Causes of Adrenal Gland Hemorrhage
Adrenal hemorrhage occurs primarily due to five major categories: trauma, coagulopathy/anticoagulation, severe physiologic stress (including sepsis), underlying adrenal tumors, and neonatal stress. 1
Primary Etiologic Categories
1. Trauma
Trauma represents the most common cause of adrenal hemorrhage overall 2. Abdominal trauma can directly injure the highly vascular adrenal glands, leading to hemorrhage.
2. Coagulopathy and Anticoagulation
- Patients on anticoagulant therapy (warfarin, heparin, low-molecular-weight heparin) are at significant risk 3
- Bleeding diatheses and coagulation disorders predispose to spontaneous adrenal hemorrhage 4, 5
- Recent reports include vaccine-induced immune thrombocytopenia and thrombosis 6
3. Severe Physiologic Stress and Sepsis
- Septicemia is a major cause, with bilateral adrenal hemorrhage in septic shock known as Waterhouse-Friderichsen syndrome 7
- Postoperative stress following major surgery 3
- Critical illness and hemodynamic instability 4
- COVID-19 infection has emerged as a recognized precipitant 6, 4
4. Underlying Adrenal Neoplasms
Hemorrhage into adrenal tumors is an important cause that requires high clinical suspicion:
- Pheochromocytoma - prone to spontaneous hemorrhage 5
- Adrenocortical carcinoma - can present with acute hemorrhage 8, 9
- Metastases (lung, breast, kidney, melanoma) 5, 9
- Adrenal adenomas - rarely hemorrhage but can occur 7
- Myelolipomas 5
5. Neonatal Stress
Birth trauma and perinatal stress can cause adrenal hemorrhage in neonates 1
Additional Contributing Factors
- Vascular abnormalities: Adrenal vein thrombosis can lead to hemorrhagic infarction 1
- Hypertension: Particularly in combination with other risk factors 7
- Hematologic disorders: Essential thrombocythemia and other myeloproliferative conditions 7
- Idiopathic: Some cases occur without identifiable cause 1
Critical Clinical Context
When evaluating for primary adrenal insufficiency, adrenal CT should be performed to assess for metastasis or hemorrhage 10. This is particularly crucial because bilateral adrenal hemorrhage leads to adrenal insufficiency in 16-50% of cases, which can be life-threatening without prompt recognition and treatment 4.
High-Risk Clinical Scenarios Requiring Suspicion:
- Unexplained abdominal pain with hemodynamic instability in patients with predisposing conditions 6
- Acute abdomen in patients on anticoagulation 3
- Septic shock with unexplained deterioration 7
- Known adrenal mass with acute symptom onset 1
- Recent surgery with persistent abdominal pain despite analgesia 3
Diagnostic Approach
CT is the modality of choice for suspected adrenal hemorrhage in adults with stress or coagulopathy 1. The imaging typically shows enlarged adrenal glands with high attenuation on non-contrast CT. When hemorrhage into an adrenal tumor is suspected, look for heterogeneous enhancement patterns that distinguish it from simple hemorrhage 1.
Important Caveat:
Most cases are diagnosed incidentally on imaging rather than with prospective clinical suspicion due to nonspecific presentation 6, 4. Therefore, maintaining high clinical suspicion in appropriate contexts (sepsis, anticoagulation, recent surgery, known adrenal lesions) is essential to prevent missed diagnosis and potentially fatal adrenal crisis.