Who Works Up Patients with Suspected Adrenal Issues
A multidisciplinary team approach is essential, with endocrinologists, surgeons, and radiologists collaborating on evaluation, but any healthcare provider can initiate the workup with focused history, physical examination, and initial biochemical screening. 1
Initial Evaluation by Any Provider
Any healthcare provider who identifies a potential adrenal issue can and should begin the workup:
Perform focused history and physical examination targeting signs/symptoms of adrenal hormone excess (Cushing's features, virilization, hypertension with hypokalemia, episodic headaches/palpitations/sweating), adrenal insufficiency (fatigue, nausea, weight loss, hyperpigmentation), and malignancy concerns 1
Order initial biochemical screening including early morning (8 AM) serum cortisol and plasma ACTH to assess for adrenal insufficiency, with primary adrenal insufficiency showing cortisol <250 nmol/L (<9 μg/dL) with elevated ACTH 2, 3
Obtain basic metabolic panel to identify hyponatremia (present in 90% of adrenal insufficiency cases) and hyperkalemia (present in ~50% of primary adrenal insufficiency) 2
When to Involve Specialists
Maintain a low threshold for multidisciplinary review involving endocrinologists, surgeons, and radiologists in the following scenarios: 1
Imaging findings not consistent with a benign lesion (HU >10 on unenhanced CT, inhomogeneous appearance, size >4 cm) 1, 4
Evidence of hormone hypersecretion on biochemical testing 1
Tumor growth during follow-up imaging 1
When adrenal surgery is being considered 1
Role-Specific Responsibilities
Endocrinologist
Perform comprehensive hormonal evaluation for all adrenal incidentalomas, including screening for autonomous cortisol secretion (1 mg dexamethasone suppression test), primary aldosteronism (aldosterone-to-renin ratio in hypertensive/hypokalemic patients), and pheochromocytoma (plasma or 24-hour urinary metanephrines if HU >10 or symptoms present) 1
Conduct confirmatory testing with cosyntropin stimulation test when morning cortisol is indeterminate (140-400 nmol/L), with peak cortisol <500 nmol/L diagnostic of adrenal insufficiency 2, 3
Determine etiology of confirmed adrenal insufficiency by measuring 21-hydroxylase autoantibodies (positive in ~85% of primary adrenal insufficiency in Western populations) 2
Manage mild autonomous cortisol secretion (MACS) by screening for cortisol-related comorbidities (hypertension, type 2 diabetes) and considering surgical referral in younger patients with progressive metabolic complications 1, 4
Radiologist
Characterize adrenal masses using non-contrast CT as first-line imaging, with homogeneous lesions measuring <10 HU confidently diagnosed as benign regardless of size 1
Perform second-line imaging with washout CT or chemical-shift MRI for indeterminate masses (HU >10 on non-contrast CT) 1
Obtain adrenal CT imaging when autoantibodies are negative to evaluate for hemorrhage, tumors, tuberculosis, or other structural causes of adrenal insufficiency 2
Surgeon (Urologist or Endocrine Surgeon)
Evaluate surgical candidacy for unilateral cortisol-secreting masses with clinically apparent Cushing's syndrome, aldosterone-secreting adenomas, pheochromocytomas, and suspected adrenocortical carcinoma 1
Perform minimally-invasive adrenalectomy when feasible for functioning tumors and suspected malignancy 1
Coordinate adrenal vein sampling prior to offering adrenalectomy in patients with primary aldosteronism to confirm lateralization 1
Critical Pitfalls to Avoid
Never delay treatment of suspected acute adrenal insufficiency or adrenal crisis for diagnostic procedures—immediately administer IV hydrocortisone 100 mg and 0.9% saline if clinically unstable 2, 3
Do not perform adrenal mass biopsy routinely for workup of adrenal incidentalomas, as it rarely changes management and carries risk of complications 1
Do not rely solely on electrolyte abnormalities to diagnose or exclude adrenal insufficiency, as 10-20% of patients may have normal electrolytes at presentation 2
Avoid starting thyroid hormone replacement before corticosteroids in patients with concurrent hypothyroidism and adrenal insufficiency, as this can precipitate adrenal crisis 2, 5