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

Discussion

Rectus sheath hematoma (RSH) is a rarely seen but important disease causing abdominal pain. There is a female predominance as may be explained by larger rectus muscle mass in man.[7] All three of our patients were also female. There are various causes resulting in RSH as abdominal trauma, previous surgery, coughing, streching, hypertension, intraabdominal injections, iatrogenic causes during laparoscopy and anticoagulation therapy.[8,9] In the abdominal wall below the arcuate line there's only transversalis fascia between peritoneum and posterior rectus sheath, therefore rupture of epigastric vessels or muscle within this sheath causes a hematoma mimicking acute abdomen.[2] Common presenting signs and syptoms are abdominal pain, abdominal wall mass, decrease in hemoglobin, abdominal wall ecchymosis, nausea, vomiting, tachycardia, peritoneal irritation, fever, abdominal distention and abdominal cramping.[7]

Fothergill's sign and Carnett sign are positive in rectus sheath hematoma, and helps to differentiate this condition from intraabdominal pathologies.[1,2,4,6] Fothergill' sign is positive when the haematoma within the rectus sheath produces a mass that does not cross the midline and remains palpable when the patient tenses his rectus muscle by touching his chest using his chin.[4] Carnett sign is exacerbation of the pain and tenderness over the hematoma by contraction of rectus muscle by sitting halfway up in a supine position.[2] Both of these tests were positive in three of our patients. Echymosis on the abdomen may occur late in the follow up period. The ecchymosis may be seen in the flanks or periumblical region causing Grey Turner's and Cullen's sign.[4,6]

Misdiagnosis may lead to unnecessary negative laparotomies with increase in morbidity and mortality.[10] US, CT and magnetic resonance imaging are widely used in the diagnosis. Although US seems to be the procedure of choice due to its high sensitivity rates, time and cost effectivity and low radiation in some series, however sometimes it is difficult to differentiate intraperitoneal lesions from extraperitoneal lesions by US as the technique is subject to error by means of probe induced tenderness and limitations of interpretation of the images.[6] This was the case in the first two cases as the ultrasonographers identified the hematomas as "intraperitoneal". CT is superior to US in localisation, extension and evaluation of the size of the hematoma. Moreover CT imaging can give the classification of the hematoma. According to the CT classification, Type I hematomas are mild and the hematoma occurrs within the muscle with an increas in muscle length and do not require hospitalization. Type II hematomas are moderate, the hematoma is within the muscle but bleeding occurs into the space between transversalis fascia and the muscle. Type III hematomas are severe and located between transversalis fascia and the muscle, anterior to the peritoneum and urinary bladder. Type II and III hematomas require hospitalization. In Type I hematomas hospitalisation is not usually required and the hematoma resorbs spontaneously within 30 days. In Type II lesions bed rest, intravenous fluid replacement and analgesia is the appropriate treatment. In Type III lesions additional blood product transfusions are required. These kind of hematomas resorb approximately in 3 months.[4,11] All three of our cases were Type II.

Conservative treatment is the mainstay of management in hemodynamically stable patients with non expanding hematoma.[1,4,6] In cases with failure of conservative treatment, surgical approach can be chosen but the mortality rates of surgery for rectus sheath hematoma is high. Coil embolisation can be an alternative in high risk patients refractory to conservative therapy.[1,4]

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