Chronic Adrenal Hematoma Associated with Splenic Rupture The following article covers a 57-year-old man who presented with an acute abdomen. Laparotomy revealed splenic rupture secondary to an impact from a large chronic adrenal hematoma. In reviewing the literature, the authors did not find any reported cases of unilateral adrenal hemor- rhage presenting with splenic rupture. DEBA P. SARMA, MD FRED H. RODRIGUEZ, JR., MD New Orleans ecently, we encountered a pa- tient with a chronic left adrenal hematoma presenting with an acute abdomen due to splenic rupture. Case Report A 57-year-old white man presented with a 20-hour history of abdominal pain. The pain had started in the epigastrium, where it was initially steady. It then gradually progressed to involve the entire abdomen, and became colicky in nature. The patient was nauseated, but denied any vomiting, hematemesis, melena, or jaundice. While in the waiting room of his local physician, he fainted, and was found to have a blood pressure of 60/40 mm Hg. An intravenous infusion of normal saline was started, and the patient was rushed to the VA Hospital's Emergency Room. Past history included tobacco and alcohol abuse, but he had had no previous hospitali- zations, major illnesses, or trauma. On admission, he had a blood pressure of 70/50 mm Hg, a pulse rate of 110 per minute, a respiration rate of 28 per minute, and a temperature of 95°F. He was conscious and responded to questions. His abdomen was distended and very tender with rebound. The bowel sounds were decreased. No evidence of trauma was noted. Laboratory findings in- cluded a hematocri t of 27 % and a WBC count of 14,000 per cu mm. After stabilizing the patient with intra- venous fluids, he was immediately taken to the operating room. An exploratory laparotomy was performed, and it revealed active hemorrhage into the peritoneal cavity. From the Department of Pathology, Vet- erans Administration Medical Center and Louisiana State University Medical School, New Orleans, Louisiana. The spleen was noted to be the site of bleed- ing, and it was removed. After additionally removing all the blood and clots from the peritoneal cavity, a large retroperitoneal mass was noted in the superior aspect of the left kidney. The mass appeared to be encapsu- lated. This was dissected free without much difficulty. A thorough examination of the rest of the abdominal organs revealed no other abnormality. The patient received 11 units of packed red blood cells and 4 units of fresh frozen plasma intraoperatively and in the re- covery room. Recovery was uneventful. On gross examination, the spleen r evealed a torn capsule and recent subcapsular hemor- rhage. It weighed 85 gms and measured 7 x 4x 3 cm. The second specimen was an oval shaped mass which measured 17x15x11 cm (Fig 1). It weighed 1200 gms. The outer surface was covered by a smooth, glistening, white, fi- brous membrane traversed by prominent blood vessels. The mass had a firm to hard consistency. The cut-surfaces were reddish- brown with focal areas of hemorrhage. In one area, a discrete large hematoma measured 6 cm in diameter. The inner surface of the cap- sule showed multiple nodules (averaging 0.7 cm) of gray-white, firm, hard t issue. Microscopically, the spleen showed a re- cent tear of the capsule with hemorrhage into the splenic stroma. The capsule of the mass showed focal areas of normal or compressed adrenal cortical tis- sue (Fig 2). The grossly visible capsular nodules were composed of adrenal tissue, dense fibro-collagenous tissue, or a combina- tion of both. The interior of the mass con- sisted of recent, organizing and organized blood clots. No neoplastic tissue was noted in the mass. Discussion In reviewing the literature, we failed to find any reported cases of unilateral adrenal hemorrhage pre- senting with splenic rupture. The signs and symptoms of ad- renal hemorrhage 1 are those of an acute abdomen, ie, nausea, vomit- ing, colicky pain and abdominal ten- derness. In our patient, however, the acute abdominal symptoms were due to splenic rupture which was found at the surgery. The adrenal hematoma, though very large, was old and asymptomatic. The patient could not recall any previous trauma or episodes of abdominal or flank R Figl