Objectives : To present a step by step approach for the diagnosis of adrenal

Objectives: To present a step by step approach for the diagnosis of adrenal incidentaloma (AI). Method: An extensive review of the literature was conducted, searching the Pub-Med and Google Scholar using the Mesh terms; Adrenal; Incidentaloma; Adrenal tumours; Radiology; Diagnosis. We also did a cross-referencing search of the literature. Comments on the new European guidelines are presented. Results: The majority of the tumours are non-functioning benign adenomas. The most important radiological characteristics of an adrenal incidentaloma is the radiation attenuation coefficient. Wash out percentage and the imaging characteristics of the tumour may help in diagnosis. Conclusion: Density less than 10 HU is characteristic of a lipid rich benign adenoma. More than 10 HU or/and history of malignancy raise the possibility for cancer. 1 mg dexamethasone test and plasma metanephrines should be done in all patients. If there is history of hypokalemia and/or resistant hypertension we test the plasma aldosterone to plasma renin ratio (ARR). Newer studies have shown that tumours even nonfunctioning and less than 4cm may increase the metabolic risks so we may consider surgery at an earlier stage.