Gastroenterology
Volume 139, Issue 2 , Page 387, August 2010

Obscure Abdominal Pain in a 55-Year-Old Man

  • Yi-Liang Lai, MD

      Affiliations

    • Division of Gastroenterology, Department of Internal Medicine, Armed-Forces Taichung General Hospital, Taichung, Taiwan, R.O.C. And Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C.
    • ,
  • Wei-Chou Chang, MD

      Affiliations

    • Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, National Defense Medical Center, Taipei, Taiwan, R.O.C.
    • ,
  • Hsin-Hung Huang, MD

      Affiliations

    • Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C.

published online 28 June 2010.

David A. Katzka and David L. Jaffe, Section Editors

Article Outline

 

Question: A 55-year-old man was referred to our hospital because of progressive, vague abdominal pain. He presented with a 7-day history of progressive, vague pain in the left upper abdomen accompanied by anorexia, dyspepsia, and postural dizziness. One week before presentation, the patient received the last intervention of repeated extracorporeal shockwave lithotripsy (ESWL) for renal calculi in the upper pole of left kidney. On admission, he looked pale and weak. Physical examination disclosed mild jaundice, palpation tenderness of the left upper quadrant without palpable mass, and percussion ache at the left costovertebral angle. Laboratory data were notable for anemia (10.2 g/dL) and unconjugated hyperbilirubinemia (1.8 mg/dL). Gastrointestinal tract bleeding had been excluded by panendoscopy and negative finding of occult blood in stool. Abdominal ultrasonography (Figure A) revealed a well-defined, hypoechoic mass over left suprarenal area. Abdominal computed tomography (CT; Figure B) showed a huge, adrenal tumor-like lesion 8 × 5 × 4 cm3 in volume.

What is the most likely diagnosis? What is the proper management?

Look on page 699 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

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Answer to the Clinical Challenges and Images in GI Question: Image 1 (page 387): Intra-Abdominal Hemorrhage With Adrenal Hematoma 

The adrenal mass showed faint hyperdensity on precontrast CT scan (Figure B), and without obvious enhancement on postcontrast CT (Figure C). The diagnosis is intra-abdominal hemorrhage with adrenal hematoma. Adrenal hemorrhage (AH), which was first recorded by Canton in 1863, is a rare but potentially fatal event. AH may result from trauma, coagulopathic states, and acute stress.1 Clinical presentations of AH are usually nonspecific and vary widely according to the amount, rate of bleeding, and compressive effect to the adrenal cortex. Reportedly, the diagnostic accuracy of a CT scan is superior to that of abdominal ultrasonography, and magnetic resonance imaging may be more useful for differentiating a hematoma from an underlying adrenal tumor.2

The shock wave energy of lithotripsy may be harmful to tissues along the transmitted path and may result in renal edema, perirenal or renal hematomas, splenic rupture, pancreatitis, and elevation of serum level of rennin and liver enzymes. Although the pathophysiology of ESWL-related AH is not well known, it may be associated with the location of the renal calculi. The adrenal gland is anatomically adjacent to the renal calculi and may be damaged by exposure to high-dose energy or by increased duration of shock waves during ESWL.

A trend toward nonoperative management for AH has evolved in trauma literature over time and is recommended in the absence of ongoing bleeding.3 Surgical exploration with adrenal repair, adrenalectomy, and angio-embolization may provide further interventions for progressing hemorrhage. Our patient was successfully treated with supportive management and careful monitoring of adrenal function. Follow-up ultrasonography revealed spontaneous shrinkage of the left adrenal hematoma 2 weeks later and fatal adrenal insufficiency did not occur within a 6-month follow-up period.

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References 

  1. Francque SM, Schwagten VM, Ysebaert DK, et al. Bilateral adrenal haemorrhage and acute adrenal insufficiency in a blunt abdominal trauma: a case-report and literature review. Eur J Emerg Med. 2004;11:164–167
  2. Murphy BJ, Cassilas J, Yrizarry J. Traumatic adrenal haemorrhage: radiologic findings. Radiology. 1988;169:701–703
  3. Udobi KF, Childs EW. Adrenal crisis after traumatic bilateral adrenal hemorrhage. J Trauma. 2001;51:597–600

 Conflicts of interest The authors disclose no conflicts.

 For submission instructions, please see the Gastroenterology web site (www.gastrojournal.org).

PII: S0016-5085(09)01878-2

doi:10.1053/j.gastro.2009.09.066

Gastroenterology
Volume 139, Issue 2 , Page 387, August 2010

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