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.