Hospital: Gerencia de Atención Integrada de Albacete.
Aut@r o Autores: I. Donoso Esteban, M.I. Tercero Azorín, I. Pérez Saus, J. Rubio Medina, R. Rodenas Lozano.
A 55-year-old woman with deterioration of general condition, two syncopal episodes, abdominal pain in the right flank of three days of evolution, hypotension and sweating with lividities in lower limbs. Upon suspicion of urgent abdominal pathology, an abdominal-pelvic CT was performed with intravenous contrast, in which a large right adrenal tumor was identified. It showed heterogeneous and cystic-necrotic areas and other solid areas with marked contrast uptake, and some small peripheral calcification, with rupture signs associated to a large retroperitoneal hematoma.
The CT findings revealed the existence of a retroperitoneal hematoma without active bleeding in relation to a right adrenal lesion that, due to its radiological characteristics and clinical data of the patient, suggested to be related to adrenal pheochromocytoma (1).Spontaneous retroperitoneal bleeding is a rare pathology which in absence of traumatic history, it should be ruled out other secondaries pathologies as tumoral etiology, especially if the hematoma includes some solid viscera(2). Pheochromocytoma is the most common primary adrenal tumor which cause massive bleeding. Other causes less frequent are metastasis (3), or carcinomas, the angiomyolipoma (Wünderlich´s syndrome) in renal tumors with spontaneous hematoma or due to damage of retroperitoneal vascular structures as aortic aneurysms or visceral branches, arteriovenous malformations, peripheral arteriopathy in anticoagulated patients or hematological patients, etc. Among them, pheochromocytoma is noteworthy, a rare tumor that originates frequently in the adrenal gland, although 10% may be extraadrenal and / or be associated with familial syndromes. CT is the initial study of choice, showing large lesions (greater than 3 cm), and heterogeneous lesions with cysticnecrotic and hypervascular areas, and calcifications in up to 7% of cases. They are catecholamine-secreting tumors and usually responsible for poorly controlled hypertension and palpitations, so it is important to maintain their radiological suspicion for a proper clinical management of the patient.
The evaluation of a retroperitoneal hematoma is a diagnostic work of the radiologist which determine the existence of active bleeding and possible underlying causes such as adrenal pheochromocytoma. It is a catecholamine-secreting tumor and its findings will determine the medical and / or surgical / endovascular management of the patient.
- Minal J. Sangwaiya, et al. Incidental adrenal lesions: accuracy of characterization with contrast-enhanced wash out multidetector CT-10 minute delayed imaging protocol revisited in a large patient cohort. Radiology 2010, 256:504-510. - Kilinç I, Dumlu