Phaeochromocytoma presenting as an acute abdomen: report of two cases.

Abstract

Phaeochromocytomas are catecholamine secreting tumours, usually arising in the adrenal medulla.The most common clinical manifestation is hypertension, although many symptoms and signs have been described.'Presentation as an acute abdominal emergency is rare.We describe two such cases, which presented within three weeks of each other to a district general hospital.Case 1 A 55 year old man presented having suddenly developed severe, constant left sided abdominal pain and vomiting three hours earlier.He appeared profoundly shocked, with a sinus tachycardia of 160 beats/min and a blood pressure of 160/110 mm Hg.There was a large, tender, ballotable left sided abdominal mass.Results of investigations were: haemoglobin concentration 145 g/l, white cell count 253x109/l, serum amylase activity 4310 IU/1, and glucose concentration 9 9 mmol/l (178 mg/100 ml).Urgent ultrasound scan showed a large retroperitoneal mass with solid and cystic areas.The spleen and left kidney could not be distinguished.Intravenous urography showed a normal but laterally displaced left kidney and renal tract.He continued to appear profoundly shocked, and we proceeded to laparotomy, suspecting massive intra-abdominal haemorrhage.In the operating room he developed severe pulmonary oedema soon after induction of anaesthesia.Laparotomy disclosed a huge left sided retroperitoneal mass containing a haematoma.The pancreas was entirely normal.Further surgery was abandoned owing to the patient's poor condition.Intermittent positive pressure ventilation was continued postoperatively.His tachycardia had persisted at 160/min and blood pressure was stable at 160/90 mm Hg.There was profound peripheral vasoconstriction, which was not relieved by an infusion of sodium nitroprusside.A phaeochromocytoma was suspected and blood samples taken for estimation of catecholamine values.The patient died before the response to ct and blockers could be tested.At necropsy a 22 cm diameter haemorrhagic phaeochromocytoma of the left adrenal was found, weighing 2180 g.Death was due to acute left ventricular failure.The plasma noradrenaline concentration immediately before death was 1150 nmol/l (195 0 ng/ml) (normal 1-6 nmol/l; 0 17- 1-02 ng/ml).Case 2 A 77 year old woman presented with an eight hour history of severe constant pain in the right hypochondrium, vomiting, and rigors.She also complained of attacks of palpitations for two years.On examination she was obviously in pain; she was sweating but had no fever, pulse was 1 10/min and irregular with multiple extrasystoles, and blood pressure was 150/90 mm Hg.There was guarding and tenderness with rebound in the right hypochondrium.Results of investigations were in keeping with a diagnosis of acute