Causes and pathogenesis of acute adrenal insufficiency

Adrenal or addison crises develop more often in patients with primary or secondary adrenal involvement. Less common in patients without previous adrenal diseases.

Decompensation of metabolic processes in patients with chronic adrenal insufficiency, resulting from inadequate replacement therapy against acute infections, trauma, surgeries, climate change and severe physical exertion, is accompanied by the development of an acute form of the disease. Development addisonicheskim crisis is sometimes the first manifestation of the disease with a latent and undiagnosed Addison's disease, the syndrome of Schmidt. Acute adrenal insufficiency constantly threatens patients with bilateral adrenalectomy, performed in patients with Isenko-Cushing's disease and other conditions.

Adrenal diseases, in which addisonic crises are possible, include adrenogenital syndrome and isolated insufficiency of aldosterone secretion. In children with a salt form of adrenogenital syndrome and in adults during intercurrent diseases and in extreme conditions, acute adrenal insufficiency occurs. Its development is possible with secondary adrenal insufficiency: diseases of hypothalamic-pituitary origin and non-endocrine diseases due to exogenous administration of corticosteroids. In hypothalamic-pituitary insufficiency, accompanied by a deficiency of ACTH and other tropic hormones, with the syndrome of Simonds, Shien, etc., the operative removal of pituitary adenomas and radiotherapy with acromegaly, Izenko-Cushing's disease, prolactinomas during stressful situations, there is the likelihood of adrenal crises.

A special group consists of patients previously treated with glucocorticoids for non-endocrine diseases. As a result of long-term use of glucocorticoid drugs, they have a reduced function of the hypothalamic-pituitary-adrenal system, most often with operational or infectious stress, the failure of the function of the adrenal cortex is revealed - an addisonic crisis develops. The "cancellation" syndrome, which occurs as an acute adrenal insufficiency, occurs in patients with rapid hormone removal, with long-term use in various diseases, often of autoimmune origin. Manifestations of acute adrenal insufficiency develop without a previous pathological process in the adrenal glands. The disease caused by thrombosis or embolism of adrenal veins is called Waterhouse-Frideriksen syndrome. A hemorrhagic infarct of the adrenal gland with this syndrome occurs against a background of meningococcal (classical variant), pneumococcal or streptococcal bacteremia, but can also be observed when the virus is infected with poliomyelitis. The syndrome of Waterhouse-Frideriksen occurs at any age. In newborns, the most common cause of apoplexy of the adrenal glands is birth trauma, followed by infectious and toxic factors.

Acute hemorrhages in the adrenal glands are described under various stresses, major surgeries, sepsis, burns, with ACTH and anticoagulant medications, in pregnant women, in AIDS patients. Severe stressful situations lead to a bilateral hemorrhage in the adrenal glands of servicemen. Acute heart attacks occur during heart surgery for cancer of the stomach, esophagus. Sepsis and septic conditions in peritonitis and bronchopneumonia may be accompanied by hemorrhages in the adrenal glands. With burn disease, both acute myocardial infarctions and a decrease in the secretion of hormones by the adrenal cortex result from prolonged stress.

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Pathogenesis of acute adrenal insufficiency

At the heart of the pathogenesis of acute hypocorticism is the decompensation of all types of metabolism and adaptation processes associated with the cessation of the secretion of hormones in the adrenal cortex.

When the disease due to the lack of synthesis of gluco- and mineralocorticoid hormones, the adrenal cortex in the body results in the loss of sodium and chloride ions in the urine and a decrease in their absorption in the intestine. Along with this, the body releases fluid. With untreated acute adrenal insufficiency, it becomes dehydrated by loss of extracellular fluid and secondary water transfer from extracellular space to the cell. In connection with the sharp dehydration of the body, the volume of blood decreases, which leads to shock. Loss of fluid occurs through the gastrointestinal tract. The onset of indomitable vomiting, frequent loose stools are a manifestation of severe electrolyte imbalance.

In the pathogenesis of acute adrenal insufficiency, a violation of potassium metabolism also participates. In the absence of hormones in the adrenal cortex, there is an increase in serum levels in the blood serum, in the intercellular fluid and in the cells. In conditions of adrenal insufficiency, the release of potassium in the urine decreases, since aldosterone promotes the excretion of potassium by the distal sections of the convoluted tubules of the kidneys. Excess potassium in the heart muscle leads to a violation of the contractility of the myocardium, local changes may occur, the functional reserves of the myocardium decrease. The heart is not able to adequately respond to increased stress.

In conditions of acute form of the disease, carbohydrate metabolism is disrupted in the body: blood sugar level decreases, glycogen reserves in the liver and skeletal muscles decrease, insulin sensitivity increases. With insufficient secretion of glucocorticoids, the synthesis and metabolism of glycogen in the liver are disturbed. In response to hypoglycemia, there is no increase in glucose release in the liver. The appointment of glucocorticoids by enhancing gluconeogenesis in the liver from proteins, fats and other precursors leads to the normalization of carbohydrate metabolism. Clinical manifestations of hypoglycemia accompany acute adrenal insufficiency, but in some cases, as a result of a sharp deficit of glucose in the tissues develops hypoglycemic coma.

With a shortage of glucocorticoids, the level of urea, the final product of nitrogen metabolism, decreases. The effect of glucocorticoids on protein metabolism is not only catabolic or anti-anabolic. It is much more complicated and depends on many factors.

Patonatomy of acute adrenal insufficiency

Adrenal disorders in Waterhouse-Frideriksen syndrome may be focal and diffuse, necrotic and hemorrhagic. The most common for this syndrome is a mixed form - necrotic-hemorrhagic. More often there are changes in the two adrenal glands, less often in one.