Adrenal Hemorrhage (Bleeding Gland)

What is adrenal hemorrhage?

An adrenal hemorrhage is bleeding within the adrenal gland, the triangular-shaped gland on top of of each kidney. Adrenal hemorrhage is an uncommon condition but can be life threatening unless medical treatment is commenced as soon as possible. It can occur in a person of any age, but is more commonly seen in the 40 to 80 year age group.

The condition at times remains undiagnosed and is only discovered upon conducting an autopsy. The bleeding may be only in one adrenal gland (unilateral) or on both sides (bilateral). When bleeding occurs on one side, the other gland is able to compensate with production and secretion of the necessary adrenal hormones. It is estimated that some 15% of people who die of shock have evidence of adrenal hemorrhage on both sides (bilateral).

Adrenal Hemorrhage Effects

Dangers of Adrenal Hemorrhage

In order to understand how adrenal hemorrhage impacts on the body, it is important to look at the functions of the adrenal gland. Located at the top of each kidney, the adrenal gland secretes a variety of different hormones. It is sometimes commonly referred to as the stress gland because the main hormones it produces and releases are involved in the stress responses.  This includes :

• epinephrine and norepinephrine (catecholamines) which are responsible for the fight or flight stress response.
• cortisol (main glucocorticoid) which regulates the blood glucose levels, blood pressure and metabolism of nutrients.
• aldosterone (main mineralocorticoid) which is important for controlling the fluid and electrolyte balance.

These hormones are essential for maintaining life and once the gland is affected, its production and secretion of these hormones are also disrupted.

Bleeding in the Adrenal Gland

The most obvious cause of bleeding is due to injury to the adrenal gland. This usually affects only one gland and the other gland is able to compensate for the loss of function. It may only cause minor symptoms but often just goes by unnoticed. However, when bleeding occurs on both sides, then the level of adrenal hormones drops and this is known as adrenal insufficiency. As it worsens and the hormone levels become excessively low, then it is is known as an adrenal crisis. Death can occur within a short period of time as essential functions in the body are not kept regulated as normal by the adrenal hormones.

Adrenal Hemorrhage Causes

The causes of both unilateral (one-sided) and bilateral (both sides) adrenal hemorrhage may overlap.

Unilateral Adrenal Hemorrhage

• Blunt trauma
• Abdominal surgery of organs or structures near the adrenal gland
• Cancer of the adrenal gland
• Long term use of NSAIDs (non-steroidal anti-inflammatory drugs)
• Pregnancy without complications
• Unknown causes (idiopathic)

Bilateral Adrenal Hemorrhage

• Infections
• Heart diseases like congestive cardiac failure or a myocardial infarction (heart attack).
• Cirrhosis (liver)
• Pancreatitis
• Inflammatory bowel disease
• Severe abdominal injury
• Pregnancy complications like toxemia of pregnancy and spontaneous abortion.
• Surgery like coronary artery bypass, hip replacement and intracranial (within the brain cavity of the skull) procedures.
• Bleeding disorders like thrombocytopenia, vitamin K deficiency, and use of blood thinning drugs.
• Vascular disorders including deep venous thrombosis (DVT), pulmonary embolism and stroke.
• Cancer spread from another site to the adrenal glands (metastasis).
• Use of ACTH (the hormone that controls the adrenal gland) for treatment of certain diseases.
• Waterhouse-Friderichsen syndrome

Adrenal Hemorrhage Symptoms

It is rare for there to be no symptoms of an adrenal hemorrhage. Even when only one gland is affected, the symptoms related to bleeding are still present although there is no sign of adrenal insufficiency. It is, however, often misdiagnosed. Not all of the symptoms below will be present in every case of adrenal hemorrhage. The presentation is largely dependent on whether it is unilateral or bilateral bleeding, the extent of the bleed, duration of blood loss and degree to which the adrenal gland function is affected.

• Abdominal pain or flank pain. Sometimes it may present with pelvic or lower back pain.
• Fever
• Rapid heart rate
• Low blood pressure
• Weight loss
• Skin hyperpigmentation (darkening)
• Fatigue
• Weakness
• Dizziness
• Muscle aches
• Joint pains
• Nausea and vomiting
• Loss of appetite
• Diarrhea

Additional symptoms may be due to the underlying disease.

Adrenal Hemorrhage Diagnosis

Clinical examination and medical history are helpful but will not conclusively indicate a hemorrhage. The main diagnostic tests to diagnose an adrenal hemorrhage are imaging studies such as :

• CT (computed tomography) scan
• MRI (magnetic resonance imaging)
• Ultrasound

Additional investigations like blood tests may help to indicate the severity of the adrenal insufficiency as well as other important biological markers to possibly indicate the cause or extent of dysfunction. This includes :

• Complete blood count (CBC)
• Urea and electrolytes
• Blood glucose
• Adrenal hormone levels – cortisol, ACTH, aldosterone, renin
• ACTH challenge

Adrenal Hemorrhage Complications

Severe bleeding of both adrenal glands can lead to acute adrenal insufficiency which is known as adrenal crisis. It can be fatal unless it diagnosed early and treated immediately. When adrenal hemorrhage occurs with conditions like Waterhouse-Friderichsen syndrome, then the fatality rate is very high. Death from bleeding itself is not common unless there is a penetrating wound with excessive blood loss. Adrenal insufficiency can become chronic but is not necessarily permanent. These chronic cases can be managed fairly effectively with glucocorticoids.

Adrenal Hemorrhage Treatment

Emergency medical attention is needed for acute adrenal hemorrhage with replacement of fluid and electrolytes, vital function support and restoring adrenal hormones. Medication is used to replace the deficient glucocorticoids normally secreted by the adrenal glands. This is only necessary in bilateral adrenal hemorrhage where there are signs of adrenal insufficiency. The following medication may be used :

• Hydrocortisone
• Prednisone
• Dexamethasone
• Fludrocortisone (mineralocorticoids)

Surgery is not usually necessary unless the hemorrhage is a result of severe trauma. In these cases surgical procedures will focus on controlling bleeding, closing the penetrating wounds and attending to any other associated injuries. In cases of cancer, the adrenal gland will most likely need to be removed. With proper management and treatment directed at the cause, the bleeding may cease spontaneously in non-traumatic cases without the need for surgery.