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correspondence

Indian Pediatr 2011;48: 738-739

Neonatal Adrenal Hemorrhage Presenting as Intestinal Obstruction


Mandar B Patil

Sangeeta Hospital for Children, Kolhapur, Maharashtra, India.
Email: [email protected]
 
 


Due to its large volume and vascularity, neonatal adrenal hemorrhage (NAH) is not uncommon. However, there is only one case report of intestinal obstruction due to NAH [1]. A 3-day-old male neonate presented with bilious vomiting, distension of abdomen, lethargy and non-passage of stools for last 24 hours. He weighed 2700 g. The clinical examination revealed mass in the right lumbar region with generalized abdominal distension and absent bowel sounds. There was no pallor or icterus. No birth asphyxia was reported at birth. Hemogram and sepsis work up was normal. X-ray abdomen erect showed multiple air fluid levels. The ultrasonography (USG) abdomen revealed right adrenal hemorrhage measuring 65×55×30 mm in dimensions, displacing the right kidney downwards. The left adrenal gland was normal. CT scan of abdomen confirmed right adrenal hemorrhage displacing the right kidney downwards with extrinsic compression of the right hemicolon due to mass effect. Urinary VMA levels were normal. The baby had no hypotension, pallor or signs of adrenal insufficiency. He was treated conservatively in neonatal intensive care unit. Abdominal distension decreased gradually. He passed stools on day 5 of admission. Repeat X-ray abdomen showed no air fluid levels. He was started on feeds gradually and discharged on day 18 of life. His serial USG abdomen showed gradual decrease in right adrenal hematoma with complete resolution by six weeks of age with no calcifications and normalization of size. Baby was thriving well at follow up and is now of nine months age.

Right adrenal gland is more affected (70%), as against bilateral (5-10%) affection [2], because the right adrenal gland is more likely to be compressed between liver and spine and, the right adrenal vein drains directly into the inferior vena cava. The various etiological factors attributable are difficult or traumatic delivery, perinatal asphyxia, and prematurity, apart from disorders of hemostasis [3]. The usual presentation is asymptomatic to anemia, hypotension, hyperbilirubinemia, bluish discoloration of scrotum and palpable abdominal mass [4].

Most cases of NAH can be managed successfully by conservative measures [4]. Shrinkage develops over weeks, and later corresponds to the shape and size of the normal adrenal gland. Although uncommon, neonatologists and radiologists are likely to encounter a newborn with NAH presenting as intestinal obstruction due to mass effect and need to be aware that it can be managed conservatively.

References

1. Levine C. Intestinal obstruction in a neonate with adrenal hemorrhage and renal vein thrombosis. Pediatr Radiol 1989;19:477-8.

2. Jacobsson H, Kaiser S, Granholm T, Ringertz HG. Neonatal adrenal haemorrhage at bone scintigraphy: a case report. Pediatr Radiol. 1998;28:896-8.

3. Emery JL, Zachary RB. Hematoma of adrenal gland in newborn. Br Med J. 1952;2:857-9.

4. Heij HA, van Amerongen AH, Ekkelkamp S, Vos A. Diagnosis and management of neonatal adrenal hemorrhage. Pediatr Radiol. 1989;19:391-4.
 

 

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