Adrenal Hemorrhage Symptoms
Adrenal hemorrhage typically presents with abdominal pain, back/flank pain, and hypotension, often accompanied by nonspecific symptoms like nausea, vomiting, weakness, and confusion that can rapidly progress to adrenal crisis if bilateral.
Clinical Presentation Framework
The symptom profile depends critically on whether the hemorrhage is unilateral or bilateral, and whether it results in acute adrenal insufficiency:
Acute Presentation (Most Common)
Pain is the hallmark symptom 1, 2, 3:
- Abdominal pain (often severe, may mimic acute abdomen)
- Back pain and flank pain (unilateral or bilateral)
- Pain typically develops within 8-12 days if related to anticoagulation 4
Hemodynamic instability:
Gastrointestinal symptoms:
Systemic symptoms:
- Severe weakness 6
- Lethargy and fatigue 4
- Fever (in some cases) 2
- Confusion and altered consciousness 6, 5
Critical Distinction: Bilateral vs. Unilateral
Bilateral adrenal hemorrhage leads to acute adrenal insufficiency and presents more dramatically 6:
- All the above symptoms plus signs of adrenal crisis
- Reduced consciousness or delirium
- Severe hypotension unresponsive to fluids
- Electrolyte abnormalities (hyponatremia, hyperkalemia, hypoglycemia) 6
- Mortality rate up to 15% 1
Unilateral hemorrhage may present with primarily pain and local symptoms without adrenal insufficiency 2, as the contralateral gland maintains function.
Common Pitfalls in Recognition
The diagnosis is frequently delayed or missed 7, 5 because:
- Symptoms are nonspecific - can be attributed to the underlying condition (sepsis, trauma, pregnancy complications)
- Classic electrolyte abnormalities may be absent initially 7 - patients may not present with hyponatremia or hyperkalemia early
- Symptoms overlap with the precipitating condition - in anticoagulated patients, symptoms attributed to the indication for anticoagulation rather than adrenal hemorrhage 4, 5
- Imaging findings may be subtle on initial review 7
High-Risk Clinical Contexts
Maintain heightened suspicion in these settings 6, 1, 4, 3:
- Anticoagulation therapy (occurs within 10 days of initiation)
- Sepsis and severe systemic stress
- Postpartum period (especially with preeclampsia/eclampsia)
- Heparin-induced thrombocytopenia with thrombosis syndrome
- Trauma
- Underlying adrenal tumors (pheochromocytoma, adrenocortical carcinoma)
Laboratory Findings
When adrenal insufficiency develops 6:
- Hyponatremia (most common)
- Hyperkalemia (develops later)
- Hypoglycemia
- Hypercalcemia (less common)
However, absence of electrolyte abnormalities does not exclude the diagnosis 7, particularly in early presentation or unilateral hemorrhage.
Diagnostic Confirmation
Computed tomography is the definitive imaging modality 1, 2, 8, showing:
- Bilateral or unilateral adrenal enlargement
- Hemorrhagic density within the glands
- Ultrasound may identify the lesion initially but CT provides confirmation 1, 2
Endocrine evaluation is mandatory 7, 3:
- ACTH stimulation testing to assess adrenal reserve
- Baseline cortisol and ACTH levels
- Required even if electrolytes are normal initially