What is Adrenal Hemorrhage?
Adrenal hemorrhage is a rare condition where bleeding occurs in the adrenal glands, the small organs located just above each kidney. This bleeding can happen in one or both glands and can cause anything from vague stomach pain to severe cardiovascular problems. This unusual condition can be caused by a variety of factors including physical trauma to the abdomen, infections, clotting disorders, use of blood thinners, pregnancy, stress, antiphospholipid syndrome, and essential thrombocytosis.
It’s difficult to diagnose adrenal hemorrhage as its symptoms can be quite diverse. These symptoms can range from vague stomach pain to acute adrenal insufficiency, depending on where and how severe the bleeding is. Testing will usually include imaging tests and biochemical evaluation.
The adrenal glands consist of two distinct parts: the outer section, or adrenal cortex, which produces crucial hormones such as glucocorticoids, mineralocorticoids, and adrenal androgens; and the inner section, or adrenal medulla, which creates adrenaline-like hormones. These glands receive a lot of blood supply from three main arteries while the venous drainage, or removal of deoxygenated blood, is limited to one main vein. This difference in blood flow may contribute to the development of hemorrhagic infarction, a condition where blood flow to the gland is blocked, leading to tissue death or damage.
What Causes Adrenal Hemorrhage?
Adrenal hemorrhage, or bleeding within the adrenal glands, can occur for a variety of reasons. It can be categorized in two ways:
1. First, it could be primary or idiopathic, which means doctors can’t identify a clear cause for the bleeding.
2. It might also be secondary, which means it’s caused by another factor. These secondary factors can include:
- Trauma to the abdomen
- Infections
- Septicemia which is severe blood infection
- Use of anticoagulant medications which thin the blood
- Pregnancy
- Severe stress
- Stress in newborns
- Surgery
- Cancerous diseases
- Autoimmune diseases such as systemic lupus erythematosus and antiphospholipid syndrome
Any major stress on the body can lead to an increased growth of the adrenal glands and cause more blood flow to the region. This, combined with the naturally high blood supply and limited outflow of blood from the glands, may increase the chance of a blood clot causing tissue death. This process is known as hemorrhagic infarction.
Often, a condition known as adrenal congestion can be seen in CT scans of patients who later develop adrenal hemorrhage. This could potentially be an early sign of adrenal hemorrhage and may be a crucial clue for early diagnosis.
Risk Factors and Frequency for Adrenal Hemorrhage
Adrenal hemorrhage, a somewhat rare condition, is found in about 0.14% to 1.8% of postmortem examinations. This disorder is serious, with an overall mortality rate of 15%. The severity of the underlying cause can influence the mortality rate. For instance, with Waterhouse-Friderichsen syndrome, where adrenal hemorrhage is often due to meningococcal sepsis, the mortality rate can be as high as 55-60%. The condition’s actual incidence might be higher than estimated due to its broad symptoms, associated illnesses, and varied lab findings, which make diagnosis problematic. The condition seems to be more common in males and appears in both newborns and middle-aged individuals.
Signs and Symptoms of Adrenal Hemorrhage
Adrenal hemorrhage is a complicated condition to diagnose, it can show up in various medical situations. It’s most common among critically ill people, so it’s vital to catch it early in these patients. Mostly, adrenal hemorrhage is found by chance during medical tests. Yet, it often causes generalized symptoms like a dull ache in the stomach or side, fatigue, weakness, tiredness, and vomiting or diarrhea. Additionally, if the bleeding is severe and affects both adrenal glands, it can lead to a serious condition known as acute adrenal insufficiency.
When a doctor examines a patient, certain signs may point to adrenal hemorrhage. Signs may include rapid heart rate and low blood pressure, which can indicate severe blood loss. There may also be pain or tenderness in the abdomen or on the side of the body. If the adrenal hemorrhage is caused by a pheochromocytoma – a rare tumor of the adrenal gland – the patient may have high blood pressure due to excess production of certain hormones.
- Generalized stomach or side ache
- Fatigue
- Weakness
- Tiredness
- Nausea
- Vomiting
- Diarrhea
- Acute adrenal insufficiency (in severe cases)
- Fast heart rate
- Low blood pressure
- Abdominal or flank tenderness
Testing for Adrenal Hemorrhage
Most patients with adrenal bleeding might show normal lab results. However, some might have an increased number of white blood cells (leukocytosis) or lower red blood cell count (anemia). Low sodium (hyponatremia), high potassium (hyperkalemia), low glucose (hypoglycemia) are few biochemical markers indicating adrenal insufficiency. Also, higher-than-normal levels of cortisol and catecholamines might be found due to their brief release from a damaged adrenal gland. Additionally, low cortisol with elevated ACTH levels can be a telltale sign of extensive adrenal gland involvement.
Imaging continues to prove vital for diagnosing adrenal bleeding. The computed tomography (CT) scan is an invaluable tool in this process. The imaging appearance depends on the age of the hematoma— the pooled blood within adrenal tissue. On a CT scan, adrenal bleeding often appears as a round or oval-shaped lesion. There could be changes in the fat surrounding the adrenal gland, and blood might spread to the area around the kidney. New hematoma can appear brighter, but they become less noticeable over time.
Ultrasound is the preferred method for infants as it works better due to their small body size and comparatively larger adrenal size. Contrast-enhanced ultrasound (CEUS) is increasingly being used in children to evaluate and monitor adrenal trauma and to distinguish between adrenal bleeding and a tumour.
The most accurate diagnostic tool is Magnetic Resonance Imaging (MRI), which can differentiate between new and old hematomas and also detect the presence of any underlying tumors.
Treatment Options for Adrenal Hemorrhage
The right treatment for adrenal bleeding (also known as adrenal hemorrhage) depends on how bad the bleeding is and the extent of the hormonal deficiency. Traditionally, people were monitored closely, with regular check-ups and scans, but lately more proactive interventions have been suggested.
The main guide on how to treat adrenal hemorrhage should be how stable the person’s body is as well as whether they have adrenal insufficiency, which is a condition where the adrenal glands aren’t producing enough hormones. Those with severe internal bleeding that doesn’t improve with blood transfusion and other mild treatments may need a more direct approach to stop the bleeding, like angiography and embolization. This is where the bleeding vessel is identified and blocked, and it often has better results than the traditional surgical method (laparotomy).
Sometimes, adrenal hemorrhage can lead to adrenal insufficiency due to the damage done by the bleeding. This should be treated with corticosteroids, a type of hormone. A CT scan, which is a type of medical imaging, may show signs of swelling in the adrenal glands which can be a sign that the glands are not functioning properly and that adrenal hemorrhage might occur. If found early, steroids can be given as a preventive measure to stop death due to adrenal insufficiency.
Adrenal hemorrhage can also be an early sign of a tumor in the adrenal glands, with pheochromocytoma being the most common. In these cases, it’s suggested to first stabilize the patient with medications to lower blood pressure and alpha-blockers, with further treatment plans made once the exact cause is confirmed.
What else can Adrenal Hemorrhage be?
Understanding what’s wrong when someone feels ill can be difficult, especially if the symptoms are vague or similar to other issues. This is particularly tricky with diseases and problems that can affect the kidneys or the adrenal glands. Things that can mimic these conditions include an aneurysm (a weak, bulging spot in an artery), cancers that have spread to the adrenal glands, and kidney tumors.
Newborn babies can also experience issues in their adrenal area, but these can often be distinguished based on various symptoms, lab results, and x-rays or other imaging. For instance, a specific type of cancer called neonatal neuroblastoma is usually not life-threatening and can be detected by measuring a specific compound in the baby’s urine over a 24-hour period. Additionally, if a newborn has both adrenal hemorrhage (bleeding in adrenal glands) and neuroblastoma, this can be identified using repeated ultrasound scans.
A recently documented case has shown that right adrenal hemorrhage could be diagnosed in a patient suffering from COVID-19 through advanced abdominal imaging, even when the adrenal glands are functioning normally.
Lastly, it’s important to accurately and quickly diagnose adrenal abscesses (localized collections of pus in the adrenal glands) since this helps rule out cancers and allows for suitable treatment planning. Although adrenal masses are rare and seldom bleed, they should be considered when figuring out causes of adrenal bleeding.
What to expect with Adrenal Hemorrhage
The outcome of a patient can change greatly depending on the cause of their illness, the severity of bleeding, and their general health. In cases of Waterhouse Friderichsen syndrome, a serious health condition, unfortunately, around 60% of patients might not survive, even with proper medical treatment involving fluids, antibiotics, and glucocorticoids.
Possible Complications When Diagnosed with Adrenal Hemorrhage
Severe bleeding in the adrenal glands can cause adrenal insufficiency, a condition where the glands do not produce enough hormones. This can be a short-term or a long-term condition. A lot of bleeding can also lead to retroperitoneal hemorrhage, which is bleeding in the space behind the abdominal cavity, and hypovolemic shock, a serious and life-threatening condition caused by a severe loss of blood.
Preventing Adrenal Hemorrhage
While there is no precise way to prevent adrenal hemorrhage, early detection is crucial for improving the outcomes. This means being alert to its possible symptoms and getting speedy medical attention.
