Acute adrenal insufficiency due to adrenal hemorrhage complicating colorectal surgery: Report of two cases and correlation with the antiphospholipid antibody syndrome

INTRODUCTION: Spontaneous bilateral adrenal hemorrhage or hemorrhagic necrosis due to adrenal vein thrombosis is an uncommon condition that may lead to acute adrenal insufficiency and death. The objective of this report is to enhance recognition of this potentially fatal disorder in surgical patients. PRESENTATION OF CASES: We present two cases of acute adrenal insufficiency due to bilateral adrenal hemorrhage associated with primary antiphospholipid antibody syndrome (APS). Both cases occurred in the early postoperative period after major colorectal surgery. Major vein thrombosis, abdominal pain, anorexia, asthenia, lethargy and an unexplained drop in patient’s hemoglobin without evidence of sepsis were the principal symptoms and signs that, with a high index of suspicion, led to the correct diagnosis. DISCUSSION: Antiphospholipid syndrome is an acquired thrombophilia caused by circulating antibodies against a heterologous group of phospholipids. Recent literature has identified a causative relation between APS and primary adrenal insufficiency (AI), identifying it as its most common endocrine manifestation. Surgeries along with inflammation or hormones have been identified as precipitating factors. Spontaneous haemorrhagic infarction of the adrenal glands has been observed in patients with APS in the postoperative period during anticoagulant treatment. Signs and symptoms are non-specific and are easily confused with those of the underlying condition. CONCLUSIONS: Early recognition and prompt treatment of adrenal insufficiency due to APS in surgical patient is of vital importance. Patients correctly diagnosed and treated that survive the critical phase have a better prognosis regarding restoration of adrenal function.