A 55-year-old man presents with headache, diaphoresis, and episodic hypertension (BP spikes to 220/130 mmHg). Between episodes his BP is normal. 24-hour urine metanephrines and normetanephrines are 5-fold above the upper limit of normal. CT of the abdomen reveals a 4 cm right adrenal mass. Which is the MOST appropriate pre-operative preparation?
- A Beta-blocker alone to control hypertension before surgery
- B Urgent surgery without preoperative blockade
- C Alpha-adrenergic blockade (phenoxybenzamine) for 10–14 days followed by beta-blockade if tachycardia develops ✓
- D Metyrosine alone for 48 hours before surgery
Explanation
Pheochromocytoma requires careful preoperative preparation to prevent intraoperative hypertensive crisis from catecholamine release during tumor manipulation. Alpha-blockade with phenoxybenzamine (a non-selective, irreversible alpha-blocker) must be established first for at least 10–14 days to allow blood pressure normalization and volume re-expansion. Beta-blockers are added only after adequate alpha-blockade to control tachycardia; giving a beta-blocker first is dangerous because unopposed alpha-stimulation can cause severe hypertensive crisis. Surgery without preparation carries prohibitive mortality from catecholamine storm. Metyrosine (tyrosine hydroxylase inhibitor) reduces catecholamine synthesis and is used adjunctively in some centers but is not the primary or sole preoperative preparation.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.