ConditionHormones & metabolism
Adrenal Hemorrhage
Adrenal hemorrhage is bleeding into one or both adrenal glands, the small hormone glands above the kidneys. Bleeding into one gland often causes no lasting harm and may be found by chance on a scan. Bleeding into both glands can destroy them and cause adrenal crisis, a life-threatening shortage of cortisol with low blood pressure, belly or flank pain, vomiting and confusion. Common causes are severe infection, blood thinners, trauma and newborn birth stress. Treatment is urgent hydrocortisone and fluids.
Also called: Adrenal gland bleeding, adrenal apoplexy, bilateral adrenal hemorrhage, Waterhouse-Friderichsen syndrome (with meningococcal sepsis)
At a glance
- What it is
- Bleeding into the adrenal gland, on one or both sides.
- Main causes
- Sepsis (especially meningococcal), anticoagulants, antiphospholipid syndrome, heparin-induced thrombocytopenia, trauma, surgery, newborn birth stress, tumors.
- Key danger
- Bilateral bleeding can cause adrenal crisis.
- Symptoms
- Sudden flank, back or belly pain, low blood pressure, fever, vomiting, confusion.
- Treatment
- Hydrocortisone and IV fluids immediately when crisis is suspected; long-term steroid replacement if glands fail.
When to get help
Call 911 or go to the ER
- Sudden severe belly, flank or back pain with dizziness, fainting or very low blood pressure
- Fever with a rapidly spreading purple rash that does not fade when pressed, especially with drowsiness
- Someone on long-term steroids or with known adrenal insufficiency who is vomiting, confused or collapsing (give their emergency hydrocortisone injection if available)
See a doctor within a day or two
- New belly or flank pain with fatigue and lightheadedness while taking blood thinners
- An adrenal mass or bleed found on a scan, which needs follow-up hormone tests
Book a routine appointment
- Persistent tiredness, weight loss, salt craving or darkening skin months after an adrenal bleed
How adrenal hemorrhage happens
Each adrenal gland has a rich blood supply flowing in through many small arteries but draining through a single vein. In severe stress, high levels of the stress hormone ACTH increase blood flow into the gland, while clots or spasm in the vein can block outflow. Pressure builds and the gland bleeds. Blood thinners and clotting problems make bleeding more likely.
The adrenal glands make cortisol, needed to maintain blood pressure and blood sugar during stress, and aldosterone, which controls salt and water balance. Losing at least 90% of adrenal tissue causes adrenal insufficiency, so one damaged gland is usually compensated for by the other, while bleeding into both can be catastrophic.
Causes
| Category | Examples |
|---|---|
| Severe infection | Meningococcal sepsis (Waterhouse-Friderichsen syndrome), other bacterial sepsis, COVID-19 |
| Anticoagulation and clotting disorders | Warfarin, heparin, DOACs; heparin-induced thrombocytopenia; antiphospholipid syndrome |
| Physical stress | Major surgery, burns, severe illness, pregnancy |
| Trauma | Blunt abdominal injury, often right-sided, in car crashes |
| Newborns | Large babies, difficult delivery, lack of oxygen at birth |
| Adrenal tumors | Bleeding into an adenoma, pheochromocytoma or metastasis |
Symptoms
Symptoms depend on how much of the glands is damaged.
- Unilateral (one side): often no symptoms, or sudden pain in the flank, back or upper belly. It may be found incidentally on a CT scan.
- Bilateral (both sides): signs of adrenal crisis develop over hours to days: - severe belly, flank or back pain - nausea, vomiting and loss of appetite - fever - weakness, confusion or drowsiness - low blood pressure and shock that does not respond well to fluids alone - low sodium, high potassium and low blood sugar on blood tests
- Newborns: a flank mass, jaundice, anemia or scrotal bruising; most resolve without problems.
Diagnosis
- CT scan shows enlarged, dense adrenal glands with blood. MRI helps identify the age of the bleed and any underlying tumor.
- Ultrasound is used in newborns.
- Blood tests: cortisol and ACTH (low cortisol with high ACTH indicates the glands have failed), electrolytes, glucose, blood count and clotting.
- Tests for the cause: blood cultures, antiphospholipid antibodies, platelet antibodies.
In suspected adrenal crisis, hydrocortisone should be given immediately, with a blood sample taken first if possible. Treatment must never wait for results.
Treatment
Emergency treatment
- Hydrocortisone given by injection or IV, which replaces both cortisol and, at high doses, aldosterone activity
- IV fluids with saline and glucose
- Treating the cause: antibiotics for sepsis, reversing or adjusting anticoagulation as appropriate, managing heparin-induced thrombocytopenia
- Blood transfusion if bleeding is large
Long-term treatment
If both glands are damaged, lifelong steroid replacement is needed: hydrocortisone or a similar steroid, plus fludrocortisone for aldosterone. People taking replacement need education on sick day rules (doubling or tripling the dose during illness), an emergency injection kit, and a medical alert ID. Some people recover enough adrenal function over months to stop replacement, so testing is repeated.
For long-term adrenal insufficiency, see Addison's disease.
Outlook
Unilateral bleeding usually has an excellent outlook. Bilateral adrenal hemorrhage is serious, and survival depends on recognizing adrenal crisis early and starting steroids. People who survive generally do well with lifelong hormone replacement. Follow-up imaging checks that the bleed has resolved and that no tumor was hidden beneath it.
Frequently asked questions
What causes adrenal hemorrhage?
The main causes are severe infection, especially meningococcal sepsis, blood thinners, clotting disorders such as antiphospholipid syndrome and heparin-induced thrombocytopenia, major surgery or trauma, and birth stress in newborns. Some occur in adrenal tumors.
What are the symptoms of adrenal hemorrhage?
Bleeding into one gland may cause sudden flank or belly pain or no symptoms. Bleeding into both glands causes adrenal crisis: severe pain, vomiting, fever, weakness, confusion and low blood pressure that can lead to shock.
Is adrenal hemorrhage life-threatening?
Bleeding into both adrenal glands can be life-threatening because it can cause adrenal crisis. With prompt hydrocortisone and fluids, most people survive. Bleeding into one gland is rarely dangerous because the other gland can compensate.
Can the adrenal glands recover after a hemorrhage?
Sometimes. The blood is reabsorbed over weeks to months, and some adrenal function may return. If both glands were badly damaged, lifelong steroid replacement is usually needed. Doctors repeat hormone tests to see whether recovery has occurred.
Sources
This guide was written from current patient and clinical guidance, including:
- Endocrine Society: Diagnosis and treatment of primary adrenal insufficiency clinical practice guideline
- MedlinePlus: Waterhouse-Friderichsen syndrome
- Society for Endocrinology: Adrenal crisis guidance
- Merck Manual Professional Version: Addison disease
- National Organization for Rare Disorders: Adrenal insufficiency