Rectus Sheath Hematoma: A Series of Unfortunate Events

Clinical and radiological risk factors for poor outcomes in patients with spontaneous muscle hematomas

PURPOSE

Spontaneous muscle hematomas (SMH) are frequently seen in the Emergency Department (ED), particularly as a complication of anticoagulation treatments. To date, there are no standard guidelines for the management of this condition in the ED. This work aims to identify clinical-radiological parameters of SMH at risk of poor outcomes.

METHOD

This is a retrospective, observational cohort study conducted in an urban teaching hospital from 2016 to 2019. A multivariate logistic regression analysis was performed to identify parameters independently associated with an adverse outcome defined as the need for treatment (blood products, TAE, surgery) or hospitalization. The parameters analyzed were hematoma size, anticoagulation therapy, age, and the Charlson Comorbidity Index (CCI). ROC analysis was performed to identify the best cut-off hematoma size value to predict poor outcomes.

RESULTS

Our study enrolled 231 patients aged between 18 and 96 years, with a mean age of 67 years. In our population, 125 patients (54.1 % %) were on anticoagulant therapy. Multivariate analysis showed that an SMH diameter > 5.5 cm was independently associated with poor outcome ((odds Ratio [95 % CI] 4,009 [1,786-9,001], p 0.001). Among clinical parameters, only advanced age was proved to be an independent predictor of adverse outcomes (odds Ratio [95 % CI] 1,035 [1,003-1,069], p = 0.033) CONCLUSIONS: Our data suggest that an SMH diameter greater than 5.5 cm on a CT scan and advanced age are predictors of poor outcomes. Surprisingly, anticoagulant therapy seems to play a minor role in the outcome of SMHs.

Trauma in the elderly: a bilateral rectus sheath haematoma

Life expectancy has more than doubled in the last century, and a new cohort of elderly and increasingly frail patients is presenting to emergency departments with new clinical challenges. When this patient cohort presents after injury, all aspects of clinical practice have to be recalibrated to provide safe and appropriate care. The prevalence of chronic disease, levels of organ failure, multiple comorbidities, greater use of anticoagulation and incidence of recurrent low- and high-impact trauma may delay and obscure diagnosis and, ultimately, increase mortality.Older age is a risk factor for rectus sheath haematoma (RSH), which is haemorrhage into the potential space surrounding the rectus abdominis muscle/s. It is a rare presentation following trauma but can provide diagnostic challenges and be fatal. Even more rare is bilateral RSH with only 12 reported in the literature since 1981.This case report describes bilateral RSH presenting in an elderly woman following a fall and the consequences of seemingly minor trauma in the elderly.

A rare cough complication: Internal oblique muscle hematoma

Cough-related hematomas occur most frequently in the rectus sheath and retroperitoneum while lateral abdominal wall hematomas are rarely reported. Intramuscular hematoma might be mistaken for tumors and acute inflammatory diseases of the abdomen. A definite diagnosis is made with computerized tomography. In the case presented in this study, a 78-year-old female patient who had cough and shortness of breath for 1 week applied to the outpatient clinic with complaints of ecchymosis on the left side of the abdomen accompanied by swelling and pain under the left rib. The International Normalized Ratio of the patient, who used Warfarin sodium 5mg / day for mitral valve replacement, was in the effective range (INR: 2.4). Superficial ultrasound revealed a heterogeneous lesion with a well-circumscribed, hypoechoic and locally cystic component in the lateral abdominal wall in the left subcostal area. On computerized tomography, the lesion in the left internal oblique muscle of 27 × 60 mm, heterogeneous density, and with smooth borders was classified as Type 2 hematoma. Hemodynamics of the patient were stable and did not exceed INR 3 in follow-up, and there was no decrease in hemoglobin values. The patient's ecchymosis disappeared on the fifth day, and control ultrasonography showed the hematoma was partially resorbed. The aim of this study is to emphasize that conservative methods should be applied and surgery should be avoided as much as possible in internal oblique muscle hematoma.

Don't Forget the Abdominal Wall: Imaging Spectrum of Abdominal Wall Injuries after Nonpenetrating Trauma

Abdominal wall injuries occur in nearly one of 10 patients coming to the emergency department after nonpenetrating trauma. Injuries range from minor, such as abdominal wall contusion, to severe, such as abdominal wall rupture with evisceration of abdominal contents. Examples of specific injuries that can be detected at cross-sectional imaging include abdominal muscle strain, tear, or hematoma, including rectus sheath hematoma (RSH); traumatic abdominal wall hernia (TAWH); and Morel-Lavallée lesion (MLL) (closed degloving injury). These injuries are often overlooked clinically because of (a) a lack of findings at physical examination or (b) distraction by more-severe associated injuries. However, these injuries are important to detect because they are highly associated with potentially grave visceral and vascular injuries, such as aortic injury, and because their detection can lead to the diagnosis of these more clinically important grave traumatic injuries. Failure to make a timely diagnosis can result in delayed complications, such as bowel hernia with potential for obstruction or strangulation, or misdiagnosis of an abdominal wall neoplasm. Groin injuries, such as athletic pubalgia, and inferior costochondral injuries should also be considered in patients with abdominal pain after nonpenetrating trauma, because these conditions may manifest with referred abdominal pain and are often included within the field of view at cross-sectional abdominal imaging. Radiologists must recognize and report acute abdominal wall injuries and their associated intra-abdominal pathologic conditions to allow appropriate and timely treatment. ^© RSNA, 2017.

Does IV contrast extravasation on CT in anticoagulant-related rectus sheath and iliopsoas hematoma predict hematoma expansion and patient outcomes?

OBJECTIVE

The purpose of the study was to evaluate if IV contrast extravasation on CT in anticoagulant-related rectus sheath and iliopsoas hematoma predict hematoma expansion and patient outcomes.

MATERIALS AND METHODS

All patients presented with anticoagulation-related spontaneous IP hematoma or RS hematoma and who underwent contrast-enhanced CT exploration, with injection of a contrast material, from January 2012 to January 2015 in our institution were included in this study. Considering the retrospective nature of our study, our institutional review board judged our study to be exempted from ethical approval and no patient consent was required. Computed tomography (CT) images were retrospectively analyzed blindly of the evolution and treatment of hematomas. The type of muscle involved; the presence of contrast extravasation after contrast injection; the volume of the hematoma, as well as, clinical and biological results (hemoglobin value g/dL); and for each patient, the type of anticoagulation used, patient's treatment and outcomes were noted. The analyses were conducted using R 3.1.0. All statistical tests were 2-sided, and probability values <0.05 were regarded as significant.

RESULTS

Sixty-eight patients were reviewed. Among 68 patients, 44 (65%) patients presented spontaneous IP hematoma and 24/68 (35%) a RS hematoma. There were 37 men (54%) and 31 (46%) women, ranging from 39 to 93 years with a median age of 75 years. Hemodynamic instability was statistically associated with IP hematomas and large volume of hematoma (p < 0.001). Only 15 patients had follow-up CT, 10 without and with IV contrast, 2 with IV contrast only, and 3 without contrast. Follow-up CT was performed from J0 to J8. Detection of contrast extravasation did not appear related to hemodynamically instability (p = 0.35), to a neurological deficit (p = 1), or to the increase in the volume of the hematoma on follow-up CT (p = 0.81). The different types of anticoagulant were not related to muscular type more than the other (p = 0.9). Among anticoagulant therapy, only vitamin K antagonist therapy was statistically associated with surgery (p = 0.04).

CONCLUSION

CT extravasation of contrast material in IP and RS hematoma does not appear to be related with clinical criteria of severity, and therefore should not be solely considered as a radiological decision criteria.

Spontaneous haematoma of the anterior rectus abdominis muscle

INTRODUCTION

Spontaneous haematoma of the rectus abdominis muscle is an uncommon cause of abdominal pain. It occurs mostly in anticoagulated patients. The objective of this paper is to analyse the onset, diagnosis and treatment in patients under anticoagulant therapy.

METHODS

A retrospective analysis of a prospectively maintained database of all patients with a diagnosis of spontaneous hematoma of the abdominal rectus muscle between March 2003 and December 2014.

RESULTS

The study included 34 patients, of whom 28 were women, with an average age of 80 years old. All the patients showed a unilateral infraumbilical haematoma. Twenty- 8 patients had received long-term anticoagulant treatment (26 with acenocumarol and 2 low molecular weight heparin); and 6 patients were under anticoagulant prophylaxis with low molecular weight heparin. The diagnosis was performed with ultrasound in 7 cases, computed tomography angiography in 27 patients, and with both methods in 6 cases. The treatment consisted of stopping the anticoagulant drug, correcting haemostasis parameters and blood transfusion when required. Ten patients displayed active bleeding in the computed tomography angiography, and 8 underwent selective arterial embolization. The evolution was successful in 34 patients, however, 2 patients required surgery and, finally, died due to persistent haemorrhage.

CONCLUSION

Spontaneous haematoma of the rectus abdominis muscle is more frequent in elderly women under oral anticoagulant treatment. Non-operative treatment is successful in most cases. Computed tomography angiography is useful to determine which patients could benefit from selective arterial embolization.

Spontaneous intraperitoneal rupture of a postpartum rectus sheath haematoma

A 35-year-old woman presented to the emergency department (ED) with acute severe abdominal pain at 4 days postpartum. CT of the abdomen revealed a type II rectus sheath haematoma for which she was initially treated conservatively and discharged. A few hours later, she returned to the ED with a picture suggestive of peritonitis. Exploratory laparoscopy was performed and revealed haemoperitoneum and a ruptured area on the posterior rectus sheath. Approximately 2 L of blood was aspirated. Haemostatic control was achieved and closed suction drains secured in position. The patient was discharged in stable condition on postadmission day 6. She continued to follow-up on an outpatient basis and was doing well 3 months postoperatively.

Abdominal Wall Hematoma as a Rare Complication following Percutaneous Coronary Intervention

Abdominal wall hematoma is a rare but potentially serious vascular complication that may develop after coronary angiographic procedures. In particular, an oblique muscle hematoma caused by an injury of the circumflex iliac artery is very rare, yet can be managed by conservative treatment including hydration and transfusion. However, when active bleeding continues, angiographic embolization or surgery might be needed. In this study, we report an uncommon case of injury to the circumflex iliac artery by an inappropriate introduction of the hydrophilic guidewire during the performance of a percutaneous coronary intervention.

Rectus sheath hematoma in a single secondary care institution: a retrospective study

PURPOSE

Rectus sheath hematoma (RSH) represents an unusual abdominal wall pathology, frequently confounded as acute abdomen, with high mortality rates reported especially among elderly patients. The purpose of this retrospective study was to delineate characteristics of the patients diagnosed with RSH at the First Surgery Department of the Saint George General Hospital of Chania, Greece over a 5-year period.

METHODS

Seven patients with a median age of 62 years (range 51–85) were included in the study. Clinical features, demographics, management and outcome are summarized.

RESULTS

The most common predisposing risk factor was anticoagulation. Acute onset abdominal pain and painful palpable abdominal mass, located more often on the right lower abdominal quadrant, were the most frequent initial symptoms. Management was mostly conservative [6 (85.7 %)] with disruption of anticoagulation, analgesia and bed rest. Blood transfusion was performed in hemodynamic compromised patients [2 (28.5 %)]. One patient was not appropriately diagnosed. On admission, the patient presented severe hemodynamic compromise and for this reason underwent emergency explorative laparotomy. The majority of the patients [6 (85.7 %)] experienced an uncomplicated clinical recovery and were discharged home after a mean hospital stay of 10 days (range 7–12).

CONCLUSIONS

Surgeons as well as primary care physicians have to be aware of the clinical diagnostic tests and include the condition in the differential diagnosis of acute onset abdominal pain. Prompt recognition will prevent unnecessary surgical intervention and potential complications.

Muscle haematoma due to antithrombotic treatment for ischaemic stroke

The purpose of this study was to evaluate the incidence and clinical features of muscle haematoma in ischaemic stroke patients. Muscle haematomas are rare complications that occur during antithrombotic treatment for acute ischaemic stroke. Clinical and laboratory records of ischaemic stroke patients with muscle haematomas in the last 3.5 years were retrospectively reviewed. Muscular haematoma developed in three of 694 (0.4%) consecutive patients with acute ischaemic stroke who were admitted to our institution. In addition, one outpatient presenting with muscle haematoma was found during the same period. The types of haematomas were rectus sheath haematoma in two patients and iliopsoas haematoma in the remaining two. All three acute patients received both antiplatelet and anticoagulant therapies. The outpatient was treated with warfarin. Initial symptoms of haematoma included pain (n = 3) and syncope (n = 1). No patient was correctly diagnosed at the onset of muscle haematoma. At initial examination of muscle haematoma, no patients showed skin lesions. An ecchymosis developed in the abdominal area at an average of 3 days after the initial symptoms. Mean decrease in haemoglobin was 6.8 g/dL from baseline. None required surgery whereas two patients required blood transfusion. Muscle haematomas in stroke patients receiving antithrombotic therapy are rare complications that are difficult to diagnose at onset. The possibility of muscle haematoma should be considered in patients with ischaemic stroke undergoing antithrombotic therapy and presenting with acute pain and syncope, even if skin manifestations or a palpable mass are lacking.

Dengue Fever with rectus sheath hematoma: a case report

Dengue fever, also known as breakbone fever, is an infectious tropical disease caused by the Dengue virus. It is associated with a number of complications, which are well documented. However, Dengue fever associated with rectus sheath hematoma (RSH) is a very rare complication. Only one case report has been published prior supporting the association of Dengue fever with RSH. We report a case of Dengue fever who presented with RSH and was successfully treated conservatively. RSH is also an uncommon cause of acute abdominal pain. It is accumulation of blood in the sheath of the rectus abdominis, secondary to rupture of an epigastric vessel or muscle tear.

Spontaneous rectus sheath hematoma in the elderly: an unusual case and update on proper management

Spontaneous rectus sheath hematoma (SRSH) is an uncommon medical emergency in the elderly. We present a case of SRSH with an atypical clinical presentation and discuss literature regarding diagnosis and proper management. A 75-year-old female patient was transferred to the emergency department due to acute dyspnoea and confusion. Her medical history revealed a viral infection of the upper respiratory tract, and no coughing or use of anticoagulants. The clinical examination showed tenderness of the left lower abdomen, although palpation was misleading due to patient's obesity. Laboratory investigations showed light anaemia. Ultrasonography and computed tomography revealed a large rectus sheath hematoma of the left abdominal wall. Despite further deterioration of the patient, conservative management including bed rest, fluid replacement, blood products transfusion, and proper analgesia was successful. No surgical intervention was needed. Prompt diagnosis and management of SRSH plays significant role in the prognosis, especially in elder patients. Independently of size and severity, conservative management remains the first therapeutic choice. Only by failure of supportive management, progressive and large hematoma or uncontrollable hemodynamic patients, interventional management including surgery or less invasive newer techniques is indicated.

Management of patients with rectus sheath hematoma: Personal experience

BACKGROUND/PURPOSE

Rectus sheath hematoma (RSH) is a rare clinical entity. It can be mistaken for other intra-abdominal disorders, which can result in diagnostic and therapeutic difficulties. This study was undertaken to analyze the clinical presentation, diagnostic modalities, and management of patients affected with RSH.

METHODS

Between January 2008 and June 2011, eight patients (5 men and 3 women with a mean age of 53 years) with RSH were evaluated according to demographic characteristics, clinical and radiological findings, and methods of treatment.

RESULTS

Six patients developed RSH after anticoagulant therapy; one after local trauma, and one after laparoscopic intervention. Six patients were treated nonsurgically; one patient underwent embolization of the inferior epigastric artery and one underwent ligation of the bleeding vessel. The average hospital stay was 6 days. There were no mortality or thromboembolic complications.

CONCLUSION

RSH is a rare nonneoplastic entity that is usually associated with abdominal trauma and/or anticoagulant therapy. The gold standard for diagnosis is computed tomography, and ultrasonography can be used in follow-up. The treatment of choice is nonsurgical therapy because RSH is a self-limited condition. Surgical intervention should be reserved for cases with hemodynamic instability.

Spontaneous rectus sheath hematoma diagnosed by point-of-care ultrasonography

Spontaneous rectus sheath hematoma is an uncommon condition that can mimic other conditions associated with an acute abdomen. We report the case of a patient with a spontaneous rectus sheath hematoma due to a ruptured inferior epigastric artery pseudoaneurysm who presented with hypotension and severe abdominal pain and was diagnosed using emergency department point-of-care ultrasonography. Point-of-care ultrasonography has been increasingly used in the evaluation of emergency department patients with acute abdomen and hypotension to expedite the diagnosis and management of aortic aneurysm and intraperitoneal bleeding. Resuscitation and urgent surgical and interventional radiology consultations resulted in the successful embolization of a branch of the inferior epigastric artery and a good outcome.

An oblique muscle hematoma as a rare cause of severe abdominal pain: a case report

Background

Abdominal wall hematomas are an uncommon cause of acute abdominal pain and are often misdiagnosed. They are more common in elderly individuals, particularly in those under anticoagulant therapy. Most abdominal wall hematomas occur in the rectus sheath, and hematomas within the oblique muscle are very rare and are poorly described in the literature. Here we report the case of an oblique muscle hematoma in a middle-aged patient who was not under anticoagulant therapy.

Case presentation

A 42-year-old Japanese man presented with a painful, enlarging, lateral abdominal wall mass, which appeared after playing baseball. Abdominal computed tomography and ultrasonography showed a large soft tissue mass located in the patient’s left internal oblique muscle. A diagnosis of a lateral oblique muscle hematoma was made and the patient was treated conservatively.

Conclusion

Physicians should consider an oblique muscle hematoma during the initial differential diagnosis of pain in the lateral abdominal wall even in the absence of anticoagulant therapy or trauma.

Correct the Coagulopathy and Scoop It Out: Complete Reversal of Anuric Renal Failure through the Operative Decompression of Extraperitoneal Hematoma-Induced Abdominal Compartment Syndrome

We report two cases of extraperitoneal compression of the intra-abdominal space resulting in abdominal compartment syndrome (ACS) with overt renal failure, which responded to operative decompression of the extra-peritoneal spaces. This discussion includes patient presentation, clinical course, diagnosis, interventions, and outcomes. Data was collected from the patient's electronic medical record and a radiology database. ACS appears to be a rare but completely reversible complication of both retroperitoneal hematoma (RH) and rectus sheath hematoma (RSH). In patients with large RH or RSH consideration of intra-abdominal pressure (IAP) monitoring combined with aggressive operative drainage after correction of the coagulopathy should be considered. These two cases illustrate how a relatively benign pathology can result in increased IAP, organ failure, and ultimately ACS. Intervention with decompressive laparotomy and evacuation of clot resulted in return to normal physiologic function.

Abdominal compartment syndrome--a fatal complication from a rectus sheath haematoma

Rectus sheath haematoma is increasingly being seen in patients with anticoagulation therapy. Abdominal compartment syndrome is a rare complication of rectus sheath haematoma with only two cases reported in literature. The authors report a case of a young male who developed abdominal compartment syndrome from a rectus sheath haematoma secondary to anticoagulation therapy. The case highlights the need for a surgical intervention in such exceptional cases.

Rectus sheath haematoma: are there prognostic risk factors of haemodynamic instability motivating an early operative treatment?

PURPOSE

Rectus sheath haematoma (RSH) is an uncommon condition caused by lesion of the superior or inferior epigastric arteries or their branches or by rupture of the rectus muscle. Treatment is usually supportive; however, if haemodynamic compromise develops, intravascular embolisation or surgery may be required. Furthermore, in some cases, bleeding may be so conspicuous that it can determine the patient's death before an adequate treatment is performed. We performed a retrospective study on 78 consecutive patients with the diagnosis of RSH admitted to the General Surgery Unit of our hospital between January 2000 and December 2010 in order to identify possible prognostic risk factors that could affect the operational approach before the onset of haemodynamic instability.

METHODS

Demographic characteristics, patient history, laboratory and diagnostic imaging examinations were investigated. The variables considered were: gender, age, anti-coagulation or anti-platelet therapy, trauma, international normalised ratio (INR) and bleeding time in the first 72 h of observation and concomitant diseases. The data were used for statistical analysis.

RESULTS

Sixty patients received a conservative treatment, while 18 underwent operative treatment for haemodynamic instability (embolisation in 2 patients and surgery in 16 patients). Three of these 18 patients (17 %) died for consumption coagulopathy after surgery. None of the variables included in the univariate statistical analysis was significant (p = ns).

CONCLUSION

Ultrasonography or computed tomography are the most common methods used to establish the diagnosis of RSH, so it is no longer a diagnostic dilemma. Most patients can be treated conservatively and an operative treatment is justified only in case of haemodynamic instability. Our retrospective study could not identify any prognostic risk factor of haemodynamic instability in RSH. We believe that only a close observation of the patients with RSH and "common sense" can prevent a possible fatal outcome.

Transcatheter arterial embolization of spontaneous life-threatening extraperitoneal hemorrhage

PURPOSE

To determine the outcomes of patients with spontaneous extraperitoneal hemorrhage (SEH) referred for endovascular therapy.

MATERIALS AND METHODS

A retrospective analysis included 25 patients (13 male) with 28 spontaneous bleeding events that occurred during the period 1998-2009. All patients had a computed tomography (CT) scan showing extraperitoneal hematoma before angiography. Hematoma location, presence of contrast extravasation or hematocrit level on CT, angiographic findings, vessels that received embolization, angiographic outcome, transfusion requirements, and mortality were recorded. Patients' medications, lowest measured hemoglobin levels, serologic coagulation parameters, and comorbidities were also noted. Mean follow-up was 37.4 months (range 2-132 mo).

RESULTS

Patients had received anticoagulation therapy before 20 of 28 bleeding events. Angiography showed contrast extravasation in 22 (79%) of 28 cases. Angiographic cessation of bleeding with embolization was achieved in all 22 cases. There was extravasation from more than one site in 17 (61%) of 28 cases. There was bleeding in more than one vascular territory in eight (29%) cases. Empiric embolization was performed in three cases. In the 48 hours following angiography, transfusion requirements decreased in 27 (96%) of 28 cases, and there were no deaths. All-cause mortality at 30 days was 29%, at 90 days was 32%, and at 12 months was 43%.

CONCLUSIONS

Multiple bleeding sites are typical in SEH. Transcatheter embolization is a safe and effective treatment; however, mortality is high in the time around angiography.

Rectus sheath hematoma: a simplified emergency surgical approach

Rectus sheath hematoma (RSH) is an uncommon clinical event usually associated with trauma or coagulation disorders. It can also occur spontaneously. RSH usually runs a benign course but it can present with hypovolemic shock. When conservative management fails, surgical exploration becomes mandatory. We propose a technique of emergency ligation of the inferior epigastric artery. This is a simple approach as this artery originates at the posterior rectus sheath above the inguinal ligament. This safe technique provides immediate hemodynamic stabilization.

Rectus Sheath Haematoma: A Rare Cause of Abdominal Pain

Objective

Rectus sheath haematoma (RSH) is a rare entity described as accumulation of blood within the rectus muscle. Patients can present with varying symptoms and signs, mimicking acute abdominal conditions. Failure to diagnose can result in unnecessary diagnostic procedures and surgical interventions.

Methods

We presented a series of 14 cases of RSH presenting to two emergency departments (ED) within a period of 3 years. Their demographic characteristics, medical history, presenting signs, symptoms and treatment were analyzed.

Results

Fourteen cases were diagnosed RSH. Seven cases were on warfarin treatment. Three RSH cases were diagnosed by ultrasonography (USG) only while the remainders had additional computed tomography (CT). Two cases had surgery due to haemoperitoneum, and the rest were treated conservatively with bed rest, analgesics and reversal of anticoagulation therapy. All patients were discharged from hospitals.

Conclusions

RSH is an important entity which must be considered in patients with known risk factors presenting to ED with abdominal pain. In elderly patients with a history of cough, anticoagulant use with palpable mass on abdominal wall, RSH must be considered as a possible diagnosis for unexplained abdominal pain. USG, together with CT in selected cases, should be performed to reveal this rare disease entity.

Diagnostic evaluation and management of patients with rectus sheath hematoma. A retrospective study

INTRODUCTION

Rectus sheath hematoma (RSH) is an uncommon cause of acute abdominal pain. It may mimic a wide variety of intraabdominal disorders thus frequently leading to delay in treatment, increased morbidity or even in an unnecessary surgery.

PATIENTS AND METHODS

This is a retrospective study of 10 patients with RSH who were treated in our department over a five-year period. There were 6 (60%) men and 4 (40%) women ranging in age from 38 to 86 years, with a mean age of 57.1 years.

RESULTS

The most common clinical presentation was a palpable abdominal mass associated with abdominal pain. Computed tomography (CT) established the diagnosis in 100% of the cases. 4 patients had type I hematoma, 3 had type II hematoma and 3 had type III hematoma. Anticoagulation therapy was the most common predisposing factor. Conservative treatment was effective in 90% of the cases and in all cases of spontaneous RSHs in patients under anticoagulation therapy. One patient, who developed a very severe RSH following an abdominal injection of low-molecular-weight heparin (LMWH), underwent surgery. All patients with type III hematoma required blood transfusion.

CONCLUSIONS

RSH should be considered in the differential diagnosis of the elderly patients under anticoagulation therapy presenting with acute abdominal pain and a palpable mass. CT is the diagnostic modality of choice. Conservative treatment is feasible in most cases. Early diagnosis is mandatory in order to avoid morbidity or unnecessary surgery. In order to prevent a traumatic RSH, trocar insertion under direct vision during laparoscopic surgery and careful attention in the abdominal administration of LMWH are essential.

Rectus sheath hematoma

Abstract

Rectus sheath hematoma (RSH) is a known complication of anticoagulation therapy and a source of potential morbidity and mortality. Early diagnosis and appropriate treatment may help to prevent complications including hemodynamic instability, the abdominal compartment syndrome or multiorgan dysfunction. Although the diagnosis can be made clinically, it can be confirmed with computed tomography of the abdomen. Most patients can be managed conservatively; however, it is often necessary to suspend anticoagulation in the acute setting. Rectus sheath hematoma is not a contraindication to resuming anticoagulation once the hematoma has been adequately managed and the patient has returned to a stable clinical baseline.

Rectus sheath hematoma: three case reports

Introduction

Rectus sheath hematoma is an uncommon cause of acute abdominal pain. It is an accumulation of blood in the sheath of the rectus abdominis, secondary to rupture of an epigastric vessel or muscle tear. It could occur spontaneously or after trauma. They are usually located infraumblically and often misdiagnosed as acute abdomen, inflammatory diseases or tumours of the abdomen.

Case presentation

We reported three cases of rectus sheath hematoma presenting with a mass in the abdomen and diagnosed by computerized tomography. The patients recovered uneventfully after bed rest, intravenous fluid replacement, blood transfusion and analgesic treatment.

Conclusion

Rectus sheath hematoma is a rarely seen pathology often misdiagnosed as acute abdomen that may lead to unnecessary laparotomies. Computerized tomography must be chosen for definitive diagnosis since ultrasonography is subject to error due to misinterpretation of the images. Main therapy is conservative management.