adrenal hemorrhage
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Etiology
- contributing factors
- adrenocorticotropic hormone (ACTH)
- stress increases ACTH secretion which stimulates adrenal arterial blood flow
- normally limited venous drainage of the adrenal may be exceeded by increased arterial blood flow
- adrenal vein spasm & thrombosis may contribute
- adrenocorticotropic hormone (ACTH)
- associated disorders
- sepsis (3%)[4] more common with bilateral adrenal hemorrhage due to
- Neisseria meningitidis (most common)
- Pseudomonas
- Streptococcus pneumoniae
- group A beta-hemolytic streptococci
- Neisseria gonorrhoeae
- Escherichia coli
- Klebsiella pneumoniae
- Haemophilus influenzae (group B)
- Salmonella choleraesuis
- Pasteurella multocida
- Acinetobacter calcoaceticus
- Plesiomonas shigelloides
- hemorrhagic diatheses (11%)[4]
- thromboembolic disorders, coagulopathy (6%)[4]
- more common with bilateral adrenal hemorrhage[4]
- congestive heart failure
- myocardial infarction
- inflammatory bowel disease
- acute pancreatitis
- hepatic cirrhosis
- granulomatous disease
- amyloidosis
- adrenal neoplasm (6%)[4]
- metastatic cancer (most common neoplasm)[4]
- obstetric causes
- pre-eclampsia
- spontaneous abortion
- antepartum or postpartum hemorrhage
- twisted ovarian cyst
- surgical procedures (41%)[4]
- liver transplantation (most common)[4]
- CABG
- hip replacement
- intracranial surgery
- hepatic arterial chemoembolization
- unilateral adrenal hemorrhage (93%)
- blunt trauma (30%)
- motor vehicle accident most common[4]
- neurofibromatosis
- long-term NSAID use
- pregnancy
- blunt trauma (30%)
- sepsis (3%)[4] more common with bilateral adrenal hemorrhage due to
Epidemiology
- reported in 0.2-1.8% of autopsies
- may be present in 15% of patients who die of shock
- male:female ratio 2:1
Pathology
- unilateral adrenal gland involvement (93%)
- extensive necrosis of all 3 adrenal cortical layers & of medullary adrenal cells
- retrograde migration of medullary cells into the zona fasciculata
- widespread hemorrhage into the adrenal gland that may extend into the perirenal fat
- adrenal vein thrombosis
Clinical manifestations
- incidental presentation (41%)
- post traumatic presentation (28%)
- presentation with pain (25%)
- abdominal pain
- low back pain
- pelvic pain
- thoracic pain
- more common with bilateral adrenal hemorrhage[4]
- critical illness more common with bilateral adrenal hemorrhage[4]
- symptoms of acute adrenal insufficiency
- fever (50-70%)
- tachycardia (40-50%)
- orthostatic hypotension (20%)
- skin hyperpigmentation (rare)
- rash (75% of patients with Waterhouse-Friderichsen syndrome)
- small, pink macules or papules, rapidly followed by petechial lesions, which gradually transform into large, purpuric, coalescent plaques in late stages
- signs of acute abdomen, including guarding, rigidity, or rebound tenderness (15-20%)
- - more common with bilateral adrenal hemorrhage[4]
- confusion & disorientation (20-40%)
- may be asymptomatic (rare)
Laboratory
- complete blood count (CBC) with differential
- comprehensive metabolic panel
- serum sodium: hyponatremia
- serum potassium: hyperkalemia*
- serum creatinine, serum urea nitrogen: prerenal azotemia
- hyponatremia, hyperkalemia, & prerenal azotemia are present in ~50% of patients with extensive, bilateral adrenal hemorrhage
- serum calcium: mild hypercalcemia may rarely occur
- serum glucose: hypoglycemia may occur, but is rarely severe
- serum cortisol, plasma ACTH, serum aldosterone
- plasma renin activity (PRA)
- Cortrosyn stimulation test confirms the diagnosis of adrenal insufficiency
* contrast with pituitary apoplexy: no hyperkalemia
Diagnostic procedures
- ultrasound of the adrenals (including Doppler)
- reveals hyperechoic masses that contain a central echogenic area in the adrenal glands
- several weeks after the acute event, the central echogenicity decreases as the hematomas become cystic.
- percutaneous biopsy is helpful in establishing metastatic disease
Radiology
Complications
- adrenal crisis (bilateral adrenal hemorrhage)
- unilateral adrenal hemorrhage is not associated with acute adrenal insufficiency
- shock
- death (rare)[4]
Management
- see adrenal insuffciency
- acute medical therapy
- correct fluid, electrolyte, & red cell mass deficits
- treat adrenal insufficiency
- rarely needed for unilateral adrenal hemorrhage[4]
- hydocortisone
- surgery
- adrenalectomy (open or laparoscopic)
- nontraumatic adrenal hemorrhage
- generally not necessary except in patients with
- primary adrenal tumors
- extensive retroperitoneal hemorrhage (rare)
- generally not necessary except in patients with
- traumatic adrenal hemorrhage
- treatment of associated injuries
- exploration of penetrating wounds
- control of bleeding
- consultations
- endocrinology
- interventional radiology
- urology or surgery
- others as needed
- chronic adrenal insufficiency
- long-term glucocorticoid replacement
- need for mineralocorticoid replacement is variable
- androgen replacement therapy may be beneficial in women
- prognosis:
- chronic adrenal insufficiency occurs in most patients who survive extensive, bilateral adrenal hemorrhage,
- rare case reports exist of patients who had complete recovery of adrenal function after an episode of extensive, bilateral adrenal hemorrhage & acute adrenal insufficiency
More general terms
More specific terms
References
- ↑ Tritos NA eMedicine: Adrenal Hemorrhage http://emedicine.medscape.com/article/126806-overview
- ↑ Rosenberger LH, Smith PW, Sawyer RG et al Bilateral adrenal hemorrhage: the unrecognized cause of hemodynamic collapse associated with heparin-induced thrombocytopenia. Crit Care Med. 2011 Apr;39(4):833-8. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21242799 Free PMC Article
- ↑ Medical Knowledge Self Assessment Program (MKSAP) 17, 18. American College of Physicians, Philadelphia 2015, 2018.
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 Dogra P et al. Adrenal hemorrhage: A comprehensive analysis of a heterogeneous entity-etiology, presentation, management, and outcomes. Mayo Clin Proc 2024 Mar; 99:375. PMID: https://www.ncbi.nlm.nih.gov/pubmed/38432745 PMCID: PMC10917120 (available on 2025-03-01) https://www.mayoclinicproceedings.org/article/S0025-6196(23)00474-3/abstract