Teaching Case

A 59-year-old male patient presented to the emergency department with abdominal pain and hypovolemic shock.

A 59-year-old male patient presented to the emergency department with abdominal pain and anaemia. The results of laboratory data indicated hemorrhage and an abdominal contrast enhanced CT-scan (Fig. 1) demonstrated a retroperitoneal hemorrhage on the left side which involved the left adrenal gland. The omolaterla adrenal gland was not dissociable from the collection above mentioned. An abdominal angiography was therefore executed, in order to locate the origin of the bleeding. At first an angiographic study of the abdominal aorta was performed with the introduction of a 5 F pig-tail catheter followed by aselective catheterization of the celiac trunk, the splenic artery and the left renal artery by means of a hydrophylic Simmons type 2 catheter, which showed no signs of any abnormal exhibits. The study continued with selective catheterization of the medium adrenal artery directly arising from the aorta, which demonstrated an extravasation of the contrast media compatible with the blood collection showed by the CT study (Fig. 2). A distal embolization of the vessel was executed using of particles of PVA (Contour) with a diameter between 150 and 250 microns. After an angiographic control was performed, the outcome of the procedure was positive (Fig. 3). Already few hours after the procedure the patient showed the complete resolution of the symptoms present at his entrance in ER. A CT study executed after a week evidenced a reduction of the retroperitoneal haematoma down to 13 cm in maximum diameter and the results of laboratory analyses also returned to normal values. The patient was discharged from the hospital. A CT study performed 3 months later (Fig. 4,5) demonstrated the resorption of the haematoma. In the pararenal region, there was an evidence of residual fluid collection and the left adrenal gland was well seen.

Retroperitoneal haemorrhages with an adrenal origin are rather rare and are generally post-traumatic in nature or caused by situations of severe stress, anticoagulant therapy or tumours. Spontaneous, monolateral or bilateral adrenal haemorrhages, usually present with an acute abdominal pain in the absence of injuries or associated pathologies. Certainly Magnetic Resonance (MR) has a high diagnostic accuracy in identifying retroperitoneal blood collections or in the visualization of a possible associated adrenal tumour, but a CT scan appears to be more adequate as a second level study, giving a panoramic view and being widely available in emergency situations. However CT is the choice to find abdominal and retroperitoneal blood collection specially with multislice CT, that let quantify the bleeding very precisely and find the probable source. The surgical treatment consists in exclusion or fastening of the bleeding artery after the identification which is not always easy, of the artery itself, with the possibility of gland asportation if found necessary, during the surgery. The transcutaneous alternative, with an endovascular procedure and a transcatheter embolization, has been widely experimented with, as reported in literature, and is certainly better tolerated by the patient, requiring shorter recovery periods. In case of a rebleeding, it is repeatable, and it always follows a definite angiographic diagnosis even if it is not technically easy, since multiple superselective catheterizations are often necessary. When a superselective embolisation with microcatheter is to be done, in our experience, the use of embolising particles is more handful instead of the use of coils or surgical glue. Coils are normally used when after the use of particles the bleeding site is not completely closed. Instead of PVA type particles, we could use other types of particles such as hydrophilic microspheres, that could be preferable because they are not deformable and they have a more homogeneous calibre, but which are not available at the moment.