Acute non-traumatic adrenal haemorrhage-management, pathology and clinical outcomes

Two cases of atraumatic adrenal hemorrhage: A review of active management, conservative management, and challenges faced

Adrenal hemorrhage (AH) is an uncommon and potentially disastrous affliction that carries an accepted mortality risk of 15%. Variable symptomatology can cause a diagnostic dilemma and may be missed. We present 2 cases of right-sided AH; both cases were initially presumed to be renal colic. Case 1 was an 86-year-old gentleman, presenting with right flank pain found to have a right-sided atraumatic AH. He presented with hemorrhagic shock, requiring angioembolization of the bleeding vessel. Case 2 was a 62-year-old gentleman who presented with right flank pain and was found to have a right-sided atraumatic AH. He was hemodynamically stable and successfully managed conservatively. Adrenal hemorrhage is a potentially fatal affliction that may be missed. CT scans are the recommended imaging modality during an acute presentation due to wider availability and fast assessment. We demonstrate a hemodynamically stable patient managed with a 'watch and wait' approach and an unstable patient managed with resuscitation followed by urgent angioembolization.

Iatrogenic adrenal insufficiency in adults

Iatrogenic adrenal insufficiency (IAI) is the most common form of adrenal insufficiency in adult patients, although its overall exact prevalence remains unclear. IAI is associated with adverse clinical outcomes, including adrenal crisis, impaired quality of life and increased mortality; therefore, it is imperative that clinicians maintain a high index of suspicion in patients at risk of IAI to facilitate timely diagnosis and appropriate management. Herein, we review the major causes, clinical consequences, diagnosis and care of patients with IAI. The management of IAI, particularly glucocorticoid-induced (or tertiary) adrenal insufficiency, can be particularly challenging, and the provision of adequate glucocorticoid replacement must be balanced against minimizing the cardiometabolic effects of excess glucocorticoid exposure and optimizing recovery of the hypothalamic-pituitary-adrenal axis. We review current treatment strategies and their limitations and discuss developments in optimizing treatment of IAI. This comprehensive Review aims to aid clinicians in identifying who is at risk of IAI, how to approach screening of at-risk populations and how to treat patients with IAI, with a focus on emergency management and prevention of an adrenal crisis.

Bilateral adrenal hemorrhage: learning notes from clinical practice and literature review

Adrenal hemorrhage is a rare, but important, diagnosis to recognize, in particular when there is involvement of both adrenal glands. Bilateral adrenal hemorrhage can in fact lead to adrenal insufficiency, with dramatic consequences if not promptly recognized and treated. It is normally caused by systemic conditions that lead to the vasoconstriction and thrombosis of the adrenal vein. Oftentimes, the clinical diagnosis of this condition can be very challenging, as its signs and symptoms are generalized and nonspecific (abdominal pain, nausea, and fatigue). Here, we present the cases of two patients admitted to the Emergency Department in 2016 and 2022 with acute abdominal pain, having recently undergone surgery and subsequently prescribed low-molecular-weight heparin. In both cases, laboratory results revealed neutrophilic leukocytosis and an unexplained anemia. Due to the persistence of abdominal pain despite medication, a CT scan was performed, showing an enlargement of both adrenal glands suggestive of bilateral adrenal hemorrhage. Adrenal function was tested that correlated with a diagnosis of adrenal insufficiency, and both patients were promptly treated with parenteral hydrocortisone as a result. On 5 years' follow-up from the acute event, the second patient's adrenal function had returned to normal, and he has not needed further adrenal replacement therapy; the first patient however demonstrated persistence of adrenal failure requiring replacement therapy. In this paper, through our experience and a literature analysis, we will aim to outline some clues to identify patients at potential risk of bilateral adrenal hemorrhage.

Bilateral adrenal hemorrhage after pancreaticoduodenectomy

The incidence of bilateral adrenal hemorrhage (BAH) in the postoperative setting is rare, but potentially life threatening. A literature review of postoperative BAH reveals that there is limited data on BAH following abdominal surgery. We present a case of BAH following pancreaticoduodenectomy, which has not been previously documented in the literature. A 70-year-old male patient with no previous history of adrenal disease underwent an uncomplicated pancreaticoduodenectomy and was discharged after a typical postoperative course. He was readmitted with abdominal pain and ileus on POD 8 and a computed tomography (CT) scan was initially unremarkable, but a repeat CT scan on POD 11 demonstrated BAH. He was found to have adrenal insufficiency and was successfully treated with steroids. Clinicians should be aware of the possibility of adrenal hemorrhage postoperatively as it can potentially be a fatal surgical complication. To enhance patient outcomes, early detection and appropriate treatment are essential.

Presumptive nontraumatic adrenal hemorrhage preceding hypoadrenocorticism in a dog

Nontraumatic adrenal hemorrhage (NTAH) has been associated with stress-induced catecholamines release in underlying conditions such as sepsis and recent surgery in humans. It can lead to primary hypoadrenocorticism (HOAC) when both adrenal glands are involved, with nonspecific clinical signs and laboratory findings that can lead to a missed diagnosis. Bilateral thickening of the adrenal glands with periadrenal fat stranding was identified in a 10-year-old male Maltese dog after abdominal surgery. The dog showed clinical signs and biochemical changes consistent with HOAC, but treatment for presumed critical illness-related corticosteroid insufficiency was initiated. Clinical signs relapsed with a 3-week dose reduction of hydrocortisone, and a reduction in adrenal size was observed on follow-up ultrasound examination. Hormonal testing confirmed HOAC in the dog. To the best of our knowledge, HOAC caused by spontaneous NTAH has not been reported in the veterinary literature. This report describes a dog that developed HOAC with presumed adrenal atrophy after suspected spontaneous bilateral NTAH.

Spontaneous adrenal haemorrhage in pregnancy and review of the literature

Spontaneous adrenal haemorrhage (SAH) is a rare condition. The incidence of adrenal haemorrhage in pregnancy is currently not known; however, an association with pregnancy has been reported.An acute presentation with severe back or flank pain should raise suspicion of this condition. Diagnosis is based on imaging. An ultrasound scan is a basic and readily available investigation in pregnancy to rule out renal and suprarenal pathology while CT or MRI scan can help to confirm the diagnosis. A multidisciplinary team (MDT) approach, involving the obstetric, anaesthetic, medical and endocrine team, is essential in management of this condition.We present a case of an SAH; managed conservatively, in an otherwise healthy and low-risk pregnant woman and describe the literature review on this rare condition, including pathophysiology and management.

Adrenal bleeding due to pheochromocytoma - A call for algorithm

BACKGROUND

Adrenal hemorrhage is a rare, usually life-threating complication. The most common neoplasm resulting in spontaneous adrenal bleeding is pheochromocytoma and it accounts for nearly 50% of cases. Currently, the recommendations for the diagnosis and management of patients with adrenal bleeding due to pheochromocytoma are unavailable.

MATERIALS AND METHODS

We performed a database search for all pheochromocytoma patients, diagnosed and treated from 2005 to 2021 in tertiary endocrinology center. 206 patients were identified, 183 with complete data were included in the analysis. We investigated clinicopathological characteristics, treatment and outcomes of hemorrhagic pheochromocytoma cases and characterize our approach to perioperative diagnosis and medical management. Finally our experiences and data from previously published articles concerning adrenal hemorrhage were analyzed to propose a diagnostic and therapeutic algorithm for hemorrhagic pheochromocytomas.

RESULTS

In the whole group, seven patients (4 men and 3 women) with adrenal bleeding were found, (3.8%). Median patient's age was 49 years (range: 36-78 years). The most common manifestation of adrenal bleeding was acute abdominal pain (5/7). Two patients developed shock. Hormonal assessment was performed in five patients, based on 24-hour urinary fractionated metanephrines with urinary 3-methoxytyramine. Normetanephrine was elevated in all patients, metanephrine and 3-methoxytyramine - in four cases (4/5). Most patients (6/7) had symptoms suggesting pheochromocytoma before hemorrhage - most commonly paroxysmal hypertension (4/7). One patient died, before the diagnosis of adrenal bleeding was made. Diagnostic imaging performed in six out of seven patients revealed adrenal tumor, with median largest diameter equal to 7.4 cm (range: 5-11 cm). Five patients had elective surgery, in one case an urgent surgery was performed. In all cases the diagnosis of pheochromocytoma was confirmed in postoperative histopathology or in autopsy. The perioperative survival rate was 85.7%.

CONCLUSIONS

Diagnosis of pheochromocytoma should be always considered in patients with adrenal bleeding, especially with accompanying abdominal pain, hemodynamic shock and previous history of pheochromocytoma-associated symptoms. Lack of proper diagnosis of pheochromocytoma before surgery is associated with an additional perioperative risk. To improve the decision making in this life-threatening clinical situation, based on our results and literature data, we proposed a diagnostic and treatment algorithm.

Haemorrhagic shock from solid tumours of the adrenal gland: a case of bleeding primary adrenal lymphoma

Suprarenal or adrenal gland haemorrhage is an uncommon but potentially lethal condition if unrecognised. Adrenal masses rarely present with haemorrhage, but they remain an important differential aetiology for adrenal bleeding. We present a novel case of primary adrenal lymphoma with adrenal haemorrhage in a middle-aged woman who presented with right-sided abdominal pain and class 1 haemorrhagic shock. She was found to have spontaneous unilateral adrenal gland haemorrhage in the absence of any underlying previous pathology. Presenting features, diagnosis and subsequent oncological management are reported.

Pitfalls and differential diagnosis on adrenal lesions: current concepts in CT/MR imaging: a narrative review

The purpose of this pictorial essay is to review the imaging findings of adrenal lesions. Adrenal lesions could be divided into functioning or non-functioning masses, primary or metastatic, and benign or malignant. Imaging techniques have undergone significant advances in recent years. The most significant objective of adrenal imaging is represented by the detection and, when possible, characterization of adrenal lesions in order to direct patient management correctly. The detection and management of adrenal lesions is based on cross-sectional imaging obtained with non-contrast CT (tumour density), contrast-enhanced CT including delayed washout (either absolute percentage washout or relative percentage one) and finally with MR chemical shift analysis (loss of signal intensity between in-phase and out-of-phase images including both qualitative and quantitative estimates of signal loss). The small incidental adrenal nodules are benign, in most of cases; some tumors such as lipid-rich adenoma and myelolipoma have characteristic features that can be diagnosed accurately in CT. On contrary, if the presenting contrast-enhanced CT shows an adrenal mass with uncertain or malignant morphologic features, particularly in patients with a known history of malignancy, further evaluations should be considered. The most significative implications for radiologists are represented by how to assess risk of malignancy on imaging and what follow-up to indicate if an adrenal incidentaloma is not surgically removed.

Adrenal haemorrhage as a complication of COVID-19 infection

We report an unusual complication of COVID-19 infection in a 53-year-old Caucasian man. He presented with shortness of breath, fever and pleuritic chest pain. A CT pulmonary angiogram (CTPA) demonstrated acute bilateral pulmonary embolism and bilateral multifocal parenchymal ground glass change consistent with COVID-19 (SARS-CoV-2) infection. Right adrenal haemorrhage was suspected on the CTPA which was confirmed on triple-phase abdominal CT imaging. A short Synacthen test revealed normal adrenal function. He was treated initially with an intravenous heparin infusion, which was changed to apixaban with a planned outpatient review in 3 months’ time. He made an uncomplicated recovery and was discharged. Follow-up imaging nearly 5 months later showed near complete resolution of the right adrenal haemorrhage with no CT evidence of an underlying adrenal lesion.

Haemorrhage in pre-existing adrenal masses. A case series

•

Diagnosis of haemorrhage in adrenal masses is more common, due to use of CT.

•

We present 13 cases either spontaneous or after blunt abdominal trauma.

•

Emergency operation is rarely warranted, due to possibility of pheochromocytoma.

•

Haemorrhage should raise the high likelihood of undiagnosed metastatic disease.

Introduction

Adrenal haemorrhage in the context of a pre-existing adrenal mass is a rare, underestimated and potentially fatal surgical emergency. It is a rare cause of acute abdominal pain.

Presentation of cases

Data from 13 patients with adrenal haemorrhage in a pre-existing adrenal mass were prospectively collected during a 9 year period from a single institution. All patients underwent CT imaging which formed the basis of diagnosis and a complete endocrinological evaluation. Seven out of 13 patients underwent an elective surgical procedure and 2 patients underwent emergency laparotomy. Five out of 13 patients were diagnosed with metastatic disease. One patient was diagnosed with pheochromocytoma.

Discussion

The likelihood of an undiagnosed pheochromocytoma renders emergency surgery extremely precarious. Complete patient evaluation includes testing for hormonally active adrenal tumors and malignancy. Emergency surgery is reserved for cases where conservative management fails.

Conclusion

Haemorrhage of an adrenal mass constitutes a diagnostic and therapeutic challenge. Most patients respond well to initial resuscitation efforts. When feasible, patients should undergo a complete hormonal and oncologic evaluation before surgical intervention is considered.