陳俐臻¹、林文榮¹、楊志東¹、邱文祥^1,2

馬偕紀念醫院泌尿科¹；陽明醫學院²

Li-Chen Chen¹, Wun-Rong Lin¹, Stone Yang¹, Allen W. Chiu^1.2

¹Department of Urology, Mackay Memorial Hospital;

²School of Medicine, National Yang-Ming University

 

    A 53-year-old man denied any systemic disease visited ER due to sudden onset of severe right flank pain for half day.  There was no past history of headache, palpitation, cold sweating, abdominal trauma, fever, nausea, vomiting, hematuria, or constipation.  Physical examination found prominent tenderness over epigastric and right upper quadrant of abdomen and right costovertebral angle knocking pain.  Tachycarida (117 beats/minute) and elevated blood pressure (164/89 mmHg) were noted.  Complete blood count revealed leukocytosis (12900/Ul) without anemia (hemoglobin, 15.7 g/dL).  Abdominal and pelvic computerized tomography with and without contrast was performed which showed 15*13 cm retroperitoneal hematoma in the right suprarenal region with a contrast extravasation and focal strong enhanced lesion about 3.5*2.4cm inside.  Adrenal hemorrhage (AH) was suspected.  Blood pressure drop (84/53 mmHg) with anemia (hemoglobin 10.3 g/dL) was noted 2 hours later.  The blood pressure returned to 100/75 mmHg after fluid resuscitation and blood transfusion (2 bags of erythrocyte suspension).  Emergent transcatheter arterial embolization (TAE) was performed 4 hours later and a branch of middle adrenal artery supplying the right adrenal lesion was identified and occluded with 3 metallic coil.  The hemoglobin stabilized around 10 mg/dL and no more blood transfusion was given.  The patient was discharged on post-TAE day 9 without sequelae.  Adrenal study including plasma rennin activity, aldosterone, cortisol, and urine catecholamine and vanillylmandelic acid (VMA) were checked 4 months later and were normal.  Follow-up abdominal CT revealed a 1.8 cm oval well-circumscribed heterogeneously low-density right adrenal mass with significant enhancement in a 4-month-interval CT  and complete resolution of adrenal mss in a 26-month-interval CT.

 

    Martin et al. analysed management of spontaneous AH associated with adrenal masses and found adrenalectomy was the major intervention in most cases (79%).  Adrenalectomy followed TAE was 5% and treatment with TAE only accounted for only 2 %.

    TAE can provides hemostasis and prevents emergent surgery which had been reported to increase postoperative mortality.  Hokotate et al. reported a 82 % successful rate using TAE compared to over 90% successful rate using open or laparoscopic adrenalectomy for aldosteronoma.  The successful rate in TAE for AH is still unknown, we presented a case with spontaneous AH treated by TAE successfully.  In our case, we found only one branch of middle adrenal arteries supplying the adrenal mass.  TAE can be used in hemorrhagic and hormone control of adrenal tumor.  Pheochromocytoma was suspected during procedure of TAE due to transient elevated blood pressure.  However, a 26-month-interval abdominal CT showed complete resolution of adrenal mass.  In Martins et al. series, only 1 in 6 patient had complete resolution of mass after TAE and they concluded it was adrenal hematoma misidentified as adrenal tumor.  The normal adrenal galnd found by follow-up CT scan attested this is a case of spontaneous AH treated successfully by TAE.  This case highlights the importance of TAE for AH which allows time for observation and prevents emergent or unnecssary surgery.