Adrenal Hemorrhage

Adrenal hemorrhage can present in a myriad of clinical contexts, and diagnosis remains challenging. Disease familiarity and a high index of suspicion are required for early diagnosis and prompt treatment. Since critically ill individuals represent a subset of patients who are at risk of developing adrenal hemorrhage, early recognition is crucial in these subsets of patients.

The majority of the cases are discovered incidentally, however, nonspecific abdominal, or loin pain is an important presenting symptom.[1] Other nonspecific symptoms include malaise, weakness, lethargy, nausea, vomiting, and diarrhea.[10] Symptoms may correlate to the severity of hemorrhage with extensive bilateral hemorrhage heralding the development of acute adrenal insufficiency.[16]

The examination may reveal signs of exsanguination such as tachycardia and hypotension, or nonspecific findings like abdominal or flank tenderness.[17] The release of cortisol and catecholamines by the expanding hematoma may present with elevated blood pressure, especially if the underlying etiology is a pheochromocytoma.

The majority of patients have normal lab parameters, possibly reflecting minor bleeding into the adrenals. Leukocytosis and anemia may be present. Biochemical markers of adrenal insufficiency such as hyponatremia, hyperkalemia, hypoglycemia may also be detected. Other important derangements include excess cortisol and elevated catecholamine levels, which may reflect the transient release from the gland destruction.[1][18] Low cortisol with elevated ACTH is also an important diagnostic clue signifying extensive cortical involvement.[4]

Imaging remains the most important diagnostic tool, with CT scans being an important modality. The appearance of imaging varies with the age of the hematoma.[19] Adrenal hemorrhage on computed tomography appears as a round to ovoid lesion. There may be peri-adrenal fat stranding, and bleeding may extend into the peri-nephric space.[20] Fresh hematomas demonstrate high attenuation, which decreases over time.[19]

Ultrasonography is the modality of choice in infants due to their small body size and relatively large adrenal size.[20]

Magnetic resonance imaging is the most accurate diagnostic modality. It can differentiate acute from chronic hematomas and can also ascertain the presence of an underlying tumor.[21]

Treatment modalities are variable and depend on the extent of hemorrhage and degree of hormonal insufficiency. Conservative management with serial imaging and close monitoring is now being referred to as a more traditional interventional approach.[22][23]

Assessment for hemodynamic instability and adrenal insufficiency should guide treatment. Individuals who have massive retroperitoneal bleeding unresponsive to transfusions and conservative management are candidates for intervention.[21] Angiography and embolization of the bleeding lesion may provide better outcomes compared with traditional surgical laparotomy.[21][24]

Adrenal insufficiency due to bilateral extensive hemorrhage should be managed with corticosteroids.

Adrenal hemorrhage may be the initial presentation of underlying adrenal mass lesions, with pheochromocytoma being the most common.[25] Initial stabilizing therapy with antihypertensive treatment and alpha-blockers with definitive management once etiology is ascertained is advisable in these cases.[25]

The vague presentation may make differentiation from the primary course of critical illness difficult. Other differentials include aneurysm of the renal artery, metastatic deposits in adrenals and, renal tumors.[25]

Prognosis is variable depending on the underlying etiology, the extent of hemorrhage, and the overall health status of the patient. Waterhouse Friderichsen syndrome has a mortality approaching 60% despite adequate medical management with fluids, antibiotics, and glucocorticoids.

Extensive adrenal hemorrhage may lead to the development of adrenal insufficiency which may be transient or permanent. Extensive hemorrhage can lead to the development of retroperitoneal hemorrhage and hypovolemic shock.

Though no specific measure prevents the development of adrenal hemorrhage, a high index for diagnosis and early diagnostic workup are key to improving prognosis.

Adrenal hemorrhage, apart from being a rare disease, is seldom considered on one's list of differentials. This situation, combined with the fact that presentation is often vague with no exceptional signs or symptoms, may lead to a missed diagnosis. A high index of suspicion, together with timely radiological and biochemical testing is the key to prompt diagnosis and treatment. An interprofessional team approach is required with the primary provider, intensivist, radiologist, endocrinologist, interventional radiologist, and surgeon to provide comprehensive management.

Prompt management of hemodynamic instability, the institution of timely adrenal replacement, and intervention for ongoing hemorrhage, whether angiographically or via laparotomy, may provide the best possible outcomes.

In essence, a patient-centered, team-oriented approach to diagnosis, evaluation, and management is necessary to provide the best outcomes.