Rectus Sheath Hematoma (RSH)is an un
Common entity in clinical practice. It
typically appearsinelderly patients on anticoagulant therapy, as a result of
trauma, surgery, pregnancy, paroxysmal coughing and other medical disorders.
They are more frequent in women and locatedon infraumbilicalregion. It
represents less than 2% of the total cases of abdominal pain collected in the
Emergency Department [1-5].RSHusually presents as a painful massassociated with a
significant decrease in hemoglobin levels. Occasionally, they may raise a
problem in differential diagnosis. Computed Axial Tomography (CT)and Abdominal
Ultrasound (US)are useful diagnostic techniques [1-5].Most of them are a self-
limiting process that respond to non-aggressivetreatment. However, some cases
will need selective embolisation or surgery [6,7].
We reporta case of giant RSH in an80-year-old woman
that was on anticoagulant therapy. The peculiarity of this case is that RSH
caused abdominal compartment syndrome and required drain and two selective
embolisation. Abdominal compartment syndrome produced by RSH has been
previously described in the literature, although it is a rarity.
80 year old female with a medical history of arterial
hypertension, rheumatic valvulopathy with mechanical mitral prosthesis and
tricuspid annuloplasty, severe pulmonary hypertension and atrial fibrillation.
She was on anticoagulant therapy(acenocumarol) and had been admitted two months
earlier to our center due to lower leg hematomas. As a result, at the moment of
admission, she was on Low-Molecular-Weight Heparin (LMWH).The patient presented
witha 12-hour history of diffuse abdominal pain, nausea, abdominal distension
and mass effect.
On physicalexamination, she was hemodynamically
stable with tenderness and palpable abdominal mass on the hypogastrium. Blood
tests revealed: hemoglobin level 10 g/dL, hematocrit 34%, platelet 177.000/UL, Activated
Partial Tromboplastin Time (APTT) 28.9 sec and International Normalized Ratio (INR)
Under the suspicion of a RSH, Computed Tomography
Angiography (CTA) was performed. It showed a 20 X 25
While the patient was in the Emergency Department,
her hemoglobin level plummeted from 10 to6 g/dl accompanied byhypotension and
tachycardia. Intravenous fluid replacement, red blood cell and fresh frozen
plasma transfusion were started. At that moment, the patient was moved to the
Intensive Care Unit, where she was stabilized.Since there was an active
bleeding, a therapeutic angiography with embolisation of the left inferior epigastric
artery was carried out.In the following days, the patient developed an
abdominal compartment syndrome with 23 mm Hg of intra- abdominal pressure, and
acute renal failure due to giantpreperitoneal hematoma.She underwent urgent
surgery. A small infraumbilicallaparotomy allowed to get into Retzius space. A
damaged rectus muscle was found, so epigastric vessels couldn’t be identified.
Clot evacuation and packing were performed. Then, 24 hours later, it was
removed and no active bleeding found.In the next 72h hours, the hemoglobin
level dropped from 11 to 8g/dl. A repeated CT showed active bleeding signs, and another embolization of the left inferior
epigastric artery was realized (Figure 2 and 3).
cm size rectus sheath hematoma withactive bleeding
signs (Figure 1).
Finally, the patient stayed stable with hemoglobin
level 11 g/dl, and anticoagulant therapy reintroduced. However, due to her
medical conditions she suffered from heart failure and passed away.
recent years, the use of anticoagulant drugsin elderly, has caused an
increasing numberof Rectus Sheath Hematoma (RSH).RSH constitutes the most
common non-neoplastic disorder occurring in Rectus Abdominis Muscles (RAM) .The
ancients already described this entity, and Hippocratesand Galenmentionedit in
their treatises. Later, in 1857, Richardson reported the first case in the
modern literature. [2,3,4].In 1946, Teske analyzed a series of 100 cases of hematoma of
the anterior rectus abdominis muscle .According
to Klinger et al. a RSH is discovered in 1.8% of patients who undergo
ultrasonographyfor acute abdominal disorder .They
mostly affect women in their sixth and seventh decades of life [2,3,6].On
contrary, Kingler in his 23 patient serie reported a slightly predilection
formen .RSH is caused by a tear of rectus abdominis musclesor
epigastric vessels. There are two epigastric vessels: the superior epigastric
artery (terminal branch of internal thoracicartery)and inferior epigastric
artery (branch of external iliac artery). Most frequently, RSH is located below
the arcuate line of Douglas, where posterior surface of RAMis only covered by a
weak transversalis fascia and peritoneum.(Figure 4).
to Nikolao, 70% of RHSs occur in the lower abdomen .
However, above arcuate line, aponeurotic expansions of external oblique,
internal oblique and transversalis musclespass anteriorly and posteriorly the
RAMs,and form a thick sheath that grants contention.They appear most commonly
in the right side [2-6,9](Figure 5).
risk factors have been associated to RSH, among them, the most common is
anticoagulant therapy that is also related to increasingmortality. Overall
mortality rate of RSH is,approximately, 4%. However, in patients under
anticoagulant therapy, it reachesaround 25% [1,5].Other
causes of RSH are abdominal direct trauma, iatrogenic (procedures such as paracentesis,
percutaneous drain, laparoscopic...etc.), Valsalva effort
(coughing)pregnancy,elderly (weak RAMs contribute to formationof RHS)
andmedical conditions as hypertension, atherosclerosis, vasculitis, renal or
blood disorders... Cough constitutes the most frequent precipitating factor [1-3,5].They
usually present as a painful mass inelderly patientson anticoagulant
medications. Pain occurs in 85-97% of patients, it appears suddenly and can
mimic acute intra-abdominalconditionssuch as appendicitis, perforated ulcer,
intestinal obstruction, strangulated hernia, ectopic pregnancy...etc[1,3,5,8,10].In
1926, two clinical signs were described. Fothergill's sign occurs when a
palpable mass in the abdominal walldoes not cross the middle line. Carnett's
sign is positivewhenat tensingabdominal wall, tenderness increases. However, in
case of intra-abdominalprocess, the fact of lifting head and shoulders
decreases the pain due toprotection of abdominal wall [3,6,11].
is the first-line imagining choice, and it reaches a sensitivity of 70-90%.
However, CT is considered the gold standardwith a sensitivity of 100%. It
allows to exclude other abdominal processes. Furthermore, itdetermines the size
of hematoma and signs of active bleeding when realized with intravenous
contrast, and identifiescasesthat will be candidates to selective embolisation.
1996, Berna proposed a classification based on CT findings:
I: unilateral hematoma that does not require hospitalization, mild, and
II: moderate intramuscular hematoma that requires hospitalization, unilateralor
III: severe hematoma on anticoagulated patients that extendsinto peritoneum and
prevesical space and requires blood transfusion .The
vast majority of RSHs are self-limitingand conservative treatment is successful
in most cases. Non- surgical management consists of suspension of
anticoagulants, blood transfusion, rest and antibiotic.Reversal
of anticoagulation is usually needed and consist of intravenous vitamin K;
prothrombin complex concentrates or fresh frozen plasma .
we emphasize that the main data to decide the correct treatmentis the
hemodynamic stability of the patient. When hemodynamic instability is present,
selective embolisation or surgery should be considered. In addition, enlarging
hematomas should undergo embolisation [2,3,12].Surgery
consist of ligation of vessels or drainage of the hematoma .We
report a case of a giant RSH that caused abdominal compartment syndromeand,
although initially selective embolisation was successful, the patient required
surgery because of the high intra-abdominal pressure. A 3 cminfraumbilical
incision was performed and middle line opened, the giant hematoma was drained
but no bleeding vessel identified, although a diffuse bleeding was present and
a packing performed. Two days later, packing was removed and no signs of
bleeding identified. However, threedays later,the hemoglobin plummeted,and a
second embolisation was carried out. This is a rare case where a second
embolisation was needed.
is a rare cause of abdominal compartment syndrome, and althoughdescribed in the
literature, is a rare presentation. When it occurs, surgery is mandatory to
reduceintra-abdominal pressure.When anticoagulationreversal has been required,
a critical issueis to determine the adequate time toreintroduce anticoagulant
therapy. The fact that most patients with RHSneed anticoagulationfor
life-threading conditions(mechanical valves, auricular fibrilation...etc) makes
it challenging. It is commonly accepted to continue with anticoagulant therapy
once the patient is hemodynamicallystable. In addition, Villa et al. recommend
a repeated contrast-enhanced CT in patients under anti-coagulation .In
our case, once patient was hemodynamically stable, anticoagulation was
initiatedLMWHs require special concern because of the high number of cases of
severe RSH due to injection technique. On this way, the deltoid region could be
a safer alternative .
summarize, RSH occurs mostly in anticoagulated elderlyon infraumbilical
location. US and CT are useful tools and allow to identify patients that will
benefit of selective embolisation.Although,most cases are self-limiting, and
nonaggressivetreatment will be effective, some patients will present active
bleeding and hemodynamicallyinestability;under these circumstances, selective
embolisation shouldbe performed, and finally,surgery considered. The fact that
RSH happens in patients with life-threadingpathologies make the management a