Endocrine Abstracts

Introduction: Adrenal haemorrhage (AH) carries high mortality and morbidity. It can be unilateral or bilateral (BAH), trauma or non-trauma (NT) related. The predisposing factors include adrenal tumours, anticoagulation, thrombocytopenia, sepsis, thromboembolic disease, pregnancy, liver transplant and vaccine-induced-immune-thrombocytopenia-and-thrombosis. BAH can result in an adrenal crisis in up to 15%. BAH is usually associated with conditions contributing to adrenal vein spasm or thrombosis.

Aim: The aim of this project was to review management, causes, outcomes and follow-up in patients presenting with AH in our organization between 2017-2022.

Results: We identified 21 patients with AH during this period. Age 19-93 y, mean- 57 y, 19% < 30 y, 52% >60 y, 62% males. 20 presented acutely, with one diagnosed electively. 20 were managed conservatively, and 1 required bleeding adrenal artery embolization. 14/21 (66.7%) were non-traumatic, 7/21 (33.3%) were trauma related. 4/21 were bilateral, and 17/21 (81%) were unilateral with slight right-sided predominance. All traumatic bleeds were unilateral. 4/21 bled into a pre-existing adrenal pathology (3/4 adenoma, 1/4 18 cm myelolipoma), 9/21 had other identifiable risk factors or their combinations (3 antiplatelets, 3 anticoagulation, 6 hypertension, 1 vasculitis, 1 Ehlers Danlos + cocaine, 1 pregnancy, 1 sepsis, 1 diabetes ketoacidosis). All 4 BAH were non-traumatic. Severe hypertension 180-200 mmHg in 3/4 and sepsis from ischaemic foot in 1/4 were the precipitants. 7 required ITU admission, 1 had cardiac arrest, 6 were severely hypertensive (BP >180 mmHg), and 2 patients died during admission. 6 cases had profound hypotension on admission (5/6 unilateral, 1/6 bilateral), 2/6 had cortisol checked, and one received Hydrocortisone. Hyponatremia (range 125-133 mmol/l) was noted in 4 cases (19%) and in 50% of BAH. 3 tested for hypoadrenalism, and 2 received Hydrocortisone. 5/21 had cortisol checked, and 4/21 were covered with Hydrocortisone. 7/21 had metanephrines checked, 11/21 patients were referred to the adrenal MDT and 14 had interval imaging during follow-up.

Discussion: The single adrenal vein draining the highly vascular glands makes them sensitive to venous pressure changes and subsequent haemorrhage. Our review demonstrated high prevalence of underlying adrenal pathology and precipitating factors, mainly hypertension, anticoagulants and procoagulant states as main precipitants for NT adrenal bleeds. We observed that testing for adrenal insufficiency and steroid cover in patients with AH could be improved by admitting teams, predominantly in those requiring ITU, those with BAH, and with associated hyponatremia and hypotension. Our aim is to ensure that all patients with AH receive Endocrine input and are tested for potential adrenal insufficiency.