Adrenal rupture after blunt abdominal trauma
M. Safioleas, M. Stamatakos, C. Safioleas, R. Iannescu, P. Safioleas, D. MantasCazuri clinice, no. 1, 2008
* 2nd Department of Propedeutic Surgery
Adrenal injury after blunt abdominal trauma in adults is rare and varies in range of overall incidence from 0.02 to 2% in hospital reviews (1, 2). In the pediatric trauma population posttraumatic adrenal hemorrhage appears a higher incidence (3%) (3).
Adrenal rupture rarely occurs as an isolated lesion but is more frequently associated with injury of the liver, spleen and kidneys. It is a hidden lesion and because the adrenal glands are seldom examined during operative abdominal exploration for blunt trauma, it can easily be overlooked leading in continued intraperitoneal hemorrhage occasionally resulting in shock (4). Posttraumatic adrenal hemorrhage is unilateral in more than 85% of cases (5-7) and with a strong predominance of involvement of the right gland (8).
Herein, we report a patient with traumatic rupture of the left adrenal gland associated with rupture of the spleen and laceration of the right lobe of the liver.
Case report
A previous healthy 21-year-old female was transferred to the operating room immediately after a car accident, which took place in front of our hospital. On admission, she was in shock with evidence of intraperitoneal hemorrhage, paleness, apathy and restleness. Blood pressure was 75/50 mmHg and she had pulse rate of 128 b/m. Abdominal examination revealed generalized tenderness and rigidity. There was an area of contusion over the right hemithorax with fractured ribs anteriorly in palpation. Subcutaneous scrupitus existed. From an urgent laboratory control the hematocrit was 34,1%, the hemoglobin was 9,3g/dl, while blood cell count was 13200/mm3 with 75% neutrophils and eosinophils 2%.
After a prompt supportive treatment the patient was operatively explored. There were 1000-1500cc of fresh blood in the peritoneal cavity and continued bleeding came from a large stellate laceration of the right lobe of the liver and the ruptured spleen. After splenectomy and resection of the partially separated section of the liver, tamponade of the liver was made to control the brisk bleeding. However, there was evidence of continued hemorrhage from another source. Further exploration of the retroperitoneal space disclosed a hematoma in the left upper retroperitoneal region. The left adrenal gland was completely divided in its middle and was actively bleeding. Thus, it was decided adrenalectomy to be performed (Fig. 1).
The postoperative course was characterized by a reoperation performed after 48 hours in order to remove the tamponade. Subsequently, the patient had a difficult postoperative course in Intensive Care Unit with atelectasia of the left lung, fever till 39,3ºC and wound infection, but finally she recovered completely and discharged from hospital on the 28th post-operative day from the initial operation. Replacement therapy due to adrenalectomy was not required. The patient is doing well 30 months after her hospitalization. Prophylactic vaccination against pneumoniococcal sepsis was used, as well as penicillin per os for one year.
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Discussion
Adrenal glands are rarely injured in blunt abdominal
trauma because of their small size and deep location in the retroperitoneal space. The most frequently affected organ in this area after blunt trauma is the kidney (9). As in introduction has been noted the incidence of adrenal injury in patients with blunt abdominal trauma is 0.02 to 2% in
hospital reviews and in postmortem studies ranges between 7 and 26% of deaths caused by severe abdominal trauma. In the case of severe trauma affecting the adrenal gland, it is reasonable that concomitant injuries to the abdominal organs of the affected side exist. The liver, the ipsilateral kidney and the spleen are the most likely to be injured due to their proximity and size (2). The risk of adrenal trauma appears to be equally rare in children (10). Isolated adrenal injury is exceedingly rare with one report involving two cases known (11). Adrenal hemorrhage occurs predominantly on the right side as anatomically the right adrenal gland is adjacent to the spine and is more likely to be
compressed during a forceful impact (75-85%) (5-8). Approximately 20% of posttraumatic adrenal hemorrhages are bilateral (12). According Ramlet bilateral hemorrhage of the adrenal glands in blunt abdominal trauma is extremely rare (0.03%), whereas even when occurred, is mostly believed to be of non-traumatic origin (5-13). The injury varies from a simple hematoma of the adrenal gland to complete transaction or massive destruction and pulverization of the entire gland.
Diagnosis is a problem in treating this injury and in many cases, the lesion will be found after careful exploration. With availability of ultrasonography in the emergency room and the computed tomography scan it is possible to be raised the suspicion of adrenal injury in the presence of a hypo-echogenic mass or a rather diffused hematoma in perirenal space. Serum cortisol is not routinely measured in trauma patients.
As regards the treatment of the adrenal injury there are two ways to be followed in the surgically explored patient. The first way includes repair to preserve adequate adrenal function and prevent adrenal insufficiency, which may complicate a polytrauma patient. The second way is adrenalectomy to eliminate continued bleeding, potential infection and avoid the risk of vena cava thrombosis from tamponade of the area. In a literature review we also found two cases of adrenal hemorrhage treated by transcatheter embolization (14, 15).
In conclusion, although adrenal injury is a rare finding in patients with blunt abdominal trauma, a high index of suspicion is necessary in cases of active retroperitoneal bleeding. This occurrence can lead to considerable blood loss resulting to life-threatening hypotension because the adrenal glands are abundantly supplied with blood.
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