Pheochromocytoma Crisis

Also known as Pheochromocytoma · Paraganglioma · Catecholamine crisis · Phenoxybenzamine · Alpha before beta · Metanephrines · Metyrosine

The pheochromocytoma the crisis — the catecholamine-secreting the tumour (the adrenal the medulla / the paraganglioma) → the massive the catecholamine the surge → the severe the hypertension, the cardiomyopathy (the Takotsubo), the pulmonary the oedema, the multi-organ. The classic the triad (the headache, the sweating, the palpitations). The alpha-blockade the FIRST (the before the beta — the unopposed the alpha), the metanephrines the screen, the metyrosine, the surgical the resection (the after the 1 to 2 weeks the alpha the prep). The trigger the avoidance (the metoclopramide, the anaesthesia, the biopsy).

high22 referencesUpdated 26 July 202613 min readVerification in progress

Practise this topic

8 MCQs

The one-line answer

Pheochromocytoma crisis is a massive catecholamine surge from an adrenal-medulla (or extra-adrenal paraganglioma) tumour, presenting with the classic triad of paroxysmal headache, sweating and palpitations plus severe hypertension, and complicated by catecholamine cardiomyopathy (Takotsubo), pulmonary oedema and intracranial haemorrhage. The diagnosis rests on plasma or urine free metanephrines — not catecholamines, which are episodic and miss the tumour. The cardinal rule of treatment is alpha-blockade first, beta-blocker only after alpha is established — beta alone leaves unopposed alpha vasoconstriction and causes a catastrophic hypertensive crisis. Definitive treatment is surgical resection after blood-pressure-targeted alpha-blockade titrated over about two weeks.^[1]^[6]^[20]

Meet the patient

A 48-year-old woman with difficult-to-control hypertension arrives with thunderclap headache, drenching sweats, palpitations and crushing chest pain. Thirty minutes after IV metoclopramide for nausea her BP has surged to 223/102, with agitation, worsening headache, chest pain and a wide-complex tachycardia on the monitor; the CT abdomen shows a 5.9 cm right adrenal mass.^[12]^[14]

This is a catecholamine storm from a pheochromocytoma, precipitated by the metoclopramide. The two questions that decide her next hour are the two that decide every pheo crisis: how do I lower the pressure without unopposed alpha vasoconstriction, and what must I never give. The answer to both is alpha-blockade first, beta only after, and avoid the dopamine antagonists, histamine releasers and indirect sympathomimetics.^[1]^[12]^[13]

References22Show

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