Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 33  |  Issue : 2  |  Page : 56-58

Isolated adrenal gland hematoma after blunt abdominal trauma: A case report and literature review


Department of Urology, Korgialenio-Benakio Hellenic Red Cross Hospital, Athens, Greece

Date of Submission25-Oct-2021
Date of Decision29-Oct-2021
Date of Acceptance05-Nov-2021
Date of Web Publication26-May-2022

Correspondence Address:
Savvas Tsakiris
Ampelokipoi 11526, Athens
Greece
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HUAJ.HUAJ_45_21

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  Abstract 


Isolated traumatic adrenal gland hematoma is a very rare condition. Our aim is to present a case of an isolated traumatic hematoma of the adrenal gland after a low-speed motorcycle accident without other associated injuries. A 30-year-old Caucasian male presented to the emergency department complaining of intense upper abdominal pain associated with shortness of breath. Trauma ultrasonography assessment, focused assessment with ultrasonography for trauma, was negative; emergency computed tomography (CT) imaging revealed a well-defined 3.8 cm × 2.8 cm mass in the location of his right adrenal gland. He was hospitalized for 48 h and was discharged hemodynamically stable, with normal hemoglobin levels. CT imaging at 1-month follow-up revealed a decrease in hematoma size and complete resolution of symptoms. Conservative treatment may be the method of choice for adrenal trauma, provided that patients remain hemodynamically stable and closely monitored.

Keywords: Adrenal gland, close monitored, conservative approach, isolated traumatic hematoma


How to cite this article:
Tsakiris S, Paparidis S, Zerva M, Katsimantas A, Bouropoulos K, Ferakis N. Isolated adrenal gland hematoma after blunt abdominal trauma: A case report and literature review. Hellenic Urology 2021;33:56-8

How to cite this URL:
Tsakiris S, Paparidis S, Zerva M, Katsimantas A, Bouropoulos K, Ferakis N. Isolated adrenal gland hematoma after blunt abdominal trauma: A case report and literature review. Hellenic Urology [serial online] 2021 [cited 2022 Aug 11];33:56-8. Available from: http://www.hellenicurologyjournal.com/text.asp?2021/33/2/56/346061




  Introduction Top


Isolated traumatic adrenal gland hematoma is a rare condition. The incidence rate of adrenal gland injury ranges from 0.03% to 4.95% of all trauma cases. Isolated adrenal hemorrhage is a very rare subset of this type of injury.[1],[2] It is very difficult to diagnose this condition because it has a nonspecific clinical presentation, and there are no specific diagnostic biomarkers.[3]


  Case Report Top


A 30-year-old Caucasian male presented to the emergency department (ED) complaining of intense upper abdominal pain associated with shortness of breath after a low-speed motorcycle accident. On presentation, the patient's Glasgow coma scale score was 15/15. Blood pressure was 148/102 mmHg, heart rate 128 beats/min, respiratory rate 23 breaths/min, temperature 37°C, oxygen saturation 98%, and FiO2 of 21%. He had no previous medical record except daily tobacco use. A physical examination revealed normal bilateral lung auscultation. Bowel sounds were present, and the abdomen examination showed mild tenderness in deep palpation of his right upper quadrant and right lower back area, without visual evidence of lacerations on his abdomen or his chest. White blood cell count was 157,000/μL (77.1% segmented neutrophils). Hemoglobin level was 16.3 mg/dL, with 48.4% hematocrit. Only hepatocellular liver enzymes were elevated (aspartate transaminase: 125 U/l and alanine transaminase: 106 U/l) without an increase in bilirubin, alkaline phosphatase, and gamma-glutamyl transferase. The rest of his blood examinations were within normal limits. Trauma ultrasonography evaluation and focused assessment with ultrasonography for trauma (FAST), performed in the ED, were negative for trauma

Emergency abdominal contrast-enhanced computed tomography (CE-CT) was performed due to the persistence of pain and abnormal liver examinations, which set high level of clinical suspicion. Abdominal CT revealed a well-defined, oval-shaped mass in his right adrenal gland, sized 3.8 cm × 2.8 cm, with 70–80 HU density, without active extravasation of contrast agent [Figure 1]. Neither no musculoskeletal trauma was identified nor injuries to his liver or kidneys. CT confirmed the diagnosis of isolated right adrenal injury. The patient was subsequently admitted to the urology clinic for close monitoring.
Figure 1: Right adrenal hematoma depicted in CE-CT scan, 2 hours after presentation in the Emergency Department (arrow)

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During hospitalization, his clinical condition remained stable [Table 1]. Right upper quadrant pain gradually subsided, along with abdominal tenderness after administration of low-dose intravenous analgesia with paracetamol and tramadol. The patient was discharged 48 h later with oral antibiotics and analgesia prescribed for 7 days. Restriction on physical activities for 1 month was also recommended. A follow-up CT scan 7 days after discharge showed no size reduction of the adrenal gland hematoma. Right upper quadrant pain and tenderness were reduced 1 week after discharge. Follow-up CT scan at 1 month after discharge revealed a small reduction in hematoma size [Figure 2] and complete resolution of symptoms.
Table 1: Hemoglobin and hematocrit

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Figure 2: CE-CT follow up scan, one month after discharge shows reduction in adrenal hematoma size, with no active contrast agent extravasation

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  Discussion Top


Adrenal hematoma is rare because of the anatomical location of the adrenal gland, which is found deep in the retroperitoneal cavity, surrounded by protective soft-tissue structures that act as a natural protective environment. The incidence of adrenal gland injury ranges from 0.03% to 4.95% of all trauma cases. Isolated adrenal hemorrhage is a very rare subset of this type of injury.[1],[2],[3]

It is very difficult to diagnose an isolated traumatic adrenal gland hematoma because it has nonspecific clinical presentation without any sensitive or specific diagnostic biomarkers.[3] FAST is the most frequently used imaging modality for trauma patients in the ED. However, FAST ultrasonography may fail to identify many traumatic lesions such as adrenal gland hematoma due to limitations in the size of the injury and variable experience of the examiner. The method of choice for the diagnosis of adrenal trauma and synchronous identification of associated injuries is CT with intravascular contrast agent infusion (CE-CT).[4],[5] In this case, diagnosis, set with CE-CT, was based on high level of clinical suspicion due to the persistence of pain, along with mild liver enzyme elevation.

Management of patients with isolated adrenal gland hematoma depends mainly on the patient's comorbidities and the severity of trauma. There is an increasing trend toward conservative management or minimally invasive procedures such as angiography instead of surgical exploration. In most of the cases, stable patients with isolated adrenal trauma are treated conservatively with monitoring, analgesic drug administration, and avoidance of activities that may increase intra-abdominal pressure.[6] If the patient becomes hemodynamically unstable with active extravasation of contrast agent, there is the choice of minimally invasive procedures such as angiographic embolization to control bleeding. However, there are no guidelines concerning monitoring and the definite timing for angiography and embolization.[7],[8] The decision on whether to proceed to more invasive treatment depends on symptom severity. In case of uncontrolled bleeding or lack of angiography, surgical exploration should be performed. There are no current guidelines about follow-up for an isolated traumatic adrenal hematoma, although follow-up imaging is necessary to reassess the size of the lesion.[9]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Raup VT, Eswara JR, Vetter JM, Brandes SB. Epidemiology of traumatic adrenal injuries requiring surgery. Urology 2016;94:227-31.  Back to cited text no. 1
    
2.
Mehrazin R, Derweesh IH, Kincade MC, Thomas AC, Gold R, Wake RW. Adrenal trauma: Elvis Presley Memorial Trauma Center experience. Urology 2007;70:851-5.  Back to cited text no. 2
    
3.
Chen KT, Lin TY, Foo NP, Lin HJ, Guo HR. Traumatic adrenal haematoma: A condition rarely recognised in the emergency department. Injury 2007;38:584-7.  Back to cited text no. 3
    
4.
Pinto A, Scaglione M, Pinto F, Gagliardi N, Romano L. Adrenal injuries: Spectrum of CT findings. Emerg Radiol 2003;10:30-3.  Back to cited text no. 4
    
5.
Sinelnikov AO, Abujudeh HH, Chan D, Novelline RA. CT manifestations of adrenal trauma: Experience with 73 cases. Emerg Radiol 2007;13:313-8.  Back to cited text no. 5
    
6.
Igwilo OC, Sulkowski RJ, Shah MR, Messink WF, Kinnas NC. Embolization of traumatic adrenal hemorrhage. J Trauma 1999;47:1153-5.  Back to cited text no. 6
    
7.
Tixedor N, Lesnik A, Vernhet H, Drianno N, Bousquet C, Sénac JP. Embolization treatment of a traumatic adrenal hemorrhage. J Radiol 1999;80:733-5.  Back to cited text no. 7
    
8.
Daoudi Y, Langlois E, Muller JM, Dacher JN, Pfister C. Management of post traumatic isolated adrenal haematoma. Ann Chir 2006;131:511-3.  Back to cited text no. 8
    
9.
Kunhivalappil FT, Hefny AF, Abu-Zidan FM. Management of blunt adrenal gland injury in a community-based hospital. Injury 2019;50:1049-52.  Back to cited text no. 9
    


    Figures

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    Tables

  [Table 1]



 

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