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Hepatoadrenal Syndrome — RACP Adult Medicine MCQ

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HardGeneral Internal MedicineHepatoadrenal SyndromeRACP Adult Medicine

A 55-year-old man with known cirrhosis develops septic shock. His serum cortisol 60 minutes after 250 mcg synthetic ACTH (Synacthen test) is 420 nmol/L (normal response >550 nmol/L). His baseline cortisol was 280 nmol/L. What does this represent?

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Correct answer: B — Primary adrenal insufficiency

Hepatoadrenal syndrome (critical illness-related corticosteroid insufficiency/relative adrenal insufficiency) occurs in up to 60% of critically ill cirrhotic patients. The impaired cortisol response results from reduced cortisol-binding globulin synthesis, decreased HDL cholesterol (substrate for steroidogenesis), cytokine-mediated adrenal dysfunction, and impaired HPA axis. Hydrocortisone replacement (50 mg IV 8-hourly) in vasopressor-dependent cirrhotic patients with relative adrenal insufficiency may improve haemodynamics and survival, though data remain controversial.

Reference: eTG – 2025 – Gastrointestinal; EASL – 2018 – Decompensated Cirrhosis; ESCIM – 2023