Images in cardiovascular medicine. Bilateral rectus sheath hematoma developing during anticoagulant therapy

Rectus Sheath Hematoma as a Complication in Patients With COVID-19: Clinical and Imaging Findings

Objectives This study aims to investigate the frequency of rectus sheath hematoma (RSH), clinical findings, imaging findings, and prognosis in patients admitted to the hospital due to COVID-19. Methods In this retrospective study, the patient's demographic characteristics, known diseases, laboratory values, RSH-related symptoms, the treatment they received, imaging modality used to diagnose RSH, and side and size of RSH were recorded. In addition, the inpatient ward to which the patients were admitted, length of hospital stay, time from the beginning of anticoagulant use to the diagnosis of RSH, and prognosis were noted. Results A total of 9,876 patients were admitted to the hospital due to COVID-19 and started anticoagulant treatment. Of these patients, 12 (0.12%) were determined to have RSH (female/male ratio: 5). The prothrombin time, activated partial thromboplastin time, international normalized ratio, hemoglobin, and hematocrit values ​​of 11 patients were within the reference ranges. The mean length of hospital stay was 12 (4.25-22.5) days, and the duration of anticoagulant use was 5.5 (4-10.75) days. RSH was diagnosed using USG in 10 patients and CT in two patients. Conclusion There has been an increase in the use of anticoagulants due to COVID-19, and accordingly, RSH is now more frequently diagnosed and has a more fatal course. Female gender, advanced age, severe COVID-19 disease, and elevated d-dimer at the time of presentation can be considered risk factors for the development of RSH. All physicians who treat and follow up on patients with COVID-19 should consider the possibility of RSH in the differential diagnosis of patients with acute abdominal pain and palpable masses. USG should be undertaken as the first-line imaging modality for the diagnosis of patients, but CT may also be necessary to detect RSH in some cases.

Non-traumatic bilateral rectus sheath hematoma during septic disseminated intravascular coagulation

A non-traumatic abdominal wall hematoma is rare, and occurs occasionally due to coughing, physical activity, or antithrombotic/anticoagulant therapy. The condition is usually unilateral; however, rare bilateral cases have been reported. Here, we report a rare case of a non-traumatic bilateral rectus sheath hematoma. The patient was a 60-year-old woman who was urgently admitted to our hospital due to the occurrence of pneumonia during postoperative chemotherapy for breast cancer. Because she exhibited disseminated intravascular coagulation, a therapy with antibacterial agents, thrombomodulin alpha, and catecholamines was initiated. During hospitalization, hemorrhagic shock due to hematomas in both rectus abdominis muscles was observed without any discernible cause. Subsequent emergency angioembolization was successful, and abdominal computed tomography performed 3 months after the onset of the rectus sheath hematoma confirmed a reduction in the hematoma size.

Spontaneous Rectus Sheath Hematoma: An Uncommon Cause of Acute Abdominal Pain

BACKGROUND A clinical condition that is often misdiagnosed, rectus sheath hematoma (RSH) is usually seen in the context of blunt abdominal trauma and/or anticoagulation therapy, rarely occurring spontaneously. We present a case of spontaneous rectus sheath hematoma (SRSH) without obvious risk factors and review the literature regarding diagnosis modalities and management. The aim of this case presentation is to highlight this rare clinical condition and emphasize the role of the physical exam in determining the appropriate treatment approach.   CASE REPORT A 50-year-old woman presented to the emergency room with right-sided pelvic pain for one day. Her medical history was specifically notable for recent coughing due to acute bronchitis, as well as the use of NSAIDs. Physical examination revealed marked tenderness in the hypogastric and right lower quadrant, with guarding and fullness in the same area. Laboratory investigation showed mild anemia and normal coagulation tests. Computed tomography demonstrated a right rectus muscle hematoma measuring 8.5×8.5 cm and extending into the lower abdomen and the extraperitoneal space, without active contrast extravasation. Close monitoring of vital signs and hemoglobin hematocrit levels along with supportive care with fluid resuscitation and pain control were initiated and the patient remained stable throughout her hospital stay. CONCLUSIONS Prompt recognition and management of SRSH are crucial. Physical examination is a key part of this process and imaging is the mainstay of diagnosis. Management remains for the most part supportive, although surgery or vascular embolization is required for uncontrolled hematomas with hemodynamic instability.

Spontaneous rectus sheath hematomas in dengue hemorrhagic fever: A case report

Muscle hematomas are rare complications in dengue hemorrhagic fever (DHF). We report a case of 58-year-old-female admitted with dengue fever who developed spontaneous rectus sheath hematoma complicating DHF. She presented with progressive thrombocytopenia with platelet count reaching 13000/μL at its lowest point. There was evidence of plasma leakage and persistent cough during the course of illness. During the recovery phase, she reported severe abdominal pain and developed hematoma in the right rectus sheath, which was confirmed by abdominal computed-tomography scan and serial magnetic resonance imaging. This complication during convalescent period of DHF needs to be recognized so it can be managed appropriately.

Bilateral rectus sheath haematoma complicating dengue virus infection in a patient on warfarin for mechanical aortic valve replacement: a case report

Background

The management of Dengue virus infection can be challenging. Varied presentations and numerous complications intrinsic to dengue by itself increase the complexity of treatment and potential mortality. When burdened with the presence of additional comorbidities and the need to continue compulsory medications, clear stepwise definitive guidance is lacking and patients tend to have more complex complications and outcomes calling to question the clinical decisions that may have been taken. The use and continuation of warfarin in dengue virus infection is one such example.

Case presentation

We report a 65 year old South Asian female who presented with dengue fever. She had a history bronchial asthma, a prior abdominal surgery, and was on warfarin and maintained a therapeutically appropriate internationalized normalized ratio for a mechanical aortic valve replacement. Though preemptive decision to stop warfarin was taken with decreasing platelet counts, her clinical course was complicated with the development of bilateral rectus sheath haematoma’s requiring resuscitation with blood transfusions.

Conclusion

Though management of dengue viral fever has seen drastic evolution with recent updated guidance, clinical scenarios seen in the course of the illness still pose challenges to the managing physician. The need to continue obligatory anticoagulation which may seem counterintuitive during a complex disease such as dengue virus infection must be considered after understanding the potential risks versus that of its benefits. Though case by case decisions maybe warranted, a clear protocol would be very helpful in making clinical decisions, as the correct preemptive decision may potentially avert catastrophic and unpredictable bleeding events.

Retracted: Spontaneous rectus sheath haematoma associated with rivaroxaban treatment

http://onlinelibrary.wiley.com/doi/10.1111/jcpt.12228/pdf The above article, published online on 10 November 2014 in Wiley Online Library (wileyonlinelibrary.com), has been retracted by agreement between the authors, the journal Editor in Chief, A. Li Wan Po, and John Wiley & Sons Ltd. The retraction has been agreed because, unknown to the authors, another group published a similar study based on the same material in the Indian Journal of Pharmacology: Kocayigit I, Can Y, Sahinkus S, et al. Spontaneous rectus sheath haematoma during rivaroxaban therapy. Indian Journal of Pharmacology. 2014;46(3):339-340. doi:10.4103/0253-7613.132193.

Rectus sheath hematoma: a review of the literature

Rectus sheath hematoma (RSH) is a relatively rare clinical condition, strongly associated among others, with abdominal trauma and anticoagulation. Although well documented over the years, it still seems to be often misdiagnosed. Estimations of further increase in incidence are made, based on the increasing use of anticoagulants. Thus it was of interest to us to perform a literature review on the available literature of this entity with the aim to facilitate a better understanding and management in primary and secondary care settings. This review intends to present a synthesis on the main topics of this condition such as pathophysiology, epidemiology, predisposing factors, clinical presentation, diagnosis and basic treatment instructions. The initial search resulted in 146 articles. Additional citations from the reference list of the relevant publication were also included. Every physician in the field of primary/emergency medicine and surgery must be familiar with it, as misdiagnosis may lead to unnecessary laparotomy or death. In contrast, faster and more accurate diagnosis can lead to mortality rate reduction and cost containment.

Bilateral rectus sheath hematoma in kidney transplant patient: case study and literature review

Rectus sheath hematoma usually occurs unilateral but rare cases of bilateral hematoma have been reported. Herein we report the first case of spontaneous bilateral Rectus Sheath Hematoma in the kidney transplanted patient.