Unilateral adrenal necrosis and haemorrhage following operations on the stomach

UNILATERAL ADRENAL NECROSIS A N D HAEMOR- R H A G E FOLLOWING OPERATIONS ON T H E STOMACH

B. Fox Department of Histopathology,

Charing Cross Hospital Medical School, London

PLATES LVI-LVIII

AMONGST 50 cases of adrenal necrosis and haemorrhage, 5 showed unilateral lesions that followed radical operations on the stomach, a complication that has not been recognised previously. In three cases there was non-haemorrhagic segmental adrenal necrosis, apparently due to occlusion of arteries; in the other two cases occlusion of the main and external capsular veins was associated with massive haemorrhage. The lesions appeared to have been caused by interruption of the vascular supply at the operation, and enabled the association between vascular and parenchymal lesions in the human adrenal to be studied. This association is important in experimental occlusion of adrenal veins because the venous return in the animals usuallyused (rat, guinea-pig and rabbit) is anatomi- cally different from that in man (Dobbie and Symington, 1966).

MATERIALS AND METHODS

The cases are sumrnarised in the table. In cases 1-3 only one paraffin block of each adrenal was available for examination.

Serial sections of all blocks were prepared. The side from which the adrenals came was deduced from the histological study (see below). In cases 4 and5 both adrenals with surrounding connective tissue were fixed in 4 per cent. neutral formaldehyde-saline; serial sections were prepared and at least every tenth section was stained with haemalum and eosin (HE). Other sections were stained with Mallory’s phosphotungstic acid-haematoxylin (PTAH), and by the picro-Mallory technique, James’ (1967) silver impregnation method for reticulin, Perk’ reaction, and the periodic acid-Schiff (PAS), Giernsa and Gram-Weigert methods.

Case 1 Histology

Parenchymal changes. There is a band-like area of ischaemic necrosis, involving the tip of one ala (Dobbie and Symington) of one adrenal gland, extending from the capsule to the inner third of the zona fasciculata (fig. 1). Medullary tissue is not present, which suggests that the specimen is from the tail of the gland (Dobbie and Symington). The reticulin pattern of the cortex, normally having an elongated columnar appearance (fig. 2), is altered to a honeycomb

~~ ~

Received 29 Mar. 1968; accepted 15 May 1968. J. PATH.-VOL. 97 (1969) 127

128 B. FOX

pattern (fig. 3). All of the cortical cells have lost their nuclei and their cytoplasm is replaced by vacuolated structureless eosinophilic material. Scattered throughout the necrotic zone is a large amount of nuclear debris, basophilic material and neutrophil polymorphonuclear leucocytes (neutrophils). There is a band of neutrophils and nuclear debris at right-angles to the capsule, which is separated from the normal zona fasciculata by a zone of coagulative necrosis. There is a similar band-like zone of neutrophils and nuclear debris approximately 150 pm beneath and parallel to the capsule. The capsular fat adjacent

F I!-- 2 M

_ _ ~

3 M

4 M

5 F

TABLE

Clinical findings in the 5 cases

84 Carcinoma of stomach



~~


~ _ _ _

48 Carcinoma of oesophagu

Diagnosis

I l l

Operation

Total gastrectomy with splenectomy

Total gastrectomy with splenectomy

Upper radical partial gastrectomy with splenectom y

Upper radical partial gastrectomy with splenectomy

Partial oesopha- gectomy and partial gastrectomy with splenectomy

Post-operative survival

4 days

8 days

24 days

6 days

8 days

to the necrotic area is infiltrated with lymphocytes, histiocytes and very occasional neutrophils. In an occasional section there are tiny foci of recent haemorrhage adjacent to the area of necrosis. Stainable iron is not found.

Vascular changes. There are very occasional fibrin thrombi within sinusoids on the inner surface of the necrotic area. In the capsular fat adjacent to the area of necrosis there are a large necrotic artery, 3 large necrotic veins (fig. l), and several smaller necrotic arteries. In some places the lumen of the large artery contains normal-staining red cells, but in other places it is partially obliterated by masses and filaments of fibrin that enmesh red cells. There are tiny deposits of fibrin and collections of red cells within the intima. The walls of the smaller arteries are completely necrotic, but the lumina contain dehaenioglobinised red cells with occasional masses of fibrin. The veins are partly or completely

Fox PLATE LVI

ADRENAL LESIONS AFTER GASTRIC SURGERY

FIG. I.-Case 1. Segmental adrenal necrosis with necrotic artery and veins in the capsular fat. Haemalum and eosin. x 27.

FIG. 2.-Case 1 . Elongated columnar reticulin pattern in opposite normal adrenal. James’ reticulin. x 67.

FIG. 3.-Case 1 . Honeycomb reticulin pattern in segmental necrosis of adrenal. James’ reticulin. x 67.

Fox PLATE LVII


FIG. 4.-Case 2. Segmental necrosis involving a third of the adrenal. HE. x 2.7.

FIG. 5.-Case 2. Fibrin thrombi in sinusoids of necrotic adrenal. Phospho- tungstic acid-haematoxylin. x 75.

FIG. 6.-Case 3. Necrosis in the adrenal with rim of surviving zona glomerulosa. HE. X 130.

Fox PLATE LVIII


FIG. 7.-Case 4. Neutrophil polymorphs and FIG. 8.-Case 4. Patent central adrenal vein nuclear debris in necrotic adrenal and peri- surrounded by a rim of surviving zona capsular connective tissue. HE. x 115. glomerulosa outside which is necrotic

cortex. HE. ~ 6 6 .

FIG. 9.-Case4. Organised thrombi in external FIG. 10.-Case 5 . Organised thrombus in capsular veins. HE. x 40. central muscular vein. Picro-Mallory. x 42.

ADRENAL LESIONS AFTER GASTRIC SURGERY 129

occluded by sheets and strands of fibrin, which enmesh red cells and neutrophils.

There are no other vascular lesions in the rest of the adrenal, and there are no parenchymal or vascular lesions in sections of the other adrenal.

Summary. In one ala from the tail of one adrenal gland there is an area of ischaemic cortical necrosis related to necrotic blood vessels in the adjacent pericapsular connective tissue.

Case 2

Histology Parenchymal changes. There is a large area of ischaemic necrosis involving

about one-third of a transverse section of one adrenal; in places necrosis involves all zones of the cortex and the medulla (fig. 4). There are areas of complete necrosis in which the cells are replaced by vacuolated structureless eosinophilic material. The normal reticulin pattern (fig. 2) is replaced by a honeycomb pattern (as in fig. 3) in the necrotic areas. There is an irregular band of basophilic material and nuclear debris that is parallel to and extends to the thickened capsule, and in places involves the pericapsular fat. In other areas there are finely scattered deposits of nuclear material and neutrophils. On the inner surface of the areas of complete necrosis there is a narrow zone of coagulative necrosis. The completely necrotic areas are separated from apparently normal cortex by a zone of degenerate cells in which there is cytoplasmic vacuolation and nuclear pyknosis. Within the damaged segment there are areas in which there is a thin rim of normal zona glomerulosa and also a small isolated area of normal zona fasciculata and medulla. In the tip of the ala there is a small area of haemorrhage in and around necrotic cells. Stainable iron is not present.

Vascular changes. There are fibrin thrombi in the sinusoids mainly in the inner zone of the completely necrotic areas (fig. 5). There are no fibrin thrombi in the sinusoids in the rest of the adrenal. There is a well-organised adherent thrombus in a central venous sinus at the edge of the necrotic zone. The main central muscular vein and the other venous sinuses are patent. Within the thickened capsule at the site of the area of necrosis there is a small necrotic artery and a small necrotic vein. The vein contains thick strands of fibrin that enmesh red cells; the artery contains only red cells. There is a small amount of pericapsular fat.

Summary. Large areas of ischaemic necrosis involve about one-third of one adrenal, but cannot be attributed to the vascular changes that are present.

Case 3 Histology

Parenchymal changes. There is a large area of ischaemic necrosis that involves the tip of one ala of one adrenal gland. There is no medullary tissue in the sections, which suggests that they are from the tail of the gland (Dobbie and Symington). Necrosis is complete and the cortex is replaced by vacuolated

J. PATH.-VOL. 97 (1969) I

130 B. FOX

eosinophilic structureless material (fig. 6) in which there are elongated cleft-like spaces.

The architecture of the necrotic cortex is still discernible, but the reticulin pattern is altered to the honeycomb type. In the subcapsular region there is loss of reticulin fibres, which in other areas are condensed and thickened. The necrotic area is separated from uninvolved cortex by a band of degenerate cortex. There are also areas of surviving zona glomerulosa (fig. 6).

There are a few scattered clumps of fibrin in the necrotic area, and in the centre there are lipofuscin-filled macrophages. There are small deposits of haemosiderin and haemosiderin-filled macrophages in the pericapsular fat and on the inner edge of (but not within) the necrotic area.

There is no nuclear debris or neutrophil infiltration. In the pericapsular connective tissue surrounding the zone of complete

necrosis there is a foreign-body giant-cell reaction around doubly refractile suture material.

Vascular changes. The only vascular changes are areas of fibrinoid necrosis in 3 larger arteries in the pericapsular connective tissue, some distance from the area of necrosis. There are no thrombi in sinusoids, or in central or capsular veins. There are patent arteries and veins containing red cells in the region of the necrotic zone.

There are no vascular or parenchymal lesions in the opposite adrenal gland. Summary. Old ischaemic necrosis without vascular occlusion. The suture

material in the pericapsular connective tissue adjacent to the area of necrosis suggests that there could have been a vascular disturbance at the time of operation.

Case 4

Necropsy Jindings The left adrenal vein was filled with organised thrombus that extended into

the left renal vein. The left adrenal gland was enlarged and appeared normal, apart from thrombus in the central vein.

The right adrenal gland appeared normal, but there was central post- mortem liquefaction.

Histology Parenchymal changes. There is an irregular band-like area of haemorrhage

mainly in the centre of the left adrenal gland. In places the haemorrhage extends through the cortex to the capsule and shows thin and thick strands of fibrin enmeshing red cells, many of which have lost their staining properties. The haemorrhage is separated in places from apparently normal zona fasciculata by a thin band of degenerate parenchymal cells, but in other places abuts on to large areas of completely necrotic cortex that consist of vacuolated structureless eosinophilic material. These necrotic areas usually extend to the capsular surface but occasionally are separated from the capsule by a thin rim of surviving zona glomerulosa and fasciculata, and a band of coagulative necrosis. There


is a thick band of nuclear debris, basophilic material and occasional neutrophils around the edges of the necrotic area, in places extending into the capsular fat (fig. 7). Where the zona glomerulosa is present the band of nuclear debris, basophilic material and neutrophils is narrower and approximately 150 pm beneath and parallel to the capsule. In a small encapsulated nodule of cortex there is ischaemic necrosis, with a rim of surviving zona glomerulosa and zona fasciculata similar to that in the main gland. There is no evidence of haemorrhage within this nodule.

The reticulin in the necrotic areas in places has a honeycomb pattern but elsewhere appears normal. Within the areas of haemorrhage there is some disruption of the reticulin pattern. There are fine deposits of haemosiderin in the capsular fat, but none in the haemorrhagic or necrotic areas.

There is suture material in the capsular fat, in close relation to the adrenal vein, and within one part of the cortex.

There are metastatic deposits of adenocarcinoma in the pericapsular fat, but there is no direct involvement of the adrenal gland.

Vascular changes. There is considerable variation in the structure of the thrombus in the main extra-adrenal vein. The vein some distance from the gland is occluded by a laminated well-organised thrombus in which there are thick masses of fibrin, dehaemoglobinised red cells, granular material that resembles platelets and large numbers of neutrophils. In sections from nearer to the gland, the thrombus is less well organised: the red cells retain their staining properties, there is much less fibrin, but there are large collections of platelets and neutrophils. In other sections the extra-adrenal vein appears patent.

Most of the muscular intra-adrenal veins are patent, but there are occasional deposits of fibrin and some sludging of red cells. In the centre of a large area of ischaemic necrosis there is a patent central muscular vein surrounded by a thin rim of surviving zona glomerulosa cells (fig. 8). Many of the external capsular veins are occluded by partly organised fibrin thrombi (fig. 9); some of these veins are some distance from the gland. Most of the other veins are filled with red cells. There is fibrinoid necrosis in the walls of many of the pericapsular arteries, and in an occasional arteria medullae within the cortex. Some of the sinusoids on the inner surface of the areas of ischaemic necrosis are filled with fibrin thrombi.

There are no obvious parenchymal or vascular injuries to the opposite gland, which shows considerable post-mortem autolysis. There is also autolysis in the left adrenal, but this is confined to the apparently normal cortex; the necrotic and haemorrhagic areas show a remarkable preservation of cellular detail.

Summary. Haemorrhagic and necrotic lesions of the left adrenal gland with thrombosis of the extra-adrenal muscular vein, external capsular veins, and fibrinoid necrosis of pericapsular arteries. Suture material in the capsular fat in close proximity to the thrombosed vein and in part of the gland suggests that this lesion was due to interruption of the blood supply at the time of operation.

132 B. FOX

Case 5

Necropsy findings There was a haemorrhage (3 x 1 x 1 cm) in the centre of the left adrenal

gland. The right adrenal gland appeared normal.

Histology Parenchymal changes. In the centre of the left adrenal gland there is a large

area of haemorrhage that has caused considerable parenchymal destruction, though there are areas of surviving cortex and medulla. In the centre of the haemorrhage there is a large amount of fibrin that enmeshes normal-staining red cells. At the periphery of the haemorrhage there are small areas of organisation in which the red cells have lost their staining reaction, and there are thick strands of fibrin and new blood vessel formation. These areas of organisation are surrounded by neutrophils, lymphocytes and some histiocytes. Around the edges of the haemorrhage there are areas of basophilic material, nuclear debris and neutrophils. Within the haemorrhage there are scattered fine deposits of haemosiderin and in some areas near the periphery a collection of haemosiderin- filled macrophages. In the cortex there is a band-like zone of coagulative necrosis adjacent to the central haemorrhage. There are 2 small rounded foci of ischaemic necrosis that involve the outer third of the zona fasciculata and extend to the capsule. There are a few neutrophils, lymphocytes and histiocytes scattered through the necrotic areas. In the pericapsular connective tissue there is a small cortical nodule in which there is a band-like area of ischaemic necrosis in the outer part of the zona fasciculata. The reticulin pattern in the ischaemic areas is mainly normal, though in places there is a change to a honeycomb pattern.

In the periadrenal connective tissue there are areas of haemorrhage, fibrous granulation tissue, and suppurative inflammation around doubly refractile suture material.

Vascular changes. Large muscular branches of the central adrenal vein are partly occluded by organised and partly recanalised thrombi (fig. 10). The thrombi are composed of fibrin and amorphous red cells that have mainly lost their staining characteristics. In some areas there are collections of platelets. In many sections there are large patent muscular veins within the areas of surviving cortex. Many of the external capsular veins are occluded by well- organised thrombi and there are ruptured capsular veins and arteries. There are no fibrin thrombi in the sinusoids in the haemorrhagic or the necrotic zones.

There are no parenchymal or vascular lesions in the right adrenal gland. Summary. Massive haemorrhage and areas of ischaemic necrosis in the left

adrenal gland. Organised and partly recanalised thrombi in the main extra- adrenal muscular vein, and in intra-adrenal muscular veins. Organised thrombi in the external capsular veins.

Ruptured vessels and suture material in the pericapsular connective tissue suggest that there had been interruption of the vascular supply at the operation.


DISCUSSION Cases 1-3 are examples of unilateral segmental necrosis of the adrenal gland.

The term segmental is used to distinguish these lesions from those of focal necrosis, which are usually confined to the outer third of the zona fasciculata and are seen with or without capsular arteritis (Balo and Nachtnebel, 1929; Mitchell and Angrist, 1943). In cases 1-3 it is not possible to be certain from which side the adrenals came, but the suture material in the pericapsular fat in case 3 and the necrotic vessels in case I strongly suggested that they had been damaged at the time of operation and therefore were from the left side. The parenchymal changes were those of ischaemia with complete loss of cellular structure, though the general pattern of the gland was still discernible. The reticulin pattern was intact though the normal elongated columnar appearance had changed to a honeycomb arrangement, which was probably due to partial collapse of reticulin following alteration in the supporting cytoplasm. These ischaemic lesions resembled those produced in the rabbit, rat and cat by ligature of a number of capsular arteries (Harrison, 1951). In case I necrotic vessels were found, but in cases 2 and 3 only a small amount of periadrenal connective tissue was present in the sections.

It is possible that the damaged vessels were removed, as it is a common practice, particu- larly when weighing adrenals, to remove as much of the periadrenal connective tissue as possible. It is important when studying cases of adrenal haemorrhage and necrosis to pre- serve the pericapsular adrenal vessels. The adrenal is supplied by up to 50 small arteries which ramify in the capsule, and tying of single arteries produces focal necrosis mainly confined to the outer third of the zona fasciculata (Harrison). One must therefore assume that when there are larger areas of necrosis there is involvement of a number of capsular arteries, or of a larger artery at some distance from the gland. Spasm of capsular arteries could occur at the time of operation and lead to large areas of cortical necrosis (Sheehan, 1955). Kovhcs, Carroll and Tapp (1966) produced areas of ischaemic necrosis in the adrenal glands of the rat by temporarily occluding the arterial supply for 2 hr. The inferior phrenic artery, which may supply blood to 60 per cent. of the adrenal (Pick and Anson, 1940), is a large vessel that could be damaged during radical operations on the stomach. The zonal arrangement of bands of neutrophils, degenerate tissue and apparently normal tissue, found at the edges of the necrotic lesions, resembles the zones seen in infarcts and in experimental renal ischaemia (Sheehan and Davis, 1958). In studies of renal ischaemia Sheehan and Davis found a well- defined zone of neutrophil infiltration in lesions 1-2 days old that practically disappeared in 6 days. The state of the zones of neutrophil infiltration in cases I , 2 and 4 supports the suggestion that the original vascular lesions occurred at the time of operation.

In cases 4 and 5 there was haemorrhage as well as necrosis in the left adrenal, and the suture material close to the adrenal vein suggests that these lesions also resulted from the operation. It is probably significant that only in these 2 cases with massive haemorrhage were the main central adrenal veins thrombosed. It has been suggested that central vein thrombosis in adrenal haemorrhage and necrosis is secondary to and not the cause of the parenchymal lesions (Crawford, 1951; Thrash and Iri, 1963). In cases 4 and 5 there seems little doubt that central vein thrombosis was the primary lesion. Apart from the suture material adjacent to the main vein, there were many patent central veins near the haemorrhage, and where there were thrombosed veins within the gland the

134 B. FOX

thrombi were obviously less well organised than those in the extra-adrenal vein. However, it has often been noticed that adrenal vein thrombosis may occur without any evidence of haemorrhage, suggesting that other factors are involved.

Dobbie and Symington (1966) pointed out an alternative venous drainage in the human adrenal gland via the emissary veins in the tail of the gland that drain into the external capsular veins (Gagnon, 1955-56). It is possible therefore that after thrombosis of the main adrenal vein blood may leave the gland through the alternative venous circulation, so that acute engorgement and consequent haemorrhage do not occur. Thus, the presence of thrombi in the external capsular veins in the present cases is significant, and explains the haemorrhage. I t is probable that in those cases of adrenal vein thrombosis in which there are no adrenal parenchymal lesions the capsular veins are patent. Hall and Hemken (1936), Keele and Keele (1942) and Botteri and Orell (1964) thought that thrombosis of the central adrenal vein was the main cause of haemorrhage, but did not mention that thrombosis of the external capsular veins was probably as significant as thrombosis of the central veins. In a personal study of 25 cases of adrenal haemorrhage found in association with different clinical conditions, thrombosis of the external capsular veins as well as thrombosis of the central veins occurred in 20 cases. Crawford examined 14 cases of adrenal haemorrhage and necrosis associated with pregnancy, found central vein thrombosis in only 3 and thought that it was an accom- paniment of the parenchymal lesions; in her cases the parenchymal lesions were confined to the cortex and in the one case in which there was massive haemorrhage the central vein was thrombosed. Unless large numbers of sections are examined, including the extra-adrenal vein, adrenal vein thrombosis may be missed. In cases 4 and 5 there were many sections in which there was gross haemorrhage and the central veins appeared patent though the extra- adrenal vein some distance from the gland was occluded by organised thrombus.

It has been suggested that adrenal haemorrhage is the result of cortical necrosis (Sheehan). It is of interest that in cases 4 and 5 the large areas of haemorrhage there were also associated with areas of ischaemic necrosis, in which there was no evidence of haemorrhage and which appeared to be unrelated to the central haemorrhage. It is also apparent from cases 1 and 3 that large areas of cortical necrosis can occur without any subsequent haemorrhage.

Margaretten, Nakai and Landing (1963) suggested that the generalised Shwartzman reaction plays a significant part in the causation of adrenal haemorrhage and necrosis. They were mainly concerned with the Waterhouse- Friderichsen syndrome in children, but they suggested that a similar mechanism explained the lesions occurring in adults. Although there is a considerable amount of experimental evidence to support this hypothesis (Gabbiani, Selye and Tuchweber, 1965; Levin and Cluff, 1965; Margaretten et al., 1965), in human cases great importance has been attached to the finding of fibrin thrombi in the adrenal sinusoids (Margaretten et al., 1963). It is possible that intra- sinusoidal fibrin thrombi may indicate a generalised Shwartzman reaction in the human adrenal, but it should be noted that in 4 of the present cases sinusoids within the necrotic areas contained fibrin thrombi that were almost certainly a consequence of occlusion of extra-adrenal arteries. In sections of the rest of the affected adrenal gland, the other adrenal gland, and all other tissues examined there was no evidence of fibrin thrombi. Fibrin thrombi in adrenal sinusoids should suggest a generalised Shwartzman reaction only if there is other substantiating evidence, such as renal cortical necrosis or fibrin thrombi in other sites (McKay, 1963).

One of the drawbacks in the experimental study of adrenal haemorrhage and necrosis is that the venous drainage in animals usually studied is entirely


different from that in man (Dobbie and Symington), though the arterial supply is fairly uniform (Harrison and Hoey, 1960). It is therefore important in assessing the role of venous occlusion in adrenal haemorrhage to study its occurrence in man, in whom the aetiology is often obscure or complex (Green- dyke, 1965). The 5 cases described in this paper have presented an unusual opportunity to assess the role of venous occlusion in human adrenal haemorrhage and necrosis due to a less complex cause.

SUMMARY

An investigation of 50 cases of adrenal haemorrhage and necrosis disclosed 5 cases in which unilateral lesions followed radical operations on the stomach. In 3 of the cases there was segmental necrosis; in the other 2 there was necrosis and massive haemorrhage. It is suggested that the blood supply to the left adrenal was damaged at the time of operation, that necrosis was due to involvement of adrenal arteries, and that haemorrhage was due to involvement of the main and external capsular adrenal veins.

The findings in these 5 cases are discussed in relation to adrenal haemorrhage and necrosis of more obscure aetiology.

I wish to thank Professor W. St. C. Symmers and Professor J. C. Sloper for encourage- ment and help with this work, and Mr A. C. Campbell for the photomicrographs.

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PLAT@ L a JANKUS

HETEROTOPIC CYST OF TONGUE

FIG. 1.-Part of the cyst showing mucosa with muscularis mucosae. Haematoxylin and eosin. x 28.

FIG. 2.-Mucosa showing mucus glands and muscularis mucosae. HE. x 115.

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Unilateral adrenal necrosis and haemorrhage following operations on the stomach