|Year : 2001 | Volume
| Issue : 1 | Page : 65-66
Hemorrhagic adrenal cyst
K Natarajan, Mahesh Rao, SJ Philipraj, K Sasidharan
Division of Urology, Kasturba Medical College, Manipal, India
Division of Urology, Kasturba Medical College, Manipal 576119
Source of Support: None, Conflict of Interest: None
Keywords: Adrenal Cyst
|How to cite this article:|
Natarajan K, Rao M, Philipraj S J, Sasidharan K. Hemorrhagic adrenal cyst. Indian J Urol 2001;18:65-6
| Introduction|| |
Cysts of the adrenal glands are rare. They are usually discovered fortuitously, either on clinical examination or on radiological check-up for a nonspecific symptomatology. Herein we present a case of hemorrhagic adrenal cyst who presented with flank pain.
| Case Report|| |
A 63-year-old gentleman presented with the history of a single episode of acute pain over the right flank which lasted for 20 minutes. On examination general condition was unremarkable and his blood pressure was 130/90. Abdominal palpation disclosed a large, smooth and well marginated mass in the right hypochondrium and lumbar region measuring 20 x 10 cms. Further characterization of the lesion with computed tomography revealed a predominately cystic lesion with mixed echogenicity, circumscribed by a well defined calcific capsule [Figure - 1]. The mass was found to displace the kidney downwards.
On transperitoneal flank exploration through the bed of tenth rib, the lesion was found densely tethered to the right lobe of the liver superiorly and to the upper pole of the right kidney inferiorly. Enbloc excision of the mass along with the right kidney was carried out [Figure - 2]. On opening the cyst it was found to have dense fibrous wall containing 750 ml reddish brown fluid. Histopathological examination revealed pseudocyst wall with dense calcification. Postoperative period uneventful.
| Discussion|| |
Adrenal cysts are often asymptomatic and are included in the larger incidentaloma group, they often reach significant size without effecting compressive symptoms and are often left undiagnosed until an ultrasonograpy or computed tomography is performed for ill defined abdominal pain or flank discomfort. Adrenal cysts were classified by Terrier and Lecene in 1906. It was modified by Abeshouse et al and Barron and Emanuel [Table - 1]. Non traumatic hemorrhage of the adrenal cyst is uncommon. The causes of such hemorrhage can be classified into four categories, namely (a) stress, (b) hemorrhagic diathesis, (c) underlying tumours, and (d) idiopathic disease.
It has been noted that when hemorrhage occurs the right gland is affected more often than the left. Usual susceptibility of the right adrenal gland for hemorrhage is not clearly understood. The right adrenal vein usually drains directly into the inferior vena cava and hence it is presumed that changes in the central venous pressure are likely to impact the right adrenal more and result in rupture of adrenal medullary sinusoids.
Hemorrhagic adrenal cysts are usually pseudocysts. The cyst wall is devoid of any epithelial lining and is made up of fibrous tissue. The dense fibrous wall frequently contains areas of calcification and may be hyalinised. The wall calcification is not an exclusive feature of hemorragic adrenal cysts and is also shown by other lesions such as hydatid and malignant cysts.
Ultrasonography, computed tomography and magnetic resonance imaging play an important role in diagnosis and management. Computed tomography is the modality of choice; magnetic resonance imaging can be used when co-existing vascular pathology is suspected. The possibility of a malignant or functioning tumour is real, hence mandatory exploration.
| Conclusion|| |
Though adrenal cysts are rare; with the refined currently available radiological techniques it is possible to make accurate preoperative diagnosis. Presence of dense calcification strongly suggests the possibility of echinococcus cyst and hemorrhagic cyst of the adrenal. Surgical exploration is recommended in almost all patients to exonerate malignancy.
| References|| |
|1.||Kearney GP, Mahoney EM. Symposium on adrenal diseases: adrenal cysts. Urol Clin North Am 1977; 4 (2): 273-283. |
|2.||Kawashima A, Sandler CM. Imaging of nontraumatic hemorrhage of the adrenal gland. Radiographics 1999; 19: 949-963. |
|3.||Rurnancik WM, Bosniak MA. Miscellaneous conditions of the adrenals and adrenal pseudotumor. In: Clinical Urography: 2399-2412. |
[Figure - 1], [Figure - 2]
[Table - 1]