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Bilateral adrenal hemorrhage after right hemicolectomy
Hemorragia suprarrenal bilateral en el postoperatorio de una hemicolectomía derecha
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(B) Control CT showing resorption of haemorrhage after 6 months.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Bilateral adrenal haemorrhage is a rare entity that can cause acute adrenal insufficiency, multiple organ failure, and death.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is commonly diagnosed <span class="elsevierStyleItalic">post-mortem</span> and its estimated incidence ranges between 0.1%–1.1% based on autopsy reports.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> The clinical manifestations are nonspecific, and, in postoperative patients, they can be attributed to other medical problems, which makes diagnosis difficult. However, early detection allows for appropriate management and can reduce the mortality rate associated with this process, which is estimated at around 15%.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report below a case of adrenal insufficiency secondary to bilateral adrenal haemorrhage after hemicolectomy. The case concerns an 84-year-old male patient. A routine control blood test showed a haemoglobin of 7.53 g/dl (13–16.7 g/dl), so a faecal occult blood test was indicated to complete the study, with a positive result. A colonoscopy was performed, which revealed a stenosing neoproliferative lesion, confirming ascending colon cancer by histological study. An abdominal-pelvic CT scan was performed, which revealed a T3N1M0 radiological stage. A right hemicolectomy was scheduled, and the patient was discharged after a week as there were no postoperative complications. Three days after discharge, the patient began to experience diffuse abdominal pain, fever, general malaise, nausea, and vomiting, for which he went to the emergency department. Refractory hypotension and a diffusely painful abdomen stand out on arrival.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A blood test was performed showing hypoglycaemia of 50 mg/dl (70–110 mg/dl) and hyponatraemia of 130 (136–145 mEq/l) with mild leukocytosis, basal cortisol of 9 µg/dl (3.7–17.3 µg/dl). A non-contrast abdominal CT scan was requested, where intra-abdominal complications secondary to the operation were ruled out, but signs of bilateral adrenal haemorrhage were observed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Intensive intravenous fluid therapy and hydrocortisone 100 mg/every 8 h were started, with progressive clinical improvement.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">After clinical stabilization, a Synachten® test was performed at standard doses, without evidence of an increase in plasma cortisol secondary to the stimulus, thus confirming the adrenal insufficiency diagnosis. In the days following admission, a dose-reduction regimen of corticosteroid treatment was indicated, with 20 mg/day at discharge.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Bilateral adrenal haemorrhage is a rare cause of hypocartisolism,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> which requires a high degree of suspicion, due to the non-specificity of the symptoms, which is manifested when approximately 90% of the adrenal cortex is destroyed.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5</span></a> It has been described after certain stressful situations such as polytrauma, sepsis (typically meningococcal), major burns, anticoagulation, and coagulopathies such as antiphospholipid syndrome, as well as surgery, especially abdominal<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a> surgery.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The pathophysiological mechanisms are not entirely clear, although they are believed to be related to the adrenal vascular architecture.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Reduced capillary resistance in the vascular bed as well as hypersensitivity to hormones involved in the stress response (ACTH, catecholamines) leads to vasoconstriction, vasospasm, and excessive platelet activation, which can cause reperfusion and subsequent haemorrhage.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In the context of postoperative patients, it usually manifests within 14 days after the intervention.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It can present clinically with nonspecific symptoms such as fever, abdominal pain, nausea, vomiting, weakness, confusion, and hypotension.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> In some patients it is an incidental finding on imaging tests and in more severe cases it can be fatal.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Some blood test elements may provide evidence for the diagnosis, such as hypoglycaemia, hyponatraemia, hyperkalaemia, decreased diurnal cortisol or inappropriately normal values in the context of a stressful situation. Advances in imaging techniques have allowed a more efficient diagnosis and management. Diagnostic evaluation should be performed by non-contrast CT or abdominal MRI,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> showing enlargement of both adrenal glands and, in the case of CT, varying degrees of adrenal hyperdensity are usually visualized.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,4</span></a> In no case should the start of intensive treatment with IV hydration therapy and intravenous hydrocortisone be delayed.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Patients may require long-term corticosteroid replacement therapy, with potential recovery of the adrenal axis and gradual corticosteroid withdrawal. In our case, a control CT scan was performed at 6 months (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B), confirming resorption of the haemorrhage. A Synachten® test was requested again, which showed complete recovery of the adrenal axis, making complete discontinuation of corticosteroid treatment possible.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Dotres Fallat KM, Nicolau J, González de Cabo M. Hemorragia suprarrenal bilateral en el postoperatorio de una hemicolectomía derecha. Med Clin (Barc). 2021;157:e291–e292.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1130 "Ancho" => 1500 "Tamanyo" => 203318 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Evidence of bilateral adrenal haemorrhage on baseline CT scan. 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