A 15-year-old boy undergoes bilateral adrenalectomy for pheochromocytoma. On the third postoperative day, the boy feels lethargic and tired. Blood pressure is 80/60 mm Hg, there is no sign of bleeding. What could be the cause of this?

Explanation

## Correct Answer: C. Addisonian crisis Bilateral adrenalectomy removes both adrenal glands, eliminating all endogenous cortisol and catecholamine production. The adrenal cortex secretes glucocorticoids (cortisol), mineralocorticoids (aldosterone), and androgens; the medulla produces epinephrine and norepinephrine. On postoperative day 3, the patient develops acute hypotension (80/60 mm Hg), lethargy, and fatigue—classic signs of acute adrenal insufficiency or **Addisonian crisis**. The absence of bleeding rules out hemorrhagic shock. This is an iatrogenic acute adrenal crisis triggered by sudden loss of cortisol and catecholamine secretion. The patient requires immediate high-dose IV hydrocortisone (100 mg stat, then 50–100 mg every 6–8 hours) and fluid resuscitation with normal saline. Long-term replacement with glucocorticoids (prednisolone 5–7.5 mg daily) and mineralocorticoids (fludrocortisone 0.1 mg daily) is mandatory. In India, this is a well-recognized complication of bilateral adrenalectomy for pheochromocytoma, and perioperative steroid cover is standard practice to prevent this life-threatening emergency. ## Why the other options are wrong **A. Cerebral salt wasting disease** — Cerebral salt wasting (CSW) causes hyponatremia with volume depletion and occurs secondary to CNS pathology (head trauma, meningitis, subarachnoid hemorrhage). There is no CNS insult here. CSW presents with low sodium and low blood volume, but the clinical picture—acute hypotension without documented hyponatremia and no CNS trigger—does not fit. Addisonian crisis is far more likely after bilateral adrenalectomy. **B. SIADH** — SIADH (syndrome of inappropriate antidiuretic hormone) causes hyponatremia with volume expansion and elevated urine osmolality. It typically follows CNS or pulmonary pathology, not adrenal surgery. SIADH would present with water retention and hyponatremia, not acute hypotension and shock. The clinical picture of acute shock with lethargy on POD 3 after bilateral adrenalectomy is pathognomonic for Addisonian crisis, not SIADH. **D. Diabetes insipidus** — Diabetes insipidus (DI) results from deficiency of ADH (central DI) or renal resistance to ADH (nephrogenic DI). It causes polyuria, polydipsia, and hypernatremia, not hypotension or lethargy. DI does not follow bilateral adrenalectomy—the pituitary and hypothalamus are intact. The acute shock state with hypotension is inconsistent with DI, which presents with dehydration and high sodium, not hypovolemic shock. ## High-Yield Facts - **Bilateral adrenalectomy** removes all cortisol and catecholamine production, precipitating acute adrenal crisis if steroid cover is not given perioperatively. - **Addisonian crisis** presents with acute hypotension, lethargy, nausea, and shock within hours to days of adrenal gland loss or severe adrenal destruction. - **Immediate management**: IV hydrocortisone 100 mg stat, then 50–100 mg every 6–8 hours, plus normal saline fluid resuscitation. - **Long-term replacement** after bilateral adrenalectomy requires glucocorticoid (prednisolone 5–7.5 mg daily) and mineralocorticoid (fludrocortisone 0.1 mg daily) replacement for life. - **Perioperative steroid cover** is mandatory before and after bilateral adrenalectomy to prevent iatrogenic Addisonian crisis—standard practice in Indian surgical units. ## Mnemonics **CRASH for Addisonian Crisis** **C**ortisol loss, **R**apid onset, **A**cute hypotension, **S**hock state, **H**igh-dose hydrocortisone needed. Use when acute adrenal insufficiency is suspected after adrenal surgery or destruction. **POST-OP ADRENAL CRISIS** **P**ostoperative day 3, **O**rgan removed (adrenal), **S**hock/hypotension, **T**iredness/lethargy = think **A**ddisonian crisis, **D**o hydrocortisone, **R**esuscitate with saline, **E**lectrolytes check, **N**eed lifelong replacement, **A**lways cover perioperatively, **L**ong-term glucocorticoid + mineralocorticoid. ## NBE Trap NBE pairs acute hypotension after adrenal surgery with water-electrolyte disorders (SIADH, CSW, DI) to distract from the straightforward diagnosis of iatrogenic Addisonian crisis. Students who focus on sodium/osmolality abnormalities miss the core pathology: loss of adrenal hormone production. ## Clinical Pearl In Indian surgical practice, perioperative steroid cover (hydrocortisone 100 mg IV 6-hourly) is given before bilateral adrenalectomy and tapered postoperatively to prevent this life-threatening complication. Any patient presenting with acute shock and hypotension within 72 hours of bilateral adrenalectomy should be treated empirically with high-dose IV hydrocortisone while investigations are pending—delay is dangerous. _Reference: Harrison Ch. 375 (Adrenal Insufficiency); KD Tripathi Ch. 47 (Adrenocorticotropic Hormone & Adrenal Steroids); Bailey & Love Ch. 40 (Endocrine Surgery)_