Chronic adrenal hematoma associated with splenic rupture

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Chronic Adrenal HematomaAssociated with Splenic Rupture

The following article covers a 57-year-old man who presented with anacute abdomen. Laparotomy revealed splenic rupture secondary to an

impact from a large chronic adrenal hematoma. In reviewing the literature,the authors did not find any reported cases of unilateral adrenal hemor-rhage presenting with splenic rupture.

DEBA P. SARMA, MD FRED H.

RODRIGUEZ, JR., MD

NewOrleans

ecently, we encountered a pa-tient with a chronic left adrenal

hematoma presenting with an acuteabdomen due to splenic rupture.

Case Report

A 57-year-old white man presented with a20-hour history of abdominal pain. The painhad started in the epigastrium, where it wasinitially steady. It then gradually progressedto involve the entire abdomen, and becamecolicky in nature. The patient was nauseated,but denied any vomiting, hematemesis,melena, or jaundice. While in the waitingroom of his local physician, he fainted, andwas found to have a blood pressure of 60/40mm Hg. An intravenous infusion of normal

saline was started, and the patient was rushedto the VA Hospital's Emergency Room.

Past history included tobacco and alcoholabuse, but he had had no previous hospitali-zations, major illnesses, or trauma.

On admission, he had a blood pressure of 70/50 mm Hg, a pulse rate of 110 per minute,a respiration rate of 28 per minute, and atemperature of 95°F. He was conscious andresponded to questions. His abdomen wasdistended and very tender with rebound. Thebowel sounds were decreased. No evidence of trauma was noted. Laboratory findings in-cluded a hematocrit of 27 % and a WBC countof 14,000 per cu mm.

After stabilizing the patient with intra-venous fluids, he was immediately taken to

the operating room. An exploratorylaparotomy was performed, and it revealedactive hemorrhage into the peritoneal cavity.

From the Department of Pathology, Vet-erans Administration Medical Center andLouisiana State University Medical School,New Orleans, Louisiana.

The spleen was noted to be the site of bleed-ing, and it was removed. After additionallyremoving all the blood and clots from theperitoneal cavity, a large retroperitoneal masswas noted in the superior aspect of the left

kidney. The mass appeared to be encapsu-lated. This was dissected free without muchdifficulty. A thorough examination of the restof the abdominal organs revealed no otherabnormality. The patient received 11 units of packed red blood cells and 4 units of freshfrozen plasma intraoperatively and in the re-covery room. Recovery was uneventful.

On gross examination, the spleen revealeda torn capsule and recent subcapsular hemor-rhage. It weighed 85 gms and measured 7 x 4x3 cm.

The second specimen was an oval shapedmass which measured 17x15x11 cm (Fig 1).It weighed 1200 gms. The outer surface wascovered by a smooth, glistening, white, fi-brous membrane traversed by prominent

blood vessels. The mass had a firm to hardconsistency. The cut-surfaces were reddish-brown with focal areas of hemorrhage. In onearea, a discrete large hematoma measured 6cm in diameter. The inner surface of the cap-sule showed multiple nodules (averaging 0.7cm) of gray-white, firm, hard t issue.

Microscopically, the spleen showed a re-cent tear of the capsule with hemorrhage intothe splenic stroma.

The capsule of the mass showed focal areasof normal or compressed adrenal cortical tis-sue (Fig 2). The grossly visible capsularnodules were composed of adrenal tissue,dense fibro-collagenous tissue, or a combina-tion of both. The interior of the mass con-sisted of recent, organizing and organized

blood clots. No neoplastic tissue was noted inthe mass.

Discussion

In reviewing the literature, wefailed to find any reported cases of unilateral adrenal hemorrhage pre-senting with splenic rupture.

The signs and symptoms of ad-renal hemorrhage1 are those of anacute abdomen, ie, nausea, vomit-ing, colicky pain and abdominal ten-derness. In our patient, however, the

acute abdominal symptoms weredue to splenic rupture which wasfound at the surgery. The adrenalhematoma, though very large, wasold and asymptomatic. The patientcould not recall any previous traumaor episodes of abdominal or flank

R

Figl



CHRONIC ADRENAL HEMATOMA - SARMA, ET AL

pain. He had no coagulation abnor-malities by routine laboratoryevaluation. It can be assumed thathis adrenal hemorrhage and sub-sequent organization into a chronichematoma was idiopathic and clini-

cally silent. It is our feeling that thelarge adrenal mass, upon contactwith the spleen, resulted in a ruptureand subsequent acute abdomen.

Summary A 57-year-old man presented

with an acute abdomen. Surgicalexploration revealed splenic rupturesecondary to an impact from a largechronic adrenal hematoma.

Reference 'Clark OH, Hall AD, Schambelan M:

Clinical manifestations of adrenal hemor-rhage. Am J Surg 128:219-224, 1974 Fig 1. Gross appearance of theretroperitoneal mass showingfibrous capsule containing bloodclots. It represents achronicadrenal hematoma.

Fig 2. Microscopically, the wall of the hematoma shows thick fibrouswall on the left with adrenal corticaltissue and organizing thrombus onthe right. (H & E, original

magnification x 24)

Fig 2

Sarma DP, Rodriguez FH (1980): Chronic adrenal hematoma associated with splenic rupture. J La State Med Soc

132:119-120. PMID: 7430756 [PubMed - indexed for MEDLINE]







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Chronic adrenal hematoma associated with splenic rupture