Clinical History
A 59-year-old male patient presented to the emergency department with abdominal pain and hypovolemic shock.
Imaging Findings
A 59-year-old male patient presented to the emergency department with abdominal pain and anaemia. The results of laboratory data indicated hemorrhage and an abdominal contrast enhanced CT-scan (Fig.
1) demonstrated a retroperitoneal hemorrhage on the left side which involved the left adrenal gland. The omolaterla adrenal gland was not dissociable from the collection above mentioned. An abdominal
angiography was therefore executed, in order to locate the origin of the bleeding. At first an angiographic study of the abdominal aorta was performed with the introduction of a 5 F pig-tail catheter
followed by aselective catheterization of the celiac trunk, the splenic artery and the left renal artery by means of a hydrophylic Simmons type 2 catheter, which showed no signs of any abnormal
exhibits. The study continued with selective catheterization of the medium adrenal artery directly arising from the aorta, which demonstrated an extravasation of the contrast media compatible with
the blood collection showed by the CT study (Fig. 2). A distal embolization of the vessel was executed using of particles of PVA (Contour) with a diameter between 150 and 250 microns. After an
angiographic control was performed, the outcome of the procedure was positive (Fig. 3). Already few hours after the procedure the patient showed the complete resolution of the symptoms present at his
entrance in ER. A CT study executed after a week evidenced a reduction of the retroperitoneal haematoma down to 13 cm in maximum diameter and the results of laboratory analyses also returned to
normal values. The patient was discharged from the hospital. A CT study performed 3 months later (Fig. 4,5) demonstrated the resorption of the haematoma. In the pararenal region, there was an
evidence of residual fluid collection and the left adrenal gland was well seen.
Discussion
Retroperitoneal haemorrhages with an adrenal origin are rather rare and are generally post-traumatic in nature or caused by situations of severe stress, anticoagulant therapy or tumours. Spontaneous,
monolateral or bilateral adrenal haemorrhages, usually present with an acute abdominal pain in the absence of injuries or associated pathologies. Certainly Magnetic Resonance (MR) has a high
diagnostic accuracy in identifying retroperitoneal blood collections or in the visualization of a possible associated adrenal tumour, but a CT scan appears to be more adequate as a second level
study, giving a panoramic view and being widely available in emergency situations. However CT is the choice to find abdominal and retroperitoneal blood collection specially with multislice CT, that
let quantify the bleeding very precisely and find the probable source. The surgical treatment consists in exclusion or fastening of the bleeding artery after the identification which is not always
easy, of the artery itself, with the possibility of gland asportation if found necessary, during the surgery. The transcutaneous alternative, with an endovascular procedure and a transcatheter
embolization, has been widely experimented with, as reported in literature, and is certainly better tolerated by the patient, requiring shorter recovery periods. In case of a rebleeding, it is
repeatable, and it always follows a definite angiographic diagnosis even if it is not technically easy, since multiple superselective catheterizations are often necessary. When a superselective
embolisation with microcatheter is to be done, in our experience, the use of embolising particles is more handful instead of the use of coils or surgical glue. Coils are normally used when after the
use of particles the bleeding site is not completely closed. Instead of PVA type particles, we could use other types of particles such as hydrophilic microspheres, that could be preferable because
they are not deformable and they have a more homogeneous calibre, but which are not available at the moment.
Differential Diagnosis List
Successful endovascular treatment of a spontaneous idiopathic adrenal haemorrhage with a huge retroperitoneal haematoma.
Final Diagnosis
Successful endovascular treatment of a spontaneous idiopathic adrenal haemorrhage with a huge retroperitoneal haematoma.