REVIEW PAPER General surgery
Adrenal hemorrhage: diagnostics, management, and treatment. Review and clinical update
Siavash Świeczkowski-Feiz1, Sadegh Toutounchi1, Ewa Krajewska1, Krzysztof Celejewski1, Remigiusz Gelo2, Piotr Kaszczewski1, Wawrzyniec Jakuczun1, Urszula Ambroziak3, Zbigniew Gałązka1
1 Department of General, Endocrine, and Vascular Surgery, University Clinical Center of the Medical University of Warsaw, Warszawa, Poland
2 Second Department of Anesthesiology and Intensive Care, University Clinical Center of the Medical University of Warsaw, Warszawa, Poland
3 Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warszawa, Poland
KEY WORDS
adrenal hemorrhage, adrenocortical carcinoma, laparoscopic adrenalectomy, open adrenalectomy, pheochromocytoma
ABSTRACT
INTRODUCTION Adrenal hemorrhage (AH) is a rare and often underdiagnosed condition that can present with nonspecific symptoms and may be life-threatening. Accurate diagnosis and tailored management are essential.
AIM The aim of this paper was to review the literature on AH with emphasis on etiology, diagnostic approaches, management strategies, and methodological quality of available studies.
MATERIALS AND METHODS A structured search of the literature was performed. Forty-one relevant ar- ticles were included in the review. Risk of bias was assessed in 3 eligible studies (2 single-center series and 1 case series with literature review) using the Joanna Briggs Institute tools and adapted criteria. RESULTS Trauma accounted for the majority of AH cases. Nontraumatic etiologies included anticoagula- tion, infection, stress, and adrenal tumors, such as pheochromocytoma, adrenocortical carcinoma, and metastases. Computed tomography and magnetic resonance imaging were the key diagnostic modalities. Management strategies ranged from conservative observation and embolization to laparoscopic or open adrenalectomy, guided by hemodynamic stability, capsule integrity, and suspicion of malignancy. All assessed studies had moderate risk of bias due to retrospective design and limited sample size.
CONCLUSIONS AH requires high clinical suspicion and structured imaging/ endocrine evaluation. Open adrenalectomy is recommended in unstable patients, in the cases of capsule rupture, or when malignancy is suspected. In patients with hemorrhage confined to the adrenal capsule, laparoscopic adrenalectomy represents the preferred surgical approach. Larger prospective multicenter studies are warranted to establish standardized guidelines.
Correspondence to:
Siavash Świeczkowski-Feiz, MD, Department of General, Endocrine, and Vascular Surgery, University Clinical Center of the Medical University of Warsaw, ul. Banacha 1A, 02-097 Warszawa, Poland, phone: +48 225992564, email: siavashfeiz@gmail.com Received: September 4, 2025. Revision accepted: September 15, 2025. Published online: September 26, 2025. Wideochir Inne Tech Maloinwazyjne. 2025; 20 (3): 255-260 doi:10.20452/wiitm.2025.17981
INTRODUCTION Hemorrhage is defined as an acute loss of blood from a damaged blood ves- sel due to traumatic or nontraumatic causes.1 Ad- renal hemorrhage (AH) remains a diagnostic chal- lenge because of its nonspecific clinical presenta- tion.2,3 It is a rare but potentially life-threatening condition that can lead to acute adrenal insuf- ficiency and may be fatal. Reported causes in- clude septicemia, coagulopathy, bleeding diathe- sis, trauma, and adrenal tumors.2-4 Based on au- topsy data, AH is estimated to occur in 0.14% to 1.1% of deaths. The pediatric population carries
a 7-fold higher risk of mortality from AH. In par- ticular, Waterhouse-Friderichsen syndrome, usu- ally associated with severe Neisseria meningitidis infection, is linked to 55%-60% mortality.3,5-7
Clinical presentation of AH is heterogeneous and nonspecific. Symptoms depend on the se- verity of bleeding, the size of the hematoma, and the extent of adrenal tissue damage. Patients may present with abdominal pain, back pain (often mis- interpreted as radicular pain), nausea, vomiting, hypotension, confusion, fever, or a hemoglobin (Hb) decrease by 1.5 g/dl or greater.3,8 Although
| Author | Study type | Participant selection | Method (randomization/ blinding) | Data reporting | Sample size | Overall risk of bias |
|---|---|---|---|---|---|---|
| Świeczkowski-Feiz et al3 | Single-clinic experience | Limited to 1 center | No randomization or blinding | Mostly complete | Small own cohort | Moderateª |
| Karwacka et al4 | Single-center experience | Limited to 1 center | No randomization or blinding | Mostly complete | Small own cohort | Moderateª |
| Marti et al® | Case series + review (6 original cases + 133 cases from the literature) | Diverse sources, heterogeneous | No randomization | Inconsistent reporting | Small own cohort, large literature sample | Moderateª |
a Risk of bias assessment was conducted for 3 clinical studies and all were classified as having a moderate risk of bias, which means that their findings are valuable and can be used to support clinical conclusions.
| Conditions predisposing to adrenal hemorrhage | Examples |
|---|---|
| Trauma (80% of the cases) | – |
| Stress | Burns |
| Hypotension | |
| Surgery (particularly orthopedic surgery) | |
| Infectious disease | Sepsis caused by Neisseria meningitidis, Pseudomonas aeruginosa, Escherichia coli, Bacteroides fragilis, Streptococcus pneumoniae |
| Medication | Anticoagulants |
| Antiplatelets | |
| Nonsteroidal anti-inflammatory drugs Synthetic adrenocorticotropic hormone Glucocorticosteroids | |
| Hematologic disorders | Antiphospholipid syndrome Systemic lupus erythematosus Heparin-induced thrombocytopenia Other thrombocytopathies Thrombocytosis |
| Obstetric causes | Pregnancy |
| Postpartum period | |
| Pre-eclampsia | |
| Perinatal injury | Asphyxia |
| Perinatal hypoxia | |
| Sepsis | |
| Fetal hematologic disorders | |
| Adrenal gland Primary tumor | Pheochromocytoma, adrenocortical cancer, myelolipoma, lipoma, hematoma, angioma, adenoma, pseudocyst |
| Metastatic | Lung cancer, renal cancer, breast cancer, colon cancer, thyroid cancer, gallbladder cancer, melanoma |
| Gastrointestinal diseases | Acute pancreatitis |
a Republished from Karwacka et al4 with permission under the Creative Commons CC BY-NC-ND license.
AH was historically diagnosed most often post- mortem, the increasing availability of computed tomography (CT) and magnetic resonance imag- ing (MRI) has led to more frequent incidental de- tection.3,9 Management strategies remain unclear and largely depend on the patient’s clinical condi- tion and the experience of the treating endocri- nologist or surgeon. Hemodynamically unstable
patients may require intensive medical treatment, including blood transfusion, management of ad- renal insufficiency, and surgical intervention, ei- ther laparoscopic or open.
AIM The aim of this review was to synthesize ev- idence on AH in adults, in terms of etiologies / risk factors, imaging-based diagnosis, and manage- ment strategies, as well as to identify gaps for fu- ture research.
MATERIALS AND METHODS Protocol and registra- tion No protocol was registered for this review.
Eligibility criteria We included primary clinical studies (randomized or observational), case se- ries (25 patients), and informative case reports on AH containing data on etiology, imaging, man- agement, or outcomes. We excluded pediatric-only cohorts, non-English papers, and nonoriginal ar- ticles without extractable data.
Information sources The information was ex- tracted from PubMed and Scopus, from 1990 to 2023. We also screened reference lists and rel- evant guidelines.
Search strategy Databases were searched using strings in the following format: (“adrenal hem- orrhage” OR “adrenal hemorrhage” OR “adre- nal bleeding”) AND (“diagnosis adrenal hemor- rhage/hemorrhage” OR “imaging adrenal hem- orrhage / hemorrhage” OR “management adre- nal hemorrhage / hemorrhage”).
Selection process Two reviewers (RG and PK) independently screened titles / abstracts and full texts. Disagreements were resolved by consensus or by a third reviewer (JW).
Data collection process We extracted study design, setting, sample size, etiology / risk factors, imag- ing features, interventions (conservative, emboli- zation, laparoscopic/ open surgery), and outcomes (mortality, adrenal insufficiency, complications).
Data items Primary outcomes included all-cause mortality, hemodynamic instability, and need for
urgent surgery. Secondary outcomes comprised imaging characteristics across hemorrhage stag- es, distribution of tumor histologies, and endo- crine activity.
Risk of bias assessment The risk of bias was eval- uated using the Joanna Briggs Institute (JBI) crit- ical appraisal tools for case series, with adapt- ed criteria applied to case reports. For the study combining a case series with a literature review,8 relevant elements of the JBI tool were applied to assess methodological quality. All included stud- ies were rated as having a moderate risk of bias, mainly due to limitations inherent to retrospec- tive single-center designs, small sample sizes, and a lack of randomization or blinding (TABLE 1).
Statistical analysis Given the heterogeneity and predominance of case series / reports, a formal meta-analysis was not performed. Descriptive statistics (counts and proportions) were used where appropriate.
Ethics Ethical approval was not required for this systematic review of published literature.
RESULTS Study selection From the available lit- erature, 41 articles were selected as relevant to AH, and included in the review. Among these, narrative reviews, single case reports without clinical out- comes, and purely imaging-focused articles were excluded from the risk of bias assessment. In to- tal, 3 studies were included for detailed method- ological appraisal: 2 single-center retrospective series3,4 and 1 combined case series with litera- ture review.8
Study characteristics Trauma accounted for the majority (ca. 80%) of AH cases reported in the literature. Nontraumatic etiologies in- cluded anticoagulation / coagulopathy, sep- sis / Waterhouse-Friderichsen syndrome, stress- -related states, and adrenal neoplasms (pheochro- mocytoma, adrenocortical carcinoma, metastases). CT and MRI were the principal diagnostic modal- ities, with stage-specific imaging features consis- tently described.2,9,27
Risk of bias The overall risk of bias in the includ- ed studies was determined as moderate, reflect- ing the limitations of retrospective, single-center designs, small patient numbers, and a lack of ran- domization or blinding.
Results of individual studies and synthe- sis Świeczkowski-Feiz et al3 and Karwacka et al4 reported clinical presentations and management outcomes of nontraumatic AH in single-center cohorts. Marti et al8 analyzed 6 original cases and 133 cases from the literature, providing in- sights into etiology, imaging characteristics, and treatment strategies (TABLE 1). Across the studies, management ranged from conservative care and selective embolization to laparoscopic or open
adrenalectomy, guided primarily by hemodynam- ic stability and capsule integrity.
DISCUSSION Anatomic and physiologic back- ground The adrenal gland is supplied by the su- perior, middle, and inferior suprarenal arteries, branches of the inferior phrenic artery, abdomi- nal aorta, and renal artery, respectively. This vas- cular configuration, known as a vascular dam, re- sults in 50-60 small arterial branches that form a delicate subcapsular plexus around the zona glo- merulosa. Consequently, the adrenal cortex is par- ticularly susceptible to destruction during hem- orrhage. Venous drainage occurs through a single adrenal vein, characterized by numerous longitu- dinally arranged smooth muscle cells in its wall. This unique structure makes the vein sensitive to catecholamines. Elevated catecholamine lev- els induce vasoconstriction, increased venous re- sistance, and blood stasis, predisposing the adre- nal gland to ischemic necrosis of small arterioles and subsequent hemorrhage upon reperfusion. Catecholamines further promote platelet aggrega- tion and vascular spasm, contributing to adrenal vein thrombosis under certain conditions.10-12,32
Etiology and risk factors Trauma remains the strongest risk factor, responsible for approx- imately 80% of the reported AH cases. The re- maining 20% were attributed to nontraumat- ic causes, including anticoagulant therapy, he- matologic disorders, infectious diseases (eg, Waterhouse-Friderichsen syndrome), obstet- ric complications, perinatal injury, adrenal neo- plasms (pheochromocytoma, adenoid cystic car- cinoma [ACC], metastases), and gastrointestinal disorders.9,13-15 This broad spectrum highlights the need for high clinical suspicion, especially in patients with sudden abdominal, flank, or back pain without obvious trauma (TABLE 2).
Diagnostic imaging The diagnostic pathway for suspected AH includes ultrasound (US), CT, and MRI. US is often the initial modality in emer- gency settings, where acute hematomas appear solid and echogenic, later evolving into mixed echogenicity and eventually anechoic cystic le- sions with possible calcified walls after 1-2 weeks. Doppler US demonstrates the avascular nature of hematomas.16,17,28
CT remains the most widely used modality for confirming AH. Nontraumatic hemorrhage typi- cally appears round or oval, with periadrenal ex- tension if the capsule ruptures. Acute and sub- acute hematomas have radiodensity of 50-90 Hounsfield units, later evolving into organized pseudocysts with hypoattenuating centers and cal- cifications. In most cases, conservative manage- ment leads to complete resolution within 1 year. Calcifications appear in the early stages of hem- orrhage development.16,17,28
MRI provides the most detailed staging of AH based on Hb degradation products. In the acute stage (<7 days), intracellular deoxy-Hb yields
Adrenal hemorrhage
Patient hemodynamically stable
Yes
No
Observation:
· diagnostics
Open surgery
· a-adrenergic blockade
Qualification for surgery:
· tumor exceeds adrenal acapsule
Yes
No
Laparoscopy even if AH >6 cm
isointense to hypointense T1 signals and hypoin- tense T2 signals.10,16,29 During the early subacute phase (2-7 days), intracellular met-Hb produc- es hyperintense T1 and hypointense T2 signals, initially at the periphery of the hematoma. By the late subacute phase (7-14 days), extracellu- lar met-Hb is hyperintense on both T1 and T2 images.10,16,28,29 In chronic hematomas, hemo- siderin deposition and fibrous capsule forma- tion cause a hypointense rim on both sequenc- es.10,16,28,29 A characteristic “train-track appear- ance” has been described in early nontraumatic AH, where the periphery enhances while the cen- tral portion shows low attenuation, resembling parallel railroad tracks.17 Recognition of this ear- ly sign may facilitate prompt diagnosis before he- matoma formation is complete.
Histology and pathology Histologic evaluation confirms that pheochromocytomas are the most frequent hemorrhagic adrenal tumors, followed by ACCs and metastatic lesions. In a series by Świeczkowski-Feiz et al,3 28.2% of hemorrhagic tumors were pheochromocytomas, 23.1% were ACCs, and 7.7% were metastases. Karwacka et al4 described 23 cases, with 9 involving surgical inter- vention. Histopathology confirmed adrenal hema- toma, and 1 case demonstrated hormonal activity.
Marti et al8 analyzed 6 original and 133 literature cases, reporting pheochromocytomas and ACCs as the predominant hemorrhagic tumors, includ- ing cases with hormonal activity. Importantly, AH may be the first and only manifestation of adrenal malignancy, necessitating thorough en- docrine and oncologic evaluation in all cases.3,4,9
Management strategies Management depends on hemodynamic stability, capsule integrity, and suspicion of malignancy. In unstable patients or in the cases of capsular rupture, urgent open ad- renalectomy is indicated to prevent catastrophic vascular or organ injury.15 In stable patients with contained hemorrhage, laparoscopic adrenalecto- my is the gold standard, even for selected tumors exceeding 6 cm, provided surgery is performed in experienced centers.25-27 Reports indicate that large adrenal tumors (>10 cm) may also be safely removed laparoscopically without compromising oncologic outcomes (FIGURE 1).25-27
Endocrine assessment is mandatory in all cas- es. Patients should undergo screening for pheo- chromocytoma with plasma free or urinary frac- tionated metanephrines.19 Cortisol excess should be excluded via the 1-mg dexamethasone suppres- sion test, with further evaluation if abnormal.19 Primary aldosteronism should be considered in hypertensive or hypokalemic patients by calcu- lating the aldosterone / renin ratio.20 This struc- tured approach, recommended by the Endocrine Society and European Society of Endocrinology, ensures accurate risk stratification of function- al lesions.20-22,30
Preoperative medical optimization is critical for pheochromocytoma. Both a-adrenergic block- ade with doxazosin and ß-blockade (if required) reduce perioperative risk.37-39 Despite adequate preparation, intraoperative hypertensive surg- es or arrhythmias may still occur during anes- thesia induction, pneumoperitoneum, or tumor manipulation.37-39 Failure to reach pharmacolog- ic optimization may result in life-threatening cri- ses. Embolization has been reported as a tempo- rizing option in selected cases, followed by defin- itive surgery.23
Own experience and observations In our cohort, hemorrhagic adrenal tumors had a mean diameter of 7 cm. Hemorrhage was the first and only mani- festation of underlying pathology in many cases.3 Histology confirmed ACC in 4 patients (1 hormon- ally active) and pheochromocytoma in 11 individu- als, of which 5 were hormonally active. Interesting- ly, several pheochromocytomas were biochemical- ly silent preoperatively, likely due to hemorrhagic necrosis masking catecholamine secretion. Oper- ative times for laparoscopic and open adrenalecto- my were consistent with published reports, with surgeon experience strongly influencing the out- comes. These findings reinforce the fact that every AH must be managed as a potential pheochromocy- toma or ACC until histologically proven otherwise.3
Summary statement AH represents a diagnostic and therapeutic challenge due to its rarity, variable presentation, and diverse etiologies. Every AH oc- curring within a mass should be regarded as a pos- sible pheochromocytoma or ACC until definitive- ly excluded on histopathology.3,37 Preoperative en- docrine evaluation and a-adrenergic blockade are mandatory. The choice of a surgical approach must consider tumor size, morphology, hemorrhagic dynamics, patient condition, and surgeon exper- tise.25,41,42 While laparoscopic adrenalectomy re- mains feasible for most contained lesions, open ad- renalectomy is recommended in unstable patients and in the cases of capsule rupture with extracap- sular bleeding.25,41,42 Ultimately, all patients with AH should be prepared for expedited surgery fol- lowing comprehensive evaluation, as conservative management carries the risk of missing underly- ing malignancy.
CONCLUSIONS AH is a rare and underdiagnosed condition that should always be considered in pa- tients presenting with nonspecific symptoms, such as sudden back, flank, or abdominal pain. Tumors, including pheochromocytomas, ACCs, and metasta- ses carry a particularly high risk of hemorrhage. In the cases of hemorrhagic tumors with capsule rup- ture, laparoscopic surgery is associated with a sig- nificant risk of vessel or adjacent organ injury, and therefore open surgery is recommended. The tim- ing of surgical intervention vs conservative obser- vation remains debated in the literature; however, surgery should always be considered when histo- pathologic diagnosis is required.
Although laparoscopic adrenalectomy has be- come routine in surgical practice and offers well- -documented advantages, such as shorter oper- ative time, less postoperative pain, lower wound infection rates, and reduced risk of postoperative hernias in patients with hypercortisolism, these benefits apply primarily to contained lesions. In contrast, open surgery remains the preferred ap- proach in the setting of capsule rupture or suspect- ed malignancy.
Overall, AH management requires high clini- cal suspicion, structured imaging, and endocrine work-up. Treatment must be individualized ac- cording to hemodynamic stability, capsule integ- rity, and oncologic risk. Open surgery is indicat- ed in unstable patients, suspected malignancy, or ruptured tumors, while laparoscopic adrenalecto- my is feasible and safe in selected cases with con- tained hemorrhage.
ARTICLE INFORMATION
ACKNOWLEDGMENTS None.
FUNDING None.
CONTRIBUTION STATEMENT SS-F: study concept and design, and man- uscript preparation; RG, PK, and JW: literature review and data collection; EK and KC: drafting of the manuscript; ST and UA: critical revision of the manu- script; ZG and ST: overall supervision.
AI STATEMENT Artificial intelligence was used solely for language edit- ing of the manuscript. The authors take full responsibility for the content of the manuscript.
CONFLICT OF INTEREST None declared.
OPEN ACCESS This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), allow- ing anyone to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, including commercial purpos- es, provided the original work is properly cited.
HOW TO CITE Świeczkowski-Feiz S, Toutounchi S, Krajewska E, et al. Adre- nal hemorrhage: diagnostics,management, and treatment. Review and clinical update. Wideochir Inne Tech Maloinwazyjne. 2025; 20: 255-260. doi:10.20452/ wiitm.2025.17981
JOURNAL INFORMATION
Videosurgery and Other Miniinvasive Techniques is an official journal of the Videosurgery Foundation.
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