Adrenal tumor bleeding versus ruptured abdominal aortic aneurysm: a diagnostic dilemma in retroperitoneal hemorrhage

BACKGROUND: Retroperitoneal hemorrhage is a life-threatening entity that can result from a range of etiologies. Rupture of an abdominal aortic aneurysm (AAA) is the most common vascular emergency associated with high morbidity and mortality. However, not all retroperitoneal hemorrhages result from this vascular emergency. Adrenal hemorrhage, though rare, represents an important, often under-recognized and potentially fatal alternative diagnosis. The diagnostic challenge is further compounded when such adrenal pathology occurs in the presence of a concurrent AAA, as overlapping clinical and radiologic features can obscure the true source of bleeding. This coexistence can lead to misdiagnosis, delays in appropriate treatment, and complex decision-making in the acute care setting. CASE REPORT: A man in his 70s presented with hemodynamic collapse and right-sided flank pain, initially raising concern for a ruptured abdominal aortic aneurysm (AAA). Imaging revealed both an infrarenal AAA and a large retroperitoneal mass consistent with a hemorrhaging adrenal lesion. Due to diagnostic uncertainty and persistent hemodynamic instability, the patient underwent emergency endovascular aortic repair (EVAR) followed by selective arterial embolization of the adrenal lesion. Postoperative recovery was favorable, with resolution of hemodynamic instability and planned delayed adrenalectomy. CONCLUSION: high-resolution imaging and a flexible interventional approach tailored to the evolving clinical picture are key to successful management. Clinicians should remain vigilant for alternative bleeding sources, even in the context of known vascular disease.