Scholarly article on topic 'Isolated adrenal hemorrhage after blunt trauma: Case report and literature review'

Isolated adrenal hemorrhage after blunt trauma: Case report and literature review Academic research paper on "Clinical medicine"

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Urological Science
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{"blunt trauma" / "chest pain" / "isolated adrenal gland hemorrhage" / "retroperitoneal hematoma"}

Abstract of research paper on Clinical medicine, author of scientific article — Yu-Hsin Lin, Tony Wu

Abstract Isolated adrenal hemorrhage following blunt abdominal trauma is rare. The wide variation in clinical manifestations and lack of specific biologic markers make its diagnosis difficult. Computed tomography (CT) remains the golden standard for detecting this injury. Although isolated adrenal hemorrhage is usually silent and self-limiting, the presence of adrenal hemorrhage in a patient with trauma is associated with higher injury severity, and coexisting injury to the liver, ribs, kidneys, or spleen is common. Blunt trauma-related acute thoracoabdominal pain and skeletal pain are common problems in the emergency room. Patients should be carefully evaluated according to their trauma mechanism and physical examination. If an unusual complaint is presented (e.g., pain associated with cold seating or pain persisting after general analgesics), the emergency room physician should be aware of adrenal injury, the possibility of associated organ injury, and the potential for adrenal insufficiency. It is also necessary for clinicians to become familiar with common diagnostic tools, treatment options, and trends for noninvasive procedures. Prompt recognition of associated injuries and the potential for mortality with adrenal insufficiency can provide the best guidance for patient treatment and care. In this article, we present the report of a 32-year-old male, who suffered from blunt chest trauma and complained of ill-defined chest pain associated with cold seating. His CT results revealed a left adrenal hemorrhage with a large retroperitoneal hematoma. The patient was treated successfully with conservative observation.

Academic research paper on topic "Isolated adrenal hemorrhage after blunt trauma: Case report and literature review"

Urological Science 24 (2013) 27-29

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Urological Science

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Case report

Isolated adrenal hemorrhage after blunt trauma: Case report and literature review

Yu-Hsin Lin a, Tony Wu

a Department of Surgery, Yongkang Veterans Hospital, Tainan, Taiwan

b Division of Urology, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan c School of Medicine, National Yang-Ming University, Taipei, Taiwan

ARTICLE INFO

Article history: Received 24 June 2011 Received in revised form 5 July 2011

Accepted 15 August 2011 Available online 7 March 2013

Keywords: blunt trauma chest pain

isolated adrenal gland hemorrhage retroperitoneal hematoma

ABSTRACT

Isolated adrenal hemorrhage following blunt abdominal trauma is rare. The wide variation in clinical manifestations and lack of specific biologic markers make its diagnosis difficult. Computed tomography (CT) remains the golden standard for detecting this injury. Although isolated adrenal hemorrhage is usually silent and self-limiting, the presence of adrenal hemorrhage in a patient with trauma is associated with higher injury severity, and coexisting injury to the liver, ribs, kidneys, or spleen is common. Blunt trauma-related acute thoracoabdominal pain and skeletal pain are common problems in the emergency room. Patients should be carefully evaluated according to their trauma mechanism and physical examination. If an unusual complaint is presented (e.g., pain associated with cold seating or pain persisting after general analgesics), the emergency room physician should be aware of adrenal injury, the possibility of associated organ injury, and the potential for adrenal insufficiency. It is also necessary for clinicians to become familiar with common diagnostic tools, treatment options, and trends for nonin-vasive procedures. Prompt recognition of associated injuries and the potential for mortality with adrenal insufficiency can provide the best guidance for patient treatment and care. In this article, we present the report of a 32-year-old male, who suffered from blunt chest trauma and complained of ill-defined chest pain associated with cold seating. His CT results revealed a left adrenal hemorrhage with a large retroperitoneal hematoma. The patient was treated successfully with conservative observation. Copyright © 2013, Taiwan Urological Association. Published by Elsevier Taiwan LLC. All rights reserved.

1. Introduction

Adrenal gland injury is an uncommon consequence caused by blunt abdominal trauma, such as motor vehicle collisions, falls, or injuries in sports.1-3 The estimated incidence rate of the injury is approximately 2—3%.3,4 Isolated adrenal hemorrhage is a very rare subset of this type of injury and usually has limited clinical signif-icance.5 The majority of adrenal gland injuries can be treated conservatively. We herein report a case of traumatic isolated adrenal hemorrhage that presented with sudden onset of severe left chest pain.

2. Case report

A 32-year-old man walked into our emergency room complaining of severe left chest pain with shortness of breath 2 hours after a motor vehicle accident. His chest had bumped the steering

* Corresponding author. Department of Surgery, Kaohsiung Veterans General Hospital, 386 Da-Chung 1st Road, Kaohsiung 813, Taiwan. E-mail address: tonywu@vghks.gov.tw (T. Wu).

wheel when the collision occurred. On arrival, the young male was alert and oriented, and his vital signs were stable. A physical examination revealed bilateral clear breath sounds, soft abdomen, but marked tenderness in the left lower chest over the midaxillary line and left lower back area. The white blood count was 26,550/mm3, and there were 88.4% segmented neutrophils. The hemoglobin level was 15.9 mg/dL, while the hematocrit was 46.4%. A chemistry panel showed elevated levels of liver enzymes (aspartate transaminase/alanine transaminase of 84/106 U/L); otherwise, blood urea nitrogen and creatinine levels were within normal limits. There was no evidence of rib fracture, pneumothorax, or pneu-mohemothorax on a plain chest film. Despite administering initial analgesics, the patient still cried out in severe pain. In addition, he also had generalized cold sweating. One hour after his arrival, a contrast-enhanced abdominal computed tomographic (CT) scan was conducted to investigate the unusual pain. Abdominal CT disclosed a large left-side retroperitoneal hematoma caused by adrenal gland injury with active bleeding (Figs. 1 and 2). The patient was managed conservatively with bed rest, parenteral fluid administration, and opioid analgesics. The hospital course was 1 week, and he recovered uneventfully. There was no evidence of adrenal insufficiency during follow-up.

1879-5226/$ — see front matter Copyright © 2013, Taiwan Urological Association. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.urols.2013.01.002

Fig. 1. A large retroperitoneal hematoma (arrow B) with haziness of the periadrenal fat. The differential diagnosis included spleen laceration, liver laceration, and kidney laceration. Arrow A points to the spleen that had a contact contour without obvious hemorrhage.

3. Discussion

The estimated incidence rate of adrenal gland injury after abdominal trauma is approximately 2—3%.2,3 Most adrenal injuries are associated with adjacent organ or skeletal injuries, and an isolated adrenal injury is even rarer.6 The adrenal gland is a highly vascularized organ, so the sudden onset of deceleration forces may

cause shearing of small vessels, which result in acute or delayed hemorrhage.5,7 Isolated adrenal gland hemorrhage is usually of limited clinical significance,5 and can be treated supportively, including pain relief and avoidance of the Valsalva maneuver or other actions that may increase intra-abdominal pressure.5 However, there are also rare reports of active adrenal hemorrhage requiring transarterial embolization to control bleeding.8 There is a trend toward conservative treatment or less-invasive procedures, for example, percutaneous transcatheter arterial embolization for bleeding vessels, instead of surgical exploration if the patient remains hemodynamically unstable. However, there are no guidelines for the definite timing for angiography and embolization. The decisions mainly depend on the physicians' observations of patients. Moreover, bilateral adrenal gland injuries or hemorrhage can lead to serious adrenal insufficiency or an adrenal crisis, which is often overlooked as a reason for a patient's deterioration.2,9,10

The most frequent presenting symptom is pain; other clinical presentations vary widely, and include abdominal pain, flank pain, nausea, vomiting, hypotension, hypertension, a palpable flank mass, agitation, mental status change, and low-grade fever.11 Lack of specific biologic markers also makes a diagnosis difficult. Some authors proposed that ultrasonography can provide information about a retroperitoneal hematoma, and even detail the adrenal gland hemorrhage.12,13 However, in an emergency setting where experienced hands are not always available, CT seems to be the tool of choice, as it can provide quick and extensive information about adjacent organs, including the liver, kidneys, spleen, lungs, and skeletal injuries.6

A traumatic isolated adrenal injury is rare; it often results from motor vehicle accidents and blunt abdominal trauma. It is usually self-limiting and does not require intensive care operative intervention. Because of the unspecified clinical symptoms and bio-markers, a diagnosis can be difficult. Prompt imaging study, especially CT, is the gold standard for diagnosis and identifying the associated injuries, which is very critical in managing patients with trauma. Acute chest pain is a frequent complaint of such patients, but it is mostly considered to result from chest contusion or rib fracture. The correlation between this young man's chest pain and adrenal injury was unclear. There is no literature that discusses adrenal injury presenting as acute chest pain. Robert and his colleagues reported a large retroperitoneal hematoma caused by a ruptured type B aortic dissection with the initial symptom of sudden onset of chest pain.14 The pain seemed to be related to the aortic dissection rather than the retroperitoneal hematoma. It was difficult for our patient to point out a specific tender point, and the physical examination showed a large, ill-defined painful area, including the left lower chest and lower back. His chest pain could possibly have been explained by a chest contusion rather than the adrenal injury. Nevertheless, the unusual presentations, such as acute severe pain over the lower chest or upper abdomen, reminded clinicians to be aware of the possibility of adrenal gland injury and the need for recognition of associated injuries after trauma.

Conflicts of interest statement

The authors declare that they have no financial or non-financial conflicts of interest related to the subject matter or materials discussed in the manuscript.

Source of funding

Fig. 2. A large hematoma extending over the suprarenal area. The arrow points to active contrast extravasation.

References

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