrenal glands: phaeochromocytoma, Conn and Cushing syndromes and adrenal insufficiency, mapped to NMC codes SU23.1 to SU23.3.
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Adrenal Glands
MBBS surgery notes on the adrenal glands: phaeochromocytoma, Conn and Cushing syndromes and adrenal insufficiency, mapped to NMC codes SU23.1 to SU23.3.
This chapter covers the surgical diseases of the adrenal glands, both cortex and medulla. It focuses on the functioning tumours, the safe preoperative preparation of phaeochromocytoma and the recognition of adrenal insufficiency.
High-yield: Adrenal Glands
- The adrenal cortex has three zones: glomerulosa making aldosterone, fasciculata making cortisol and reticularis making androgens.
- The adrenal medulla secretes the catecholamines adrenaline and noradrenaline.
- Phaeochromocytoma is a catecholamine-secreting tumour of the medulla causing episodic headache, sweating, palpitation and hypertension.
- Phaeochromocytoma follows a rule of tens: about ten percent bilateral, extra-adrenal, malignant and familial.
- Diagnosis of phaeochromocytoma uses raised plasma or urinary metanephrines.
- Before removing a phaeochromocytoma the patient must have alpha blockade first, then beta blockade, to prevent a hypertensive crisis.
- Conn syndrome is primary hyperaldosteronism, usually from an adenoma, causing hypertension with hypokalaemia.
- Cushing syndrome is chronic cortisol excess with central obesity, moon face, striae, hypertension and diabetes.
- The commonest cause of Cushing syndrome overall is exogenous steroid use, while Cushing disease is a pituitary cause.
- An adrenal incidentaloma is an adrenal mass found on imaging done for another reason and must be assessed for function and malignancy.
- Adrenocortical carcinoma is rare, often large at diagnosis and carries a poor prognosis.
- Addison disease is primary adrenal insufficiency with hyperpigmentation, hypotension, hyponatraemia and hyperkalaemia.
- Patients on long-term steroids need extra steroid cover around surgery to avoid an Addisonian crisis.
- Laparoscopic adrenalectomy is the preferred approach for most benign functioning adrenal tumours.
- Neuroblastoma is a malignant tumour of the adrenal medulla in young children and is one of the commonest solid childhood tumours.
Functioning adrenal tumours
- **Phaeochromocytoma:** Medullary catecholamine excess; episodic hypertension; alpha then beta blockade before surgery.
- **Conn syndrome:** Aldosterone excess; hypertension with hypokalaemia.
- **Cushing syndrome:** Cortisol excess; central obesity, striae, hypertension and diabetes.
- **Adrenocortical carcinoma:** Rare, often large and functioning; poor prognosis.
NMC competencies in this chapter
- **SU23.1:** Adrenal anatomy, physiology and functioning tumours
- **SU23.2:** Phaeochromocytoma: features, diagnosis and preparation
- **SU23.3:** Adrenal insufficiency and perioperative steroid cover
Frequently Asked Questions
How does phaeochromocytoma present?
With episodic headache, sweating, palpitation and paroxysmal or sustained hypertension from catecholamine excess. It is diagnosed by raised plasma or urinary metanephrines.
Why is alpha blockade given before beta blockade?
Giving a beta blocker first leaves alpha-mediated vasoconstriction unopposed and can trigger a hypertensive crisis, so alpha blockade is established first in phaeochromocytoma.
What is Conn syndrome?
Primary hyperaldosteronism, usually from an adrenal adenoma, causing hypertension with hypokalaemia due to excess aldosterone acting on the kidney.
Why do patients on long-term steroids need surgical cover?
Chronic steroids suppress the adrenal axis, so the gland cannot mount the stress response to surgery, and extra steroid cover is given to prevent an Addisonian crisis.
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