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Let's get started with Addison's and Cushing's Addison's and
Cushing's. What are they dealing with?
So, first and foremost, let's start with the beginning,
they're starting with the adrenal gland.
Where do the adrenal glands sit? Well, they sit on top of the
kidney. And they have two parts to it.
They have the center which is the medulla Or as I used to call
it in med school, mid Eula. So, and it was a middle and then
you've got the cortex, which is the outer part.
The way that I would remember, what the cortex would produce is
I would do salt. Sugar.
And sex. So from the outside in this
part, produces salt, sugar, and sex.
So what is the salt sugar sex? Mean, it's just the way I
remembered it. Salt with sodium and sodium is
controlled by Aldosterone. So aldosterone sugar cortisol,
right? So, the middle part was
cortisol, sex, is your androgens?
And androgens meaning estrogen testosterone.
So your sex hormones So this is what normally happens.
Normally our adrenals produce, Aldosterone cortisol and
androgens, and in the middle are are catecholamines.
And what are catecholamines? Epinephrine.
And norepinephrine. So salt, sugar, sex will.
Now we know what normal is Let's take a look at something.
That's abnormal. Let's start with Cushing's.
So in Cushing's, we've got excess cortisol.
We've got really, really high levels of cortisol.
Those of you that that were in the pharmacology crash course
over the weekend. Heard me talk about
corticosteroids and all their effects and cortisol acts just
like that. So cortisol can increase blood
pressure, it can increase sugar, it can decrease bone density and
I'll go through all of these in a little bit.
But what we've got is, we've got increased cortisol total
sidenote, totally forgot to tell you this.
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But if you're not in the course, is that pop up is going to be a
really good pop up. So cortisol, why does this
cortisol increase? Let's see.
We got a tumor here. Let's say we got a tumor here,
so not just stress, stress increases cortisol, but this is
ridiculously high levels of cortisol.
We've got a tumor here, a primary tumor in the adrenals
that is increase in cortisol. Well, let's go up to another way
that we can increase cortisol, or develop Cushing's how about
in the pituitary. The pituitary releases.
What? ACTH adrenocortical tropen
hormone. And that also can stimulate
cortisol. So if I've got a tumor here
that's increasing, ACTH will that's going to stimulate the
production of cortisol so I'll get really high cortisol.
So you've got one that's a tumor right in the adrenal.
Second one is a tumor in the pituitary, that's signaling to
make more cortisol. And the third one is just
Exogenous, you're eating it. So people that are on long-term
steroid use So, first and foremost, we have to be able to
identify this. So, what types of signs and
symptoms? Are we going to see?
Hypertension. Think about people that are
stressed out and their cortisol levels go up.
They're going to gain weight. How about those moon phases?
They literally look like a moon. How about abdominal striae?
That buffalo hump. Hyperglycemia.
Osteoporosis. Alright, these are some of the
symptoms that you're going to see your some of the signs that
you're going to see. So, look for them.
Look for them. and we've got increased cortisol caused by a
tumor of the adrenal or tumor in the pituitary or exogenous use.
So what are we going to do? Well, first and foremost we got
to figure out where it's coming from.
So we're going to do labs and what labs are we going to check?
Our cortisol. And are ACTH. so if cortisol is
elevated ridiculously elevated, and ACTH is low Then where do
you think this tumor lies? Or which one of the three do you
think this is? Which one of the three, could it
be? It could be two of the three. it
could be the adrenal tumor, and An exogenous.
How do we know which one it is? How do we know which one it is,
if the labs are the same and what if it's an adrenal tumor,
what if it's exhaustion, is, how are we going to?
How are we going to know? Ask them.
It's simple, as them. Are you taking any medication?
Are you taking any steroids? And they'll tell you, yeah, I've
been on it since whatever reason, you know, and they've
been on it but if they're not taking steroids.
Okay, now we got to get some Imaging.
What's going on right now? We don't know.
So we have to do some investigation.
So this could be the adrenal tumor or exogenous Hughes.
Well. If it's a pituitary tumor, we're
still going to see that increased cortisol because
that's what we're dealing with here, but we're also going to
see increased ACTH. So being able to identify it and
knowing the difference between the three is very important.
Identify the signs and symptoms. How are the board's going to ask
Cushing syndrome? Well more than likely exactly.
Joe, they're gonna say select all that apply and what they're
going to want you to know is all the signs and symptoms.
If they ask a question on Cushing's, they're going to want
you to know all the signs and symptoms.
So understand what's going on. Let's talk about the different
things that happen with cortisol.
And the mnemonic is a. Big.
Fehb. So A is for increase in
appetite. Hence, the weight gain.
B is increase in blood pressure. Because at high concentrations,
it will bind to aldosterone. And what do we say aldosterone
was? It was your salt so we can get
as some other people said, hypernatremia And with salt,
what follows saltwater. If I've got more salt, I've got
more water. I've got higher blood pressure,
But salt doesn't just increase by itself.
It goes in opposite directions. As what?
Potassium sodium, potassium pump.
So if sodium goes up, guess what will go down?
Potassium. I is increased insulin
resistance. So if you've got increased
insulin resistance, will we've heard this pathology before,
what medical condition do? We see this in type 2 diabetes?
Insulin resistance type 1, we don't make insulin right.
The G is another way that we get increased blood sugar, which is
gluconeogenesis, which is just the new formation of sugar. if
you break down the words, new formation of sugar, The FIB
everything in FIB is decreased. So let me So you get decreased
fibroblasts. Fibroblasts are used for wound
healing. They're using in tissue and
skin. So look at the stretch marks or
the striated that you get. Look at their skin thin out
fibroblasts decreased. The eye is decreased immune
response or inflammation. We use it for inflammation.
That's what we use steroids for right by decreasing
inflammation. We do that by decreasing our
immune response. so if we are decreasing our immune system
response, What are we susceptible for?
Infection infection infection, good.
So watch for infection. and then decreased bone formation, and
the reason why is they decrease your osteoblasts and your
osteoblasts build bone, That's how I used to remember it.
The osteoblast, build bone, bone formation decreases.
So you can see all the different things.
That cortisol affects and now we've increased it.
So everything that's here whether it's increased or
decreased is now going to be Amplified.
So now your appetites me way
higher. Your BP is me way higher, your
blood sugar's be way higher your wound.
Healing is going to be way lower.
Your immune system is me way lower and your bone formation is
going to be way lower. so now, We've got this is situation with
Cushing's. So what are we going to do with
this patient? Well, if they've got a primary
or a secondary tumor, we're going to have to get rid of the
tumor. And if we get rid of the tumor,
do you think that they're going to produce cortisol?
No. So what are we going to have to
supplement? What they don't make steroid if
they're taking it and it's exogenous well it's kind of a
catch-22. Are Aldis going to outweigh.
What we're trying to suppress. Who knows?
if they need to be on steroids and there, it means or their
inflammatory process or actually hurting them more than we can
control blood pressure, we can control the high blood sugar, we
can control supplementation for bones, vitamin D and calcium We
can educate them to not. Go out into crowded places for
the infection, right? We have to look at The
cost-benefit analysis here and say, hey, look, is it worth it
for them to take cortisol long-term?
Well, if the disease process needs it.
Yeah, we're going to do it and then we'll just can't control
others diet exercise, give them some blood pressure meds.
Give him some type 2. Diabetes meds.
Educate them about infection and supplementing with vitamin D and
calcium so realistically that's what we got to do.
And that's not bad. If the person needs to be on an
exogenous corticosteroids, that's not a lot to control
versus what we could be suppressing, right?
Cool. Alright, so that's Cushing's.
Now, let's get into as hey guys. Dr. Zeeshan here.
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