Adrenal Case: 68-year-old Man with Nausea, Lightheadedness, Back and Abdominal Pain

00:01 Let's go on to another case.

00:03 A 68-year-old man is evaluated in the hospital for several hours of nausea, lightheadedness, and abdominal pain.

00:10 He underwent a laparoscopic cholecystectomy four days ago.

00:14 He had been doing well postoperatively until now.

00:17 Medical history is significant only for gouts.

00:20 Medications are prophylactic dose unfractionated heparin and as needed oxycodone.

00:27 On physical examination, his temperature is 37.2 degrees Celsius.

00:31 Blood pressure is 80/50.

00:33 Pulse rate is 110 beats per minute with a respiration rate of 18.

00:39 His BMI is 26.

00:41 Examination of the abdomen shows a clean and dry surgical wound.

00:46 Cardiac exam reveals regular tachycardia.

00:49 There is no pain with palpation of the abdomen or lower back.

00:54 His skin pigmentation is normal.

00:58 There is a low serum sodium of 130 mEq/L.

01:03 Potassium is 6.0 mEq/L. Random cortisol is less than 2 μg/dL.

01:12 What is the most likely diagnosis? Here we have a patient presenting with fairly nonspecific features after surgery but does manifest with postoperative hypotension as well as abdominal pain and nausea.

01:30 He has a low serum cortisol.

01:33 This, in conjunction with the low blood pressure, gives us the most likely diagnosis of adrenal insufficiency.

01:43 When a stem in a USMLE CK question mentions the word skin pigmentation, either in the positive or the negative, always consider adrenal insufficiency.

01:55 Primary adrenal insufficiency does manifest with hyperpigmentation within the palmar creases of the hands or in the buccal mucosa or the mouth.

02:05 This, when found, is very specific for a diagnosis of Addison’s disease.

02:11 The absence of skin pigmentation certainly doesn't rule out the diagnosis as in this case.

02:17 The labs are typical for low cortisol state, particularly the electrolytes where you see a low sodium and a high normal potassium as well as a low cortisol.

02:30 The conclusion here is this patient has adrenal insufficiency probably caused by his use of unfractionated heparin that has caused bilateral adrenal hemorrhage.

02:41 The next test to confirm the low cortisol is to perform a cosyntropin stimulation test.

02:47 This patient's primary adrenal failure is likely due to the bilateral adrenal hemorrhage.

02:53 Acute onset of nausea, lightheadedness, back and abdominal pain as well as hypotension are usually consistent features of acute adrenal failure.

03:03 Lab studies show hyponatremia, hyperkalemia, and hypocortisolemia which are also consistent with the diagnosis.

03:11 The risk factors for adrenal hemorrhage include anticoagulant therapy, which may occur with treatment levels as well as levels within the therapeutic range, also the post-operative state, abnormalities of hemostasis such as heparin-induced thrombocytopenia or the antiphospholipid antibody syndrome, and in the presence of sepsis.

03:33 Failure to identify acute adrenal failure in a timely manner may lead to cardiovascular collapse.

03:39 Adrenal hemorrhage can often be visualized on abdominal CT scanning.

03:45 That would be indicated in the management of this patient.

03:48 Treatment of acute adrenal failure with stress-dose glucocorticoids is indicated.

03:53 Hydrocortisone in a range of 50-100 mg intravenously every six to eight hours is recommended.

04:02 Further supportive care with intravenous fluids and vasopressors may be needed if the patient's blood pressure does not respond.