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Adrenal crisis is a severe and life-threatening medical condition caused by lack of cortisol, a hormone normally produced by the adrenal glands as well as several other hormones of this gland. Normally, the adrenal glands produce more than 50 steroids, cortisol and aldosterone. All of these are in charge of numerous physiological processes in the body.

Adrenal insufficiency can be classified as primary and secondary. Primary adrenal insufficiency develops if there is some kind of damage to the cortex of the adrenal gland and is characterized by lack of all hormones produced by the cortex. In case of secondary adrenal insufficiency the problem is basically connected with malfunction of the pituitary gland and there is only mineralocorticoid function preserved. Secondary adrenal insufficiency is in majority of cases caused by chronic exogenous steroids. Still, it may also affect people suffering from hypopituitarism. In such case there is lack of all hormones produced by the pituitary gland and the problem is even more complex.

Each and every emergency physician must know a lot about adrenocortical insufficiency in order to diagnose this potentially lethal condition on time and prescribe appropriate treatment. Physical findings together with laboratory findings are generally sufficient enough for doctor to diagnose the condition.

Adrenocortical Insufficiency Pathophysiology

The medulla of the adrenal gland synthesizes 80% epinephrine and 20% norepinephrine. The cortex of the gland, on the other hand, produces cortisol, aldosterone and androgens.

Glucocorticoids play major role in many physiological processes in the body. They are essential for gluconeogenesis and decrease of cellular glucose use. Furthermore, these hormones mobilize amino and fatty acids, inhibit the effects of insulin, stimulate ketogenesis, elevate RBC and platelet levels and posses substantial anti-inflammatory characteristics.

Aldosterone is in charge of maintaining electrolyte balance via different organs such as the kidneys, gut, salivary and sweat glands. If there is not enough aldosterone in the body, there is evident sodium loss, hyperkalemia and acidosis.Causes of Primary and Secondary Adrenocortical Insufficiency

Primary adrenocortical insufficiency develops as a consequence of the anatomic destruction of the gland. It can be either acute or chronic and initiated by tuberculosis, fungal infections, tumors infiltrating the adrenal gland or bleeding into the gland. In some cases the underlying cause may not be identified (idiopathic adrenocortical insufficiency) or is autoimmune in origin. Finally, the condition may result from metabolic failure.

Secondary adrenal insufficiency is associated with hypopituitarism or hypothalamic-pituitary disease. Exogenous or endogenous steroids may also trigger the lack of adrenal hormones.

Finally, it is essential to mention acute adrenocortical insufficiency which is usually caused by sepsis or surgical stress, adrenal hemorrhage or septicemia and anticoagulation complications.

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