From the Guidelines
Adrenal hemorrhage requires immediate attention and treatment to prevent adrenal insufficiency, with the most recent and highest quality study 1 guiding the management approach. The condition is characterized by bleeding into the adrenal glands, which can lead to adrenal insufficiency if severe.
Key Considerations
- Treatment depends on the cause and severity but typically includes hemodynamic stabilization, addressing the underlying cause, and hormone replacement therapy.
- For patients with adrenal insufficiency, immediate administration of hydrocortisone is crucial, usually starting with 100mg IV bolus followed by 50-100mg every 6-8 hours, as recommended by 2 and 3.
- Mineralocorticoid replacement with fludrocortisone (0.05-0.2mg daily) may be needed for long-term management.
- Surgical intervention is rarely required unless there is ongoing bleeding or a large hematoma causing compression symptoms.
Diagnostic Approach
- Evaluate AM levels of ACTH and cortisol level, as well as basic metabolic panel, renin, and aldosterone, as suggested by 1.
- Consider standard dose ACTH stimulation test for indeterminate results.
- Adrenal CT for metastasis or hemorrhage is essential for diagnosing the underlying cause of primary adrenal insufficiency.
Patient Education and Management
- Patients should be educated about stress dosing of steroids and carrying a medical alert card or bracelet indicating their adrenal insufficiency status, as emphasized by 2.
- Regular follow-up is necessary to assess health and well-being, measurement of weight, blood pressure, and serum electrolytes, and to monitor for complications of glucocorticoid therapy.
From the Research
Adrenal Hemorrhage Overview
- Adrenal hemorrhage is a rare condition that can lead to acute adrenal insufficiency and may be fatal 4.
- The risk factors of adrenal hemorrhage include focal adrenal lesion, abdominal trauma, and anticoagulation therapy 4.
- Adrenal hemorrhage can follow abdominal trauma or appear on a background of predisposing conditions such as adrenal tumors, sepsis, or coagulopathy 5.
Clinical Presentation and Diagnosis
- The clinical manifestation of adrenal hemorrhage varies widely; the symptoms may be related to adrenal insufficiency or may reflect multiple organ failure 4.
- Unexplained abdominal pain with hemodynamic instability in a patient with a predisposing condition should alert the physician to the possibility of adrenal hemorrhage 5.
- Diagnosis of adrenal hemorrhage is challenging due to its nonspecific clinical features, and it remains a diagnosis that is made serendipitously on imaging of acutely unwell patients rather than with prospective clinical suspicion 5.
Treatment and Management
- Bilateral adrenal hemorrhage can lead to adrenal insufficiency and potentially fatal adrenal crisis without timely recognition and treatment 5.
- Treatment with replacement doses of corticosteroids is necessary, and in most cases, fludrocortisone should be continued at a dosage of 0.05-0.1 mg/day, depending on blood pressure and sodium and potassium levels 6.
- Immediate treatment is necessary by substituting hydrocortisone in a higher dosage, and the amount of hydrocortisone can be reduced to a substitution dosage (15-25 mg/day divided into two to three doses/day) during the course of treatment 6.
Long-term Follow-up and Prognosis
- Long-term follow-up of patients with acute adrenal insufficiency attributable to adrenal hemorrhage demonstrates the absence of need for prolonged mineralocorticoid replacement and some improvement in endogenous glucocorticoid function in at least some of these patients 7.
- Adrenal histologic findings in some patients reveal previously undescribed changes consistent with regeneration and myelolipoma 7.
- Computed tomography can confirm bilateral atrophic adrenal glands in patients with a history of bilateral adrenal hemorrhage 7.