Internal Medicine

0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:57

1168 Pheochromocytoma

➣Phentolamine: IV alpha-adrenergic blocker for acute manage-

ment of hypertension or adrenergic crisis

■Beta-adrenergic blockade:

➣After alpha-blockade established, initiate beta-blockade for

heart-rate control (Note: beta blockers alone lead to unopposed

alpha-blockade and exacerbated hypertension)

■Inhibition of catecholamine synthesis:

➣Metyrosine (alpha-methyl-tyrosine) inhibits catecholamine syn-

thesis

Surgery:

■Usually abdominal approach, occasionally flank or laparoscopic

approach

■Intraoperative hypotension best avoided by preoperative alpha-

blockade and vigorous IV fluid replacement

■Medical and surgical coordination with anesthesia team

follow-up

During Medical Treatment:

■Evaluate q 3–4 d to monitor heart rate, BP, orthostatic BP and pulse,

and side effects (eg, nasal stuffiness) to gradually increase dose of

alpha-blockers

Postoperative:

■Intraoperative fluids and volume replacement for hypotension

■During 1st wk postop, monitor blood glucose or CBG q 4–6 h for

hypoglycemia

■1–2 wks: repeat catecholamine tests to assess biochemical cure of

catecholamine excess

Long-Term:

■Difficult to distinguish benign vs malignant pheochromocytoma at

pathology, so review for pheochromocytoma recurrence or metas-

tases

■Annual evaluation to assess and manage hypertension, screen for

recurrence of symptoms, and measure urinary catecholamines and

metabolites

complications and prognosis

■Acute: hypertensive encephalopathy, hypotension, cardiovascular

collapse

■Chronic: dilated cardiomyopathy, angina and MI, CVA