DR.

SHAMIM RIMA
MBBS.DMU.FCGP
M.PHIL
BSMMU
 THE ADRENAL GLANDS

Anatomy And Physiology

The adrenal glands, one located atop each of the kidneys,

release hormones into the bloodstream, and are involved in
the regulation of blood pressure and the levels of salt and
water in the body.

The right adrenal gland is pyramid-shaped, while the

left is crescent-shaped
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 THE ADRENAL GLANDS

Each adrenal gland is composed of

 medulla (inner part) and
cortex (outer part).

Medulla

The medulla releases

  Epinephrine (adrenalin) and  
Norepinephrine (noradrenalin)

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 THE ADRENAL GLANDS

Cortex

The cortex releases 3 major types of hormones: 

Glucocorticoids (e.g., cortisol)
Mineralocorticoids (e.g., aldosterone)
Androgens (e.g., testosterone).

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 ULTRASOUND OF THE ADRENAL GLANDS

Patient preparation with overnight fasting.

Land mark
Right side: kidney and IVC.
Left side : aorta, spleen, upper pole of left kidney.
Transducer
The test is done with a high frequency linear transducer
( 7.5 or 10 MHz).

Visualization
Right side: subcostal flank scan or oblique scan
Left side : intercostal flank scan through the spleen.
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 ULTRASOUND OF THE ADRENAL GLANDS

Shape :
Right : linear or V-shape
Left : V or Y-shape

Size :
wings are 2-3 cm long
6-8 mm thick.

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Contd ..
 NORMAL ADRENALS

The normal adrenals are seen well in these ultrasound

images in a neonate. They have a typical Y- shape and
the central medulla is hyperechoic with a hypoechoic
cortex.

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 ADRENAL DISORDERS

Adrenal Cortical hyperfunction Adrenal disorders not resulting

in altered hormonal activity
Cushingg’s syndrome
Non-hyper functioning adrenal
Conn’s syndrome adenoma
Adrenocortical adenoma Primary adrenocortical ca
Adrenocarcinoma Adrenal metastesis
Adrenogenital syndrome Primary adrenal lymphoma
Adrenal Medullary Tumours Adrenal cyst
Adrenal myelolipoma
Phaeochromocytomas Adrenal haemorrhage
Neurobastoma infection
Paraganglioma
Chemodectoma Hypoadrenalism
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 CUSHING'S SYNDROME

Hormonal disorder caused by prolonged exposure of the body's

tissues to high levels of the hormone cortisol. Sometimes called
"hypercortisolism," 

 Symptoms

Common Cushing's syndrome symptoms include:

Weight gain, particularly around your midsection and upper back
Fatigue
Muscle weakness
Rounding of your face (moon face)
Facial flushing
Fatty pad or hump betweenDryour shoulders (buffalo hump)
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 CUSHING'S SYNDROME

 Symptoms

Pink or purple stretch marks (striae) on the skin of

abdomen, thighs, breasts and arms
Thin and fragile skin that bruises easily
Slow healing of cuts, insect bites and infections
Depression, anxiety and irritability
Loss of emotional control
Thicker or more visible body and facial hair (hirsutism)
Acne
Irregular or absent menstrual periods in females
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 CUSHING'S SYNDROME

 Symptoms

Decreased libido
Erectile dysfunction in males
New or worsened high blood pressure
Glucose intolerance that may lead to
diabetes
Headache
Bone loss, leading to fractures over
time

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Contd ..
 CUSHING'S SYNDROME

Causes 

Pituitary Adenomas

Ectopic ACTH Syndrome

Lung tumors 
Carcinoid tumors
Thymomas
pancreatic islet cell tumors, and
medullary carcinomas of the thyroid
Adrenal Tumors
Familial Cushing's Syndrome
Exogenous source Dr Shamim Rima 12
 CONGENITAL ADRENAL HYPERPLASIA

Ultrasound demonstrated marked enlargement and wavy morphology

of the adrenal glands.
mean adrenal length greater than 20 mm and mean width greater
than 4 mm suggest the diagnosis

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Longitudinal sonogram of the left adrenal in a 26-day-old boy with
congenital adrenal hyperplasia. The adrenal is markedly enlarged, with a
limb width well above 4 mm in thickness. There is a clearly lobulated
surface to the gland, seen better on transverse scan. The central
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echogenic stripe has been replaced by diffuse stippled echogenicity
Adrenal hyperplasia. Longitudinal sonogram shows an
enlarged right adrenal gland in a 3-year-old girl. Normally the
glands are not as easily seen on ultrasound at this age.

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 ADRENAL MASS

These sonographic images reveal a

space occupying lesion above the
right kidney in the region of the
right adrenal gland. The mass is
large, echogenic and poorly defined
and pushes the kidney downwards.
It shows an inhomogenous
appearance, but no calcification is
present. The retroperitoneal fat
stripe is displaced anteriorly by the
mass proving that it is of adrenal
and not hepatic origin
Differential diagnosis includes:
adrenal adenoma
pheochromocytoma Dr Shamim Rima 16
metastasis. 
 PHEOCHROMOCYTOMA

USG findings

Well-defined, round or ovoid masses with uniform

reflectivity. Large tumors under go he, necrosis with loss of
homogenity.

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 ADENOMA

Adrenal gland are enlarged.

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ADENOMA

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Well defined hypoechoic mass in adrenal region, post to IVC and
indenting it.

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Double adrenal adenoma

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 NEUROBLASTOMA 

USG Findings

Hyperechoic mass in adrenal or central retroperitonium, often with

flecks of calcification.
Occasionally cystic in neonate.
Encasement of adjacent vessels.
The Aorta & IVC are displaced anteriorly and partially or completely
encased by the mass, together with renal vessels and origin of
mesenteric vessels..

Metastesis

Bone cortex, bone marrow, liver

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Ultrasound Findings: There is a large right upper quadrant mass

inferior to the liver displacing the right kidney inferiorly, the inferior

vena cava is compressed but is without obvious thrombus .

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 ADRENAL HAEMORRHAGE IN NEONATE

Avuscular heterogeneous adrenal that becomes cystic &

smaller over the following wks as clot retraction occurs.
Hypoechoic rim may develop due to calcification.
May be unilateral or bilateral

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Acutely the hemorrhage appears solid with inhomogeneous
echogenicity ;
Subacutely blood products begin to liquefy with mixed echogenicity ;
Cronically the gland resumes normal size : calcifications may be seen
in the walls.
The probable predisposing factors are difficult delivery, foetal hypoxia,
thrombocytopenia , coagulation defects and Meningococcal
septicaemia ( Waterhouse – Friederichsen syndrome).
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Prenatal ultrasound shows a heterogeneous mass (calipers)
superior to the right fetal kidney (white arrows) and inferior to the
fetal liver (L). Fetal ribs are also seen (black arrows)
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somewhat irregular border that is still hyperechoic as a result of the
calcification.
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 ADRENAL CARCINOMA

Ultrasound findings

Tumors exceed 6cm in diameter at time of presentation.

Aprx 15% less than 6cm & resemble adenoma.
Heterogeneous with area of necrosis & calcification.
May invade adjacent organs,extend into IVC, & involve LN.
Metastesis to liver, lung and bone.

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 ADRENAL METASTESIS

Most commonly from:

Lung, kidney, melanoma, breast, GIt, ovary

Metastesis tend to be larger than adenomas, less well defined,

inhomogenoeus,thick and irregular wall.
Commonly unilateral than bilateral.

Adrenal gland may show defuse enlargement without evidence of

metastesis in pt with known malignancy.

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A solid appearing, well-defined mass is seen in the right
suprarenal region. The visualized liver and IVC appear normal.

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The well-defined, heterogeneous mass is noted again. It indents
the IVC, but does not invade it.

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 ADRENOGENITAL SYNDROME

Androgen producing
tumour are usually ,
carcinoma, less commonly
adenoma.
Exceed 2cm in diameter.
Gross enlargement of
adrenal gland occur.

The significantly enlarged right adrenal gland is noted

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 ADRENOGENITAL SYNDROME

The left adrenal gland is also enlarged. The visualized spleen appears
normal.

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 ADRENOGENITAL SYNDROME

The enlarged left adrenal gland is seen again. The visualized spleen
and left hemidiaphgram appear normal.

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 ADRENAL CYST

Uncommon
Unilateral more in women than in men.
Endothelial or epithelial in origin, may be parasitic or pseudo cyst.
Represent previus haemorrage.
Well-defined, thin walled fluid-filled structure.
Calcification seen in 15% of cyst is often peripheral and curviliniar.

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 ADRENAL MYELOLIPOMA

Benign neoplasms composed of fat & bone marrow tissue in varying

proportionate.
Hge & necrosis within tumor cause pain.
Dx based on demonstration of fat within lesion.

Hyperechoic, solid mass which attenuates sound. Located superior

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and slightly medial to the left kidney.
 ADRENAL MYELOLIPOMA

Hyperechoic, solid mass (white arrows), which attenuates

sound (black arrows), located superior and slightly medial44to
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left kidney.
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