Isolated Adrenal Hematoma Presenting as Acute Right Upper Quadrant Pain

doi:10.1016/j.jemermed.2009.11.022

The Journal of Emergency Medicine

Volume 43, Issue 4, October 2012, Pages e215-e217

https://doi.org/10.1016/j.jemermed.2009.11.022 Get rights and content

Abstract

Background: Adrenal hematoma is an infrequent occurrence in the setting of adult trauma care. It is typically associated with diffuse abdominal injury, and its presence is commonly correlated with high injury severity and mortality. Objectives: To discuss the recognition of adrenal hematoma as a cause of right upper quadrant pain. Case Report: We present the case of a 23-year-old man who presented to the Emergency Department (ED) with acute right upper quadrant pain after blunt trauma to the area; he was initially diagnosed with an abdominal contusion with an incidental adrenal adenoma. After experiencing continued pain for 2 days, the patient returned to the ED for re-evaluation. Subsequent imaging revealed that the adrenal mass had enlarged, and it was determined that this patient had suffered an acute adrenal hematoma. The lesion was determined to be self-limited and the patient was treated with supportive care. Follow-up images 8 weeks later revealed resolution of the hematoma and the patient reported complete resolution of symptoms. We also discuss adrenal hematoma in the trauma setting and explain that in our patient, given the clinical scenario and statistical evidence, an initial diagnosis of adrenal hematoma should be favored over abdominal contusion with incidental adenoma. Conclusion: We describe a case of a traumatic isolated adrenal hematoma that presents acutely as right upper quadrant pain. This unusual presentation highlights the need for recognition of the adrenal gland as a potential cause of right upper quadrant pain in the trauma setting.

Introduction

Adrenal hematoma is an infrequent occurrence in the setting of adult trauma care (1). It is typically associated with diffuse abdominal injury, and its presence is commonly correlated with high injury severity and mortality (1, 2, 3, 4). To our knowledge, we report the first described case of a traumatic isolated adrenal hematoma that presents acutely as right upper quadrant pain.

Section snippets

Case Report

A 23-year-old man presented to the Emergency Department (ED) complaining of intense upper abdominal pain. The pain began after an injury sustained during a non-contact football game. The patient was extending his body to catch the football and landed with high intensity in a position parallel to the ground. During the fall, the football was trapped between his body and the ground, with the tip of the football lodging into his abdomen. No protective equipment was worn. No contact was made with

Discussion

Several studies have examined the prevalence of adrenal hematoma in the trauma setting, showing all-trauma incidence rates ranging from 0.03% to 4.95%, whereas studies restricted to abdominal trauma report adrenal involvement in 2–3% of cases (1, 2, 4, 5). Adrenal trauma can result in an acute hemorrhage, as occurred in our patient, or it can present insidiously as a delayed hemorrhage.

Theories regarding the mechanism of acute adrenal injury suggest that it may occur when the gland is

Conclusion

Unilateral adrenal hematoma is a rare occurrence that typically presents with associated abdominal trauma. In this case it was self-limited and was managed with supportive care. We present a case of isolated traumatic unilateral adrenal hematoma presenting as acute pain. This unusual presentation highlights the need for recognition of the adrenal gland as a potential cause of right upper quadrant pain in the case of trauma.

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Cited by (10)

Adrenal gland injury after blunt abdominal trauma: Two case series and review of the literature
2020, International Journal of Surgery Case Reports
Citation Excerpt :
Our first patient was punctual on follow-up, whereas the second one missed her scheduled follow-up. In addition, the main question mark in borderline situations as in Case 2, that was to clarify whether or not the AH occurred on a pre-existing adrenal lesion or misdiagnosed as adrenal adenoma with similar cases reported in the past [11]. In adult patients in Greece, to our knowledge, there are no former described cases of adrenal blunt injury.
Adrenal gland injury (AGI) is a rare form of trauma that is often misdiagnosed, especially if isolated.
Herein we describe two rare cases of adrenal hematoma (AH) and adrenal contusion due to blunt abdominal trauma. A 33-year-old Caucasian male who was transported to the emergency department after a low-speed motorbike accident and a 69-year old Caucasian female who fell from 50 cm height. Both where complaining of intense pain in the right flank. Neither were under anti-coagulant or anti-platelet therapy. In both patients thoracoabdominal CE-CT revealed the injury.
AGI is an uncommon finding in blunt trauma and isolated adrenal injuries usually result from low force accidents. Treatment is most commonly conservative, but depends on patient’s status. In Greece, to our knowledge, these are the first such cases reported in adults.
Diagnosis needs high level of clinical suspicion.
Epidemiology of Traumatic Adrenal Injuries Requiring Surgery
2016, Urology
Citation Excerpt :
Rates from 4% to 6.2% have been reported, but rarity of isolated injuries makes single-institution analysis difficult.2,12 These injuries typically present with upper quadrant abdominal pain after blunt trauma.13-15 In our study, isolated adrenal injuries were associated with lower ISS, female gender, younger age, Caucasian race, and penetrating injury.
To analyze adrenal injuries using the National Trauma Data Bank. Adrenal trauma is rare and current literature is lacking in data from large case series.
A retrospective analysis of the National Trauma Data Bank from the years 2007-2011 was performed. Patient demographics, Injury Severity Score (ISS), mechanism of injury, type of trauma, associated injuries, and development of shock were assessed. Multivariable models were used to determine association with outcomes, such as characterization of injury, need for adrenalectomy, intensive care unit admission, and death.
Of the 1,766,606 trauma cases recorded, 7791 involved 1 or both adrenal glands (0.44%). Common associated injuries were to the ribs (50.9%), thorax (50.0%), and liver (41.6%). Eighty adrenal injuries required surgery (80/7791, 1.0%), none of which were isolated adrenal injuries (0/120, P = .63). Higher ISS (P = .009), Black race (P = .031), penetrating injury (P < .001), and splenic (P < .001) and intestinal injuries (P = .018) were associated with need for adrenalectomy. No isolated adrenal injuries were associated with death (12% vs 0%, P < .0001). Older age (P < .001), higher ISS (P < .001), chronic kidney disease (P = .009), penetrating injuries (P < .001), and injuries to the aorta/vena cava (P = .008), peripheral vasculature (P < .0001), thorax (P = .029), brain/spinal cord (P < .001), and abdominal polytrauma (P = .005) were associated with mortality.
Adrenal injuries are rare, comprising 0.44% of recorded traumatic injuries. Isolated adrenal injuries were not fatal and did not require surgery, and thus should be managed conservatively. Detection of adrenal injury in polytrauma patients is key, particularly penetrating trauma and concurrent splenic and/or intestinal injuries, as these patients are more likely to require adrenalectomy.
Isolated adrenal hemorrhage after blunt trauma: Case report and literature review
2013, Urological Science
Citation Excerpt :
The estimated incidence rate of the injury is approximately 2–3%.3,4 Isolated adrenal hemorrhage is a very rare subset of this type of injury and usually has limited clinical significance.5 The majority of adrenal gland injuries can be treated conservatively.
Isolated adrenal hemorrhage following blunt abdominal trauma is rare. The wide variation in clinical manifestations and lack of specific biologic markers make its diagnosis difficult. Computed tomography (CT) remains the golden standard for detecting this injury. Although isolated adrenal hemorrhage is usually silent and self-limiting, the presence of adrenal hemorrhage in a patient with trauma is associated with higher injury severity, and coexisting injury to the liver, ribs, kidneys, or spleen is common. Blunt trauma-related acute thoracoabdominal pain and skeletal pain are common problems in the emergency room. Patients should be carefully evaluated according to their trauma mechanism and physical examination. If an unusual complaint is presented (e.g., pain associated with cold seating or pain persisting after general analgesics), the emergency room physician should be aware of adrenal injury, the possibility of associated organ injury, and the potential for adrenal insufficiency. It is also necessary for clinicians to become familiar with common diagnostic tools, treatment options, and trends for noninvasive procedures. Prompt recognition of associated injuries and the potential for mortality with adrenal insufficiency can provide the best guidance for patient treatment and care. In this article, we present the report of a 32-year-old male, who suffered from blunt chest trauma and complained of ill-defined chest pain associated with cold seating. His CT results revealed a left adrenal hemorrhage with a large retroperitoneal hematoma. The patient was treated successfully with conservative observation.
Unilateral traumatic adrenal hemorrhage with shock
2023, Journal of Emergencies, Trauma and Shock
Adrenal hemorrhage and hemorrhagic masses; diagnostic workup and imaging findings
2021, British Journal of Radiology
Unilateral adrenal hematoma with associated giant mass: a report of two cases
2019, Acta Chirurgica Belgica

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Clinical Communications: AdultsIsolated Adrenal Hematoma Presenting as Acute Right Upper Quadrant Pain

Abstract

Introduction

Section snippets

Case Report

Discussion

Conclusion

Injury

Curr Surg

Urology

Eur J Radiol

Surg Clin North Am

Endocrinol Metab Clin North Am

Clinical Communications: Adults
Isolated Adrenal Hematoma Presenting as Acute Right Upper Quadrant Pain