eMedicine Specialties > Endocrinology > Adrenal Gland

Adrenal Hemorrhage: Treatment & Medication

Author: Nicholas A Tritos, MD, DSc, MMSc, FACE, FACP, Assistant Professor of Medicine, Tufts University School of Medicine; Senior Staff Physician, Department of Endocrinology, Lahey Clinic Medical Center
Contributor Information and Disclosures

Updated: May 27, 2008

Treatment

Medical Care

  • In patients with suspected acute adrenal hemorrhage, evaluation should take place in an inpatient setting, because acute adrenal insufficiency may occur. However, most of these patients are acutely ill and already are in the hospital at the time of acute adrenal hemorrhage.
  • In asymptomatic patients presenting with an adrenal mass or calcifications, outpatient evaluation is appropriate.
  • Medical therapies are used to replace adrenal function, to provide vital function support as needed, to treat the underlying condition(s), and to correct fluid, electrolyte, and red cell mass deficits.

Surgical Care

  • Adrenalectomy (open or laparoscopic) may be performed.
    • Surgery generally is not required in cases of nontraumatic adrenal hemorrhage, except in patients with primary adrenal tumors or in rare cases, of extensive retroperitoneal hemorrhage secondary to adrenal hemorrhage.
    • In traumatic adrenal hemorrhage cases, surgery may be necessary for the treatment of associated injuries, the exploration of penetrating wounds, or the control of bleeding.

Consultations

  • Endocrinologist
  • Interventional radiologist
  • Urologist or surgeon
  • Cardiologist, infectious diseases specialist, or other specialists as needed, to optimize the management of the underlying condition(s)

Diet

  • Critically ill patients with suspected adrenal hemorrhage are kept on nothing by mouth (NPO) status.
  • Patients with acute adrenal hemorrhage also may be kept NPO, depending on the presence of symptoms, such as vomiting.
  • In cases of chronic adrenal hemorrhage complicated by adrenal insufficiency, patients must maintain adequate hydration and salt intake. Liberal salt intake is contraindicated in the presence of hypertension, congestive heart failure, or renal failure.

Activity

  • Patients with suspected acute adrenal hemorrhage are kept on bed rest.
  • Activity is unrestricted after resolution of the acute event; however, patients must receive appropriate adrenal replacement therapy. Depending on the underlying condition(s), activity restrictions may still be necessary,

Medication

Immediately after a serum sample (for cortisol assay) has been obtained, but without awaiting biochemical confirmation, glucocorticoids should be urgently administered to patients with suspected acute, bilateral adrenal hemorrhage in order to prevent or treat acute adrenal insufficiency.

In acutely ill patients, supportive therapy and specific treatments for the underlying condition(s) must be provided urgently as well.

After the acute adrenal hemorrhagic event, long-term glucocorticoid replacement with or without mineralocorticoid replacement therapy may be necessary, based on the results of adrenal function testing.

Corticosteroids

Administered in a stress-dose regimen, these medications adequately replace glucocorticoid hormone requirements in patients with suspected acute, bilateral adrenal hemorrhage whose adrenal function may be compromised. After discharge, oral prednisone, hydrocortisone, or dexamethasone commonly is used. Only the former 2 glucocorticoids possess some mineralocorticoid properties, whereas dexamethasone is devoid of any such activity.


Hydrocortisone (Solu-Cortef, Hydrocortone, Hydrocort)

Intravenous hydrocortisone, in conjunction with supportive measures, frequently is used and averts or adequately treats acute adrenal crisis.

Adult

10-12 mg/m2/d PO for maintenance; usually administered as 2 doses, including 10-20 mg when waking up in am, and 5-10 mg in early afternoon; may administer 50-100 mg IV tid under conditions of severe stress

Pediatric

10-12 mg/m2/d PO divided tid for maintenance
80-100 mg/m2/d IV under conditions of stress

Corticosteroid clearance may decrease with estrogens; may increase digitalis toxicity secondary to hypokalemia

Documented hypersensitivity; viral, fungal, or tubercular skin infections
When administered for chronic adrenal insufficiency, replacement with some corticosteroid must be maintained and monitored, and the contraindications should not be considered absolute and may represent a requirement for increased doses of replacement corticosteroid; clinical judgment must be exercised

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Abrupt discontinuation of glucocorticoids is likely to cause adrenal crisis; administration of supraphysiologic replacement doses is likely to result in symptoms and signs of Cushing syndrome, including hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, and propensity to infection; caution in hypertension, congestive heart failure, or renal failure


Prednisone (Deltasone, Meticorten, Orasone)

After discharge, oral prednisone commonly is used for maintenance. Possesses some mineralocorticoid properties.

Adult

2.5-7.5 mg PO qd (usually 5 mg PO qd) in am upon awakening

Pediatric

5 mg/m2/d PO divided bid

Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections; GI disease
When administered for chronic adrenal insufficiency, replacement with some corticosteroid must be maintained and monitored, and the contraindications should not be considered absolute and may represent a requirement for increased doses of corticosteroid; clinical judgment must be exercised

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Abrupt discontinuation of glucocorticoids is likely to cause adrenal crisis; administration of supraphysiologic replacement doses is likely to result in symptoms and signs of Cushing syndrome, including hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, and propensity to infection; caution in hypertension, congestive heart failure, or renal failure


Dexamethasone (Decadron, AK-Dex)

In conjunction with supportive measures, it is used frequently and averts or adequately treats acute adrenal crisis. Preferred if a Cortrosyn stimulation test is planned soon after the patient has been stabilized, because it does not interfere in a cortisol assay. After discharge, dexamethasone commonly is used for maintenance.

Adult

0.25-0.5 mg PO qd for maintenance
4 mg IV bid under conditions of acute stress

Pediatric

Not established

Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; dexamethasone decreases effect of salicylates and vaccines used for immunization

Documented hypersensitivity; active bacterial or fungal infection
When administered for chronic adrenal insufficiency, replacement with some corticosteroid must be maintained and monitored, and the contraindications should not be considered absolute and may represent a requirement for increased doses of corticosteroid; clinical judgment must be exercised

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Abrupt discontinuation of glucocorticoids is likely to cause adrenal crisis; administration of supraphysiologic replacement doses is likely to result in symptoms and signs of Cushing syndrome, including hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, and propensity to infection; caution in hypertension, congestive heart failure, or renal failure


9-alpha-fludrocortisone (Florinef)

May be indicated in patients with a history of bilateral, extensive adrenal hemorrhage in order to replace mineralocorticoid hormone requirements, based on results of adrenal function testing. Therapy is unnecessary in (acutely ill) patients receiving more than 100 mg of hydrocortisone daily, because this dose also provides adequate mineralocorticoid replacement.

Adult

0.05-0.2 mg PO qd; usual dose is 0.1 mg PO qd

Pediatric

0.05-0.15 mg PO qd

Antagonizes effects of anticholinergics; rifampin, hydantoins, and barbiturates decrease effects of fludrocortisone; decreases salicylate levels

Documented hypersensitivity; systemic fungal infections
When administered for chronic adrenal insufficiency, replacement with some corticosteroid must be maintained and monitored, and the contraindications should not be considered absolute and may represent a requirement for increased doses of corticosteroid; clinical judgment must be exercised

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Abrupt discontinuation of glucocorticoids is likely to cause adrenal crisis; administration of supraphysiologic replacement doses is likely to result in symptoms and signs of Cushing syndrome, including hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, and propensity to infection; caution in hypertension, congestive heart failure, or renal failure; caution in patients with potassium loss or sodium retention

More on Adrenal Hemorrhage

Overview: Adrenal Hemorrhage
Differential Diagnoses & Workup: Adrenal Hemorrhage
Treatment & Medication: Adrenal Hemorrhage
Follow-up: Adrenal Hemorrhage
Multimedia: Adrenal Hemorrhage
References
Further Reading
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References

  1. Rao RH. Bilateral massive adrenal hemorrhage. Med Clin North Am. 1995;79(1):107-29. [Medline].

  2. Vella A, Nippoldt TB, Morris JC 3rd. Adrenal hemorrhage: a 25-year experience at the Mayo Clinic. Mayo Clin Proc. Feb 2001;76(2):161-8. [Medline].

  3. Adem PV, Montgomery CP, Husain AN, et al. Staphylococcus aureus sepsis and the Waterhouse-Friderichsen syndrome in children. N Engl J Med. Sep 22 2005;353(12):1245-51. [Medline]. [Full Text].

  4. Pianta M, Varma DK. Bilateral spontaneous adrenal haemorrhage complicating acute pancreatitis. Australas Radiol. Apr 2007;51(2):172-4. [Medline].

  5. Gutenberg A, Lange B, Gunawan B, et al. Spontaneous adrenal hemorrhage: a little-known complication of intracranial tumor surgery. Case report. J Neurosurg. Jun 2007;106(6):1086-8. [Medline].

  6. Arnason JA, Graziano FM. Adrenal insufficiency in the antiphospholipid antibody syndrome. Semin Arthritis Rheum. Oct 1995;25(2):109-16. [Medline].

  7. Caron P, Chabannier MH, Cambus JP, et al. Definitive adrenal insufficiency due to bilateral adrenal hemorrhage and primary antiphospholipid syndrome. J Clin Endocrinol Metab. May 1998;83(5):1437-9. [Medline]. [Full Text].

  8. Vasinanukorn P, Rerknimitr R, Sriussadaporn S, et al. Adrenal hemorrhage as the first presentation of hepatocellular carcinoma. Intern Med. 2007;46(21):1779-82. [Medline]. [Full Text].

  9. Gavrilova-Jordan L, Edmister WB, Farrell MA, et al. Spontaneous adrenal hemorrhage during pregnancy: a review of the literature and a case report of successful conservative management. Obstet Gynecol Surv. Mar 2005;60(3):191-5. [Medline].

  10. Shah HR, Love L, Williamson MR, et al. Hemorrhagic adrenal metastases: CT findings. J Comput Assist Tomogr. Jan-Feb 1989;13(1):77-81. [Medline].

  11. Sinelnikov AO, Abujudeh HH, Chan D, et al. CT manifestations of adrenal trauma: experience with 73 cases. Emerg Radiol. Mar 2007;13(6):313-8. [Medline].

  12. Itoh K, Yamashita K, Satoh Y, et al. MR imaging of bilateral adrenal hemorrhage. J Comput Assist Tomogr. Nov-Dec 1988;12(6):1054-6. [Medline].

  13. Bhatia KS, Ismail MM, Sahdev A, et al. (123)I-metaiodobenzylguanidine (MIBG) scintigraphy for the detection of adrenal and extra-adrenal phaeochromocytomas: CT and MRI correlation. Clin Endocrinol (Oxf). Apr 3 2008;[Medline].

  14. Arlt W, Callies F, van Vlijmen JC, et al. Dehydroepiandrosterone replacement in women with adrenal insufficiency. N Engl J Med. Sep 30 1999;341(14):1013-20. [Medline]. [Full Text].

  15. Jahangir-Hekmat M, Taylor HC, Levin H, et al. Adrenal insufficiency attributable to adrenal hemorrhage: long-term follow-up with reference to glucocorticoid and mineralocorticoid function and replacement. Endocr Pract. Jan-Feb 2004;10(1):55-61. [Medline].

  16. Dahlberg PJ, Goellner MH, Pehling GB. Adrenal insufficiency secondary to adrenal hemorrhage. Two case reports and a review of cases confirmed by computed tomography. Arch Intern Med. Apr 1990;150(4):905-9. [Medline].

  17. Duffy TP. Clinical problem-solving. The sooner the better [see comments]. N Engl J Med. Sep 2 1993;329(10):710-3. [Medline].

  18. Espinosa G, Santos E, Cervera R, et al. Adrenal involvement in the antiphospholipid syndrome: clinical and immunologic characteristics of 86 patients. Medicine (Baltimore). Mar 2003;82(2):106-18. [Medline].

  19. Giraud T, Dhainaut JF, Schremmer B, et al. Adult overwhelming meningococcal purpura. A study of 35 cases, 1977-1989. Arch Intern Med. Feb 1991;151(2):310-6. [Medline].

  20. Hiroi N, Yanagisawa R, Yoshida-Hiroi M, et al. Retroperitoneal hemorrhage due to bilateral adrenal metastases from lung adenocarcinoma. J Endocrinol Invest. Jun 2006;29(6):551-4. [Medline].

  21. Korobkin M, Francis IR. Adrenal imaging. Semin Ultrasound CT MR. Aug 1995;16(4):317-30. [Medline].

  22. Kovacs KA, Lam YM, Pater JL. Bilateral massive adrenal hemorrhage. Assessment of putative risk factors by the case-control method. Medicine (Baltimore). Jan 2001;80(1):45-53. [Medline].

  23. Rao RH, Vagnucci AH, Amico JA. Bilateral massive adrenal hemorrhage: early recognition and treatment. Ann Intern Med. Feb 1 1989;110(3):227-35. [Medline].

  24. Schuchmann JA, Friedman PA. Bilateral adrenal hemorrhage: an unusual complication after bilateral total knee arthroplasty. Am J Phys Med Rehabil. Nov 2005;84(11):899-903. [Medline].

  25. Shifren JL. The role of androgens in female sexual dysfunction. Mayo Clin Proc. Apr 2004;79(4 Suppl):S19-24. [Medline].

  26. Siu SC, Kitzman DW, Sheedy PF 2nd, et al. Adrenal insufficiency from bilateral adrenal hemorrhage. Mayo Clin Proc. May 1990;65(5):664-70. [Medline].

  27. Takebayashi K, Aso Y, Tayama K, et al. Primary antiphospholipid syndrome associated with acute adrenal failure. Am J Med Sci. Jan 2003;325(1):41-4. [Medline].

  28. Varon J, Chen K, Sternbach GL. Rupert Waterhouse and Carl Friderichsen: adrenal apoplexy. J Emerg Med. Jul-Aug 1998;16(4):643-7. [Medline].

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Keywords

AH, adrenal apoplexy, adrenal hemorrhagic necrosis, Waterhouse-Friderichsen syndrome, acute adrenal crisis, adrenocorticotropic hormone, ACTH, corticotropin, bilateral gland, necrosis, medullary adrenal cells, adrenal vein thrombosis

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Contributor Information and Disclosures

Author

Nicholas A Tritos, MD, DSc, MMSc, FACE, FACP, Assistant Professor of Medicine, Tufts University School of Medicine; Senior Staff Physician, Department of Endocrinology, Lahey Clinic Medical Center
Nicholas A Tritos, MD, DSc, MMSc, FACE, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians-American Society of Internal Medicine, American Medical Association, Endocrine Society, Massachusetts Medical Society, and Pituitary Society
Disclosure: Nothing to disclose.

Medical Editor

Dimitris A Papanicolaou, MD, Assistant Professor, Department of Medicine/Endocrinology, Emory University
Dimitris A Papanicolaou, MD is a member of the following medical societies: American College of Physicians, Endocrine Society, and Royal Society of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Arthur B Chausmer, MD, PhD, FACP, FACE, FACN, CNS, Professor of Medicine (Endocrinology, Adj), Johns Hopkins School of Medicine; Affiliate Research Professor, Bioinformatics and Computational Biology Program, School of Computational Sciences, George Mason University; Principal, C/A Informatics, LLC
Arthur B Chausmer, MD, PhD, FACP, FACE, FACN, CNS is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Endocrinology, American College of Nutrition, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Informatics Association, American Society for Bone and Mineral Research, American Society of Law Medicine and Ethics, Endocrine Society, and International Society for Clinical Densitometry
Disclosure: Nothing to disclose.

CME Editor

Mark Cooper, MBBS, PhD, FRACP, Head, Diabetes & Metabolism Division, Baker Heart Research Institute, Professor of Medicine, Monash University
Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD, Professor of Medicine, St Louis University School of Medicine
George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
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