Contemporary SurgeryCASE QUIZ
How to manage a rectus sheath hematoma
Department of Surgery, University of North Dakota, School of Medicine and Health Sciences, Grand Forks, NDBhargav
Department of Surgery, Meritcare Medical Group, Fargo, ND
This woman complained of acute abdominal pain after anticoagulation for a myocardial infarction.
A 61-year-old woman was admitted to the cardiac intensive care unit with a suspected myocardial infarction and respiratory distress. The patient was unstable and required vasopressors. She was also given IV heparin.
She complained of increasing abdominal pain and left-sided abdominal swelling with bruising.
Two days later, she complained of increasing abdominal pain and left-sided abdominal swelling with bruising in the rectus area. Her hemoglobin had decreased from 14.8 mg/dl to 9.6 mg/dl. Abdominal and pelvic CT scans revealed a large rectus sheath hematoma extending from the subcostal to the pelvic area (FIGURE).
In the OR
After reversing anticoagulation, we took the patient to the operating room. We evacuated a large hematoma that extended from the costal margin to the pelvis. We preserved the posterior rectus sheath and peritoneum.
After ligating the left inferior epigastric vessels, we thoroughly irrigated the cavity and packed it with two Kerlix rolls (Covidien, Mansfield, MA). Two days later we removed the packing and closed the rectus sheath and skin. The patient remained stable and was discharged three days later.
A rare cause of abdominal pain
Rectus sheath hematoma is an uncommon cause of acute abdominal pain. It may occur spontaneously1 or result from direct trauma, abrupt twisting or positional changes, anticoagulation, recent surgery, medication injection, or increased intra-abdominal pressure from pregnancy or coughing.2
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Typically, the hematoma forms from a muscle tear or rupture of epigastric vessels. Rectus sheath hematoma has been reported in unusual circumstances such as rupture of an internal iliac artery aneurysm and after percutaneous endoscopic gastrectomy.3,4
Risk factors for rectus sheath hematoma
Blunt or penetrating trauma.
Prolonged extreme coughing or sneezing.
Pregnancy and child birth.9
Subcutaneous injection of heparin or insulin.
Long-term steroid usage.
Collagen vascular disease.
Infections such as influenza, typhoid fever, and tetanus.6,12
Epidemiology is difficult to ascertain because of its rarity. Estimated prevalence is approximately 1.2 to 1.5 events per year.5 Women are almost twice as likely as men to have rectus sheath hematoma (1.8:1). Older age, increased international normalized ratio, and elevated activated partial thromboplastin time levels are associated with a higher incidence of rectus sheath hematoma formation. Mortality is rare.6
If the mass persists with the patient lying supine as well as partially sitting up, consider rectus sheath hematoma.
Rectus sheath hematomas are found in the infraumbilical right-lower quadrant (35%), the infraumbilical left-lower quadrant (26%), and the left epigastric area (4%).5
Risk factors for rectus sheath hematoma include uremia7 with its associated platelet abnormalities (BOX).
Signs and symptoms vary in severity (BOX). Presenting symptoms vary: abdominal pain (84%), visible abdominal wall mass (63%), hemoglobin drop of 0.4 g/dL or greater (55%), and abdominal wall ecchymosis (17%).6 A rare case of abdominal compartment syndrome due to rectus sheath hematoma was described.8
Signs and symptoms of rectus sheath hematoma6
Common presenting signs:
Abrupt onset of severe, unilateral abdominal pain aggravated by movement.
Abdominal wall or flank mass and/or ecchymosis.
Hypotension or tachycardia in the event of major blood loss.
Less frequent signs and symptoms:
Nausea or vomiting.
What to look for
Physical examination usually uncovers a tender mass, although not in all cases.
If the mass persists with the patient lying supine as well as partially sitting up (Fothergill’s sign), consider rectus sheath hematoma. In addition, tenderness that remains unchanged or increases with tensing of the abdominal wall (Carnett’s sign) is suggestive. Ecchymosis tends to be a late sign, presenting several days after the onset of symptoms.8
A broad differential
The differential diagnosis for rectus sheath hematoma varies greatly. It usually includes:5,9
In pregnant patients, rectus sheath hematoma can be misdiagnosed as placental abruption, uterine rupture, ovarian torsion, and degenerating uterine leimyomas.9
MRI may be more useful as a tool to differentiate chronic disease from anterior abdominal tumors or metastatic lesions.
A timely diagnosis is necessary to minimize morbidity. Although US with a good history and physical examination is effective,1 diagnostic failure is reported at more than 50%, and at least 30% with US imaging.5 Clinical or sonographic misinterpretation may be a factor.
CT scan is best for radiological diagnosis.6 A classification schema is based on CT-scan findings (TABLE).10
MRI can identify rectus sheath hematomas. However, it may be more useful to differentiate chronic disease from anterior abdominal tumors and metastatic lesions, especially absent a precipitating event.1
Managing the hematoma
Supportive medical management of rectus sheath hematomas is appropriate, with pain control and blood transfusion as needed.6 Without surgical drainage, type II hematomas typically resolve in 2–4 months. Type III hematomas require more than 3 months to disappear.11
An unstable patient may require invasive therapy with embolization of the bleeding vessel or surgery. In a large series, only 8% of patients required surgery or endovascular embolization.6
Authors have used therapeutic US to facilitate hematoma absorption after the patient was stabilized. Further study is needed to validate this intervention.11
Classifying rectus sheath hematomas based on CT-scan findings10
||Intramuscular; increase in muscle size; unilateral
||Does not dissect adjacent fascial planes
||Intramuscular; unilateral or bilateral
||Bleeding between muscle and transversalis fascia; no blood in prevesical space.
||May affect muscle
||Bleeding between transversalis fascia and muscle, in peritoneum and prevesical space
||Observed; possible hemoperitoneum
The authors did not disclose any relationships.
, et al.
Spontaneous rectus sheath hematomas: clinical and radiological features.
Abdom Imaging. 1996;21:58–61.
Rectus sheath hematoma as a cause of acute abdominal pain.
Am Fam Physician. 2001;64:1681–1682.
- De Donato
Rupture of internal iliac artery aneurysm presenting as rectus sheath hematoma: case report.
J Vasc Surg. 2004;39:250–253.
Rectus sheath hematoma complicating percutaneous endoscopic gastrostomy.
Surg Laparosc Endosc Percutan Tech. 2002;12:430–432.
The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders.
Surg Endosc. 1999;13:1129–1134.
Rectus sheath hematoma: review of 126 cases at a single institution.
Medicine (Baltimore). 2006;85:105–110.
Rectus sheath hematoma in patients with renal disease.
Nephrol Dial Transplant. 2002;17:1832–1835.
Abdominal compartment syndrome as a consequence of rectus sheath hematoma.
Am Surg. 2003;69:975–977.
Rectus sheath hematoma in pregnancy.
J Clin Ultrasound. 2001;29:306–311.
Rectus sheath hematoma: diagnostic classification by CT.
Abdom Imaging. 1996;21:62–64.
Ultrasound therapy in rectus sheath hematoma.
Phys Ther. 2005;85:352–357.
Mushroom cloud appearance of hemorrhage into the superficial anterior abdominal wall associated with an underlying rectus sheath hematoma.
Clin Anat. 2005;18:141–145.