Case Report

Isolated adrenal hemorrhage after minor blunt trauma

A 29-year-old man was presented to the emergency department with isolated left adrenal hemorrhage after minor blunt trauma without sign of local bruising, external wounds, and tenderness. We did not consider the possibility of internal organ injury; however, abdominal pain was not improved by analgesics. The lesion was diagnosed by computed tomography. Unilateral adrenal injury tends to be clinically silent without Massive bleeding. The emergency physician should consider the possibility of adrenal hemor- rhage after minor blunt trauma and be familiar with the computed tomography finding of adrenal hemorrhage.

A 29-year-old man was presented to the emergency department with abdominal pain for 2 hours. He slipped down the stairs the night before in drunken state. The morning after, he had abdominal pain in the left lower quadrant. He does not have any other past history. He had no nausea, vomiting, diarrhea, or hematemesis.

On physical examination, the vital signs were as follows: blood pressure, 105/84 mm Hg; respiratory rate, 20/min; pulse rate, 78/min; and temperature, 36.8^oC. His abdomen was soft and flat, bowel sounds were normoactive. He had no direct tenderness, rebound tenderness, and costovertebral angle tenderness. He had no sign of local bruising or external wounds. The white blood cell count was 20,160/ mm³ with 92.4% segmented neutrophils. Hemoglobin was 16.3g/dL, and hematocrit was 45.7%. The chemistry panel was within normal limits including normal aspartate transaminase, amylase, blood urea nitrogen, and creatinine. Abdominal Plain radiography was unremarkable. We did not consider the possibility of a surgical abdomen; however, his symptom did not improve by analgesics.

At 3 hours after arrival, contrast-enhanced computed tomography (CT) was performed to search for the etiology of abdominal pain. The CT shows isolated hematoma in the left adrenal gland (Figs. 1 and 2). He was admitted to the general ward for conservative management.

Adrenal hemorrhage is quite rare because the adrenal gland is located deep within the abdomen and is well cushioned by surrounding soft tissue structures. Recent studies estimate the incidence to be 0.8% to 2% [1]. Several mechanisms of adrenal injury have been proposed including direct Crush injury, increased adrenal venous pressure from compressed inferior vena cava or adrenal venous thrombo-

sis, and the shear injury of small adrenal vessels due to rotational or deceleration forces [2,3]. We postulated that the momentary shearing force by the slip caused bleeding of the small adrenal vessels.

Adrenal trauma is usually accompanied by other injuries and requires thorough evaluation. The isolated adrenal hematoma, such as in this case, was only 4% of all adRenal injuries [1]. We could not recognize the adrenal hemorrhage without CT scanning. On precontrast axial CT scan, there is a 3 x 2.5 cm, oval-shaped, well-defined, homogeneous relatively high attenuation density (Hounsfield number, 57) lesion on the left adrenal gland area (Fig. 1). The contrast- enhanced CT scan shows that there is no change in the attenuation density of the lesion for the same adrenal lesion (Fig. 2). This suggests that the lesion is an acute hemorrhage rather than the other tumorous condition. There is subtle Hemorrhagic fluid at adjacent retroperitoneum, but neither sign of active bleeding nor evidence of other intra- abdominal solid organ injury is found.

Unilateral adrenal injury tends to be clinically silent without massive bleeding. However, bilateral injuries could result in Adrenal insufficiency, which is a life-threatening

Fig. 1 The precontrast axial CT scan shows a 3 x 2.5 cm, oval-shaped, well-defined, homogeneous, relatively high attenua- tion density (Hounsfield number, 57) lesion on left adrenal gland area (arrow).

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984.e6 Case Report

Fig. 2 The contrast-enhanced coronal reformatted CT scan shows no change in the attenuation density of the same adrenal lesion (arrow). Acute hemorrhage is suggested rather than the other tumorous condition.

condition requiring steroid replacement therapy [4]. The emergency physicians should be familiar with the CT findings of adrenal hemorrhage.

Je Sung You MD Sung Pil Chung MD Yoo Seok Park MD Hyun Soo Chung MD

Hahn Shick Lee MD, PhD Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea

E-mail address: [email protected]

Jeong-Sik Yu MD Department of Diagnostic Radiology, Yonsei University College of Medicine, Seoul, Republic of Korea

doi:10.1016/j.ajem.2007.02.024

References

1. Sinelnikov AO, Abujudeh HH, Chan D, Novelline RA. CT manifes- tations of adrenal trauma: experience with 73 cases. Emerg Radiol 2007.
2. Pinto A, Scaglione M, Guidi G, Farina R, Acampora C, Romano L. Role of multidetector row computed tomography in the assessment of adrenal gland injuries. Eur J Radiol 2006;59:355 - 8.
3. Hubens A, van Thielen F, Wyffels G. Isolated unilateral adrenal hemorrhage after a motorcycle race. J Trauma 1984;24:765 - 7.
4. Guichelaar MM, Leenen LP, Braams R. Transient adrenocortical insufficiency following traumatic bilateral adrenal hemorrhage. J Trauma 2004;56:1135 - 7.