Rectus Sheath Hematoma: Three Case Reports

Selin Kapan; Ahmet N Turhan; Halil Alis; Mustafa U Kalayci; Sinan Hatipoglu; Hakan Yigitbas; Ersan Aygun

Disclosures

J Med Case Reports 

In This Article

Case Presentation

Case 1

A 64 year old woman presented to the Emergency Department with complaints of abdominal pain, nausea and an abdominal mass in the right upper quadrant. She had a history of excessive coughing due to acute bronchitis. Additionally she had diabetes mellitus and hypertension under medical therapy. She had a diagnosis of Polycythemia Vera for 10 years and had been taking an antineoplastic agent containing hydroxyurea 500 mg per day since then. Physical examination revealed a large mass in the right upper quadrant of the abdomen extending to the lower abdomen. The mass was tender on palpation, but there was no rebound tenderness and muscular rigidity. Carnett and Fothergill tests were positive. Bowel auscultation revealed no pathologic sound. Mean arterial pressure was 140/80 mmHg, pulse rate was 86/min, hemoglobin level 10.56 g/dL, hematocrit 37.3%, platelet 528000/UL, activated partial tromboplastin time (aPTT) 21.8 sec, prothrombin time (PT) 17.7 sec and international normalized ratio (INR) 1.45. The other biochemical tests were normal. Ultrasound (US) examination of the abdomen confirmed a nonmobile heterogeneous mass on the right upper quadrant extending below the liver with a suspect of intestinal loop within the mass. Further imaging study of computerized tomography (CT) revealed a hematoma on the abdominal wall (Figure 1). Complete blood cell count examination on the 12th hour of admission revealed a decrease in the hemoglobin and hematocrit levels (7.63 g/dl and 22.6% respectively). Ecchymosis occurred on the third day on the abdominal wall. After intravenous fluid replacement, 3 units of erythrocyte transfusion, 2 units of fresh frozen plasma and analgesic treatment with strict bed rest, patient was discharged from the hospital on the 8th day of admission.

Figure 1.

CT appearance of rectus hematoma on the right upper abdomen.

Case 2

A 60 year old woman presented to the Emergency Department with complaint of acute abdominal pain. She had history of chronic constipation. Physical examination revealed a painful palpable mass within the left lower quadrant of the abdomen. There was no muscular rigidity or rebound tenderness. Mean arterial pressure was 110/80 mmHg, pulse rate was 76/min, hemoglobin level 10.46 g/dL, hematocrit 32.3%, platelet 199000/UL. The other biochemical tests were normal. US revealed suspect of invaginated intestinal loop with a sign of "Target sign" (Figure 2), but the clinical examination did not confirm the prediagnosis of intestinal obstruction. CT revealed a rectus sheath hematoma. During the 3 day follow up, there was no change in the hemodynamic conditions, so no transfusion was required. Ecchymosis occurred on the third day on the abdominal wall. Partial resorption of the hematoma was observed in the follow up CT 45 days after discharge.

Figure 2.

US appearance misdiagnosed as intestinal obstruction "Target sign".

Case 3

A 76 years old woman presented to the Emergency Department with complaints of abdominal pain, and an abdominal mass in the right upper quadrant. She had a history of congestive heart failure, chronic atrial fibrillation, chronic obstructive lung disease, ischemic cerebrovascular disease and myocardial infarction. The patient had been taking warfarin sodium 5 mg/day for atrial fibrillation for 2 years without medical supervision. On physical examination painful mass in the left lower quadrant and suprapubic region of the abdomen was observed. Ausculatation of the abdomen revealed hypoactive bowel sound. Mean arterial pressure was 140/80 mmHg, pulse rate 118/min, hemoglobin level 13.32 g/dL, hematocrit 30.26%, platelet 199000/UL, PT: 79.2 sec, aPTT: 56 sec, INR: 6.68. The other biochemical tests were normal. Abdominal CT revealed rectus sheath hematoma (Figure 3). During the follow up period 6 units of fresh frozen plasma was administered. Due to the hemodynamic stability patient was referred to the Internal Medicine Department.

Figure 3.

US appearance misdiagnosed as intestinal obstruction "Target sign".

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