Adrenal Hemorrhage

Adrenal haemorrhage is bleeding into the adrenal gland, which may cause adrenal insufficiency when bilateral.

Causes: anticoagulation, antiphospholipid syndrome, heparin induced thrombocytopenia, sepsis (Waterhouse-Friderichsen syndrome with meningococcus), trauma, surgery, pregnancy, adrenal tumour, neonatal birth trauma.

Bilateral haemorrhage in 15 to 20%; high mortality in untreated adrenal crisis.

Adrenal vein predisposition to thrombosis.

• Flank, abdominal or back pain, nausea, vomiting, fever.
• Hypotension, shock, confusion; hyponatraemia, hyperkalaemia.
• May be incidental on imaging, or present subacutely.
• Neonates: abdominal mass, jaundice, anaemia.

• CT: enlarged adrenal with hyperdense (50 to 90 HU) acute blood; MRI for tumour exclusion; follow up imaging at 3 to 6 months (resolution or calcification, ensure no underlying mass).
• Cortisol (random below 10 micrograms/dL in stress, 5 or less diagnostic) and ACTH, short synacthen test, electrolytes.
• Check coagulation, platelets, antiphospholipid antibodies, HIT assays, blood cultures.

• Suspected adrenal crisis: hydrocortisone 100 mg IV immediately, then 200 mg/24 hours, with saline resuscitation (do not wait for cortisol).
• Correct coagulopathy, stop or reverse anticoagulants where life threatening; manage antiphospholipid syndrome and HIT with non heparin anticoagulation if needed.
• Treat the underlying cause (antibiotics for meningococcal sepsis: ceftriaxone 2 g IV).
• Embolisation or surgery for haemodynamic instability from retroperitoneal bleeding.
• Long term glucocorticoid (hydrocortisone 15 to 25 mg daily) and fludrocortisone 0.05 to 0.2 mg daily if permanent failure; steroid education.
• Reassess adrenal function after recovery (recovery of function possible in unilateral cases).