MON-493 Acute Abdominal Pain due to Spontaneous Hemorrhage in a Small Adrenal Myelolipoma

Abstract Disclosure: W.J. Santiago Colberg: None. M.J. Kanwal: None. C. Lovato: None. Adrenal myelolipomas are benign tumors comprised of adipose tissue and hematopoietic cells. They are often discovered incidentally during imaging for unrelated conditions, and most remain asymptomatic without significant growth over time. Hemorrhage is a rare, but severe complication, usually occurring in large lesions exceeding 8-10 cm. Hormonal excess is rare in patients with myelolipomas and is typically associated with adrenocortical hyperplasia or a concomitant adrenal adenoma. Management varies; small tumors often require no intervention, while larger lesions may require adrenalectomy, if causing mass effect or complicated by hemorrhage. The patient is a 42-year-old American Indian male with a history of alcohol abuse and class I obesity who presented to the emergency department with a one-day history of acute and severe right-sided abdominal pain. The patient also endorsed having nausea and vomiting. The patient’s blood pressure was 148/98 mmHg and heart rate 113 bpm on presentation. Physical exam was notable for right upper quadrant tenderness on palpation but no rebound tenderness. The patient did not have any Cushingnoid features. CT abdomen and pelvis without contrast revealed a right adrenal myelolipoma measuring 4.6 x 4.2 x 4.7 cm, with evidence of moderate hemorrhage within the lesion and extension into the adrenal gland, as well as a small amount of hemorrhage surrounding the right retroperitoneal space. Emergency general surgery as well as interventional radiology were consulted for possible surgical intervention or embolization with recommendation for repeat imaging. Repeat CT abdomen and pelvis with contrast 4 hours after presentation showed no sign of active extravasation and the patient had stable hemoglobin and hematocrit levels. Given this, the patient was managed conservatively. Endocrinology was consulted to evaluate the need for hormonal evaluation. Random serum cortisol was 11.9 ug/dL (n 6-18.4 ug/dL) with repeat morning cortisol that was borderline at 5.5 ug/dL and ACTH of 23 pg/mL (n 7-63 pg/mL). Potassium levels were normal. Vital signs remained stable, and the patient did not have any signs or symptoms of adrenal insufficiency. On outpatient follow up with endocrinology, the patient was pain-free and normotensive. Cosyntropin stimulation test showed an appropriate rise in serum cortisol. Repeat imaging 6 months after presentation showed a 2.9 x 2.8 x 2.2 cm right adrenal myelolipoma with interval resolution of the previously noted hemorrhage. This is a rare case of a patient presenting with acute abdominal pain due to spontaneous hemorrhage of a small right adrenal myelolipoma. He had a transient decrease in serum cortisol, which may have been due to mild autonomous cortisol secretion that was previously unrecognized. This case highlights the need for close follow up and hormonal evaluation in select cases. Presentation: Monday, July 14, 2025