Abstract
Adrenal cysts are uncommon and in most cases discovered accidentally during evaluation of non specific abdominal pain or autopsy. We present a case of 55 yr old female who presented with lump in abdomen. The surgical exploration revealed it to be unilateral haemorrhagic adrenal cyst of left side. This is being reported for the rare present as a palpable mass in abdomen, which could not be appropriately diagnosed on preoperative imaging.

Introduction
Adrenal gland cysts are rare entities.
Incidence of cystic lesions of adrenal gland is 0.06-0.18%.1 It can occur in all age groups with female predominance. Adrenal cyst is usually unilateral and is mostly seen on right side.²

Case Report
A 55 yr old female patient presented with dull aching pain in left flank of one week duration. There were no other associated symptoms. General examination revealed no abnormality. Per abdomen examination revealed a non tender lump in the left hypochondrium. Routine haemogram and biochemical investigations were normal. The Ultrasonography of abdomen revealed a large left cystic retroperitoneal mass 15 cm X 15 cm in size. MRI abdomen showed a large left sided well- defined and well- marginated retroperitoneal space occupying lesion, 14 cm X 12 cm in size, showing cystic as well as solid component with displacement of spleen laterally and the tail of pancreas antero-superiorly and the left kidney inferiorly. The patient was explored under general anaesthesia, via an upper abdominal roof top incision. A large cystic mass was found postero-inferior to the pancreas- adherent to the tail and the transverse mesocolon. Left adrenal gland was adherent to the cyst. The cyst was separated from surrounding structures. Adrenal vein was doubly ligated and the haemorrhagic cyst was removed along with the left adrenal gland. Histopathology confirmed the diagnosis of haemorrhagic cyst of the adrenal. Post operatively patient recovered well with no adrenal insufficiency.

Fig. 1 : MRI abdomen showing large well defined and well marginated mixed signal intensity Retroperitoneal space occupying lesion measuring 14 cm X 2 cm in the left half of upper mid abdomen.

Discussion
Adrenal cysts are uncommon finding and usually asymptomatic. Rarely large cysts cause displacement and compression of adjacent organ. Seldom cause adrenal hypo function, Cushing syndrome or phaeochromocytoma.4 Incidence of cystic lesions of adrenal gland is 0.06-0.18% out of this the incidence of haemorrhagic cyst is 39 %.4,5 As most lesions are small and asymptomatic, true incidence of adrenal cyst is not known. Yet commonly seen in female in 3rd to 4th decade.²
The adrenal cysts are either neoplastic or non neoplastic. The non neoplastic category includes endothelial (45%), haemorrhagic (39%), epithelial (9%) and parasitic (7%).^5,10 The haemorrhagic category includes traumatic and nontraumatic. Nontraumatic haemorrhage of the adrenal gland is uncommon.6 Nontraumatic haemorrhage of the adrenal gland is uncommon.⁶ The causes of such haemorrhage can be classified into sub categories: (a) stress, (b) haemorrhagic diathesis or coagulopathy, (c) neonatal stress, and (d) idiopathic.⁸
Diagnosis is generally suggested on imaging techniques like USG/CT/ MRI. But in large cyst it may not be possible to identify adrenals as the origin of cyst and malignant nature can not be excluded just on the imaging findings.

Treatment
Treatment is determined by the size and symptoms related to the mass. Conservative management is appropriate for the newborns with adrenal haemorrhage and resulting pseudo cyst formation. Spontaneous resolution of pseudo cyst in newborns usually occurs by 6 weeks.4 Percutaneous aspiration or drainage of accessible cysts reduces the morbidity associated with surgical intervention.3 Surgical excision is done for- large and complicated cyst, parasitic, functioning and malignant cysts. Recent trends includes laparoscopic management. Laparoscopic decortications and marsupialization can be the preferred treatment option for symptomatic adrenal cysts. Laparoscopic partial adrenalectomy or a total adrenalectomy can be performed in cases of large cyst which compromise most of the adrenal gland.⁹

References

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