Rectus sheath haematoma: a rare cause of abdominal pain

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1 Hong Kong Journal of Emergency Medicine Rectus sheath haematoma: a rare cause of abdominal pain 腹直肌血腫 : 腹痛的罕見原因 S Akay, C Caliskan, H Gonullu, O Dal, MA Korkut, N Erkan Objective: Rectus sheath haematoma (RSH) is a rare entity described as accumulation of blood within the rectus muscle. Patients can present with varying symptoms and signs, mimicking acute abdominal conditions. Failure to diagnose can result in unnecessary diagnostic procedures and surgical interventions. Methods: We presented a series of 14 cases of RSH presenting to two emergency departments (ED) within a period of 3 years. Their demographic characteristics, medical history, presenting signs, symptoms and treatment were analyzed. Results: Fourteen cases were diagnosed RSH. Seven cases were on warfarin treatment. Three RSH cases were diagnosed by ultrasonography (USG) only while the remainders had additional computed tomography (CT). Two cases had surgery due to haemoperitoneum, and the rest were treated conservatively with bed rest, analgesics and reversal of anticoagulation therapy. All patients were discharged from hospitals. Conclusions: RSH is an important entity which must be considered in patients with known risk factors presenting to ED with abdominal pain. In elderly patients with a history of cough, anticoagulant use with palpable mass on abdominal wall, RSH must be considered as a possible diagnosis for unexplained abdominal pain. USG, together with CT in selected cases, should be performed to reveal this rare disease entity. (Hong Kong j.emerg.med. 2011;18: ) 目的 : 腹直肌血腫 (RSH) 是一種罕見的病況, 其描述為血液積累在腹直肌內 病人可以有不同的症狀和體徵, 並模仿急性腹痛的表現 未能正確診斷, 可能會導致不必要的診斷程序和手術治療 方法 : 我們報告了一系列 14 例的 RSH 個案, 病人 3 年期內曾到兩個急診室 (ED) 診治 我們分析了病人的人口特徵, 病史, 症狀, 體徵和治療 結果 :14 例病人確診為 RSH 七宗在接受華法林治療 三例 RSH 只需要超聲診斷 (USG), 其餘的需要額外的電腦斷層掃描 (CT) 兩例因腹腔積血需要手術治療, 其餘的只需要保守治療, 包括 : 臥床休息, 止痛劑和逆轉抗凝治療 所有患者均治愈出院 結論 : RSH 的是一個重要的診斷, 在已知有危險因素的腹痛患者必須考慮到 老年患者有咳嗽或使用抗凝血劑的歷史, 並呈現為腹壁腫塊時, 必須考慮 RSH 為不明原因腹痛的一個可能診斷 在某些選定的個案, 進行 USG 以及 CT 檢查, 應可確診這種罕見的疾病 Keywords: Abdominal muscle, anticoagulant, haemorrhages, rectus abdominis, spontaneous rupture 關鍵詞 : 腹部肌肉 抗凝血劑 出血 腹直肌 自發破裂 Correspondence to: Serhat Akay, MD Izmir Bozyaka Training and Research Hospital, Department of Emergency Medicine, Izmir, Turkey howls_castle@mynet.com Hayriye Gonullu, MD Onur Dal, MD Ege University Faculty of Medicine Hospital, Department of Surgery, Izmir, Turkey Cemil Caliskan, MD Mustafa Ali Korkut, MD Izmir Bozyaka Training and Research Hospital, Department of Surgery, Izmir, Turkey Nazif Erkan, MD

2 162 Hong Kong j. emerg. med. Vol. 18(3) May 2011 Introduction Rectus sheath haematoma (RSH) is a rare condition consistent with accumulation of blood within the rectus muscle lining the anterior abdominal wall presenting with acute onset abdominal pain and palpable mass. It is caused by ruptures of superior or inferior epigastric arteries, their branches or a tear of the rectus muscle. 1 Anticoagulation therapy, pregnancy, blunt trauma, abdominal straining, obesity, coughing, pregnancy are common risk factors for RSH. RSH is usually self limiting. Due to the absence of posterior sheath below the arcuate line of Douglas, rectus muscle is in direct contact with the transverse fascia and peritoneum. This can cause an expanding haematoma turning into haemoperitoneum, and becoming life threatening. The diagnosis and treatment can be challenging to the emergency medicine physicians. Failure to aware in the differential diagnosis can lead to unnecessary intervention. Complications include hypovolaemic shock, abdominal compartment syndrome and muscle necrosis. 2 Depending on the location, RSH can mimic other causes of abdominal pain such as appendicitis, abscess, abdominal wall tumours, diverticulitis or cholecystitis. Conservative follow-up with bed rest, pain relief and reversal of coagulopathy can be sufficient for limited, non-expanding RSH. For continued bleeding, surgery or embolisation of the vessel can be applied. 3 The aim of this study was to examine the epidemiology, clinical features, diagnosis and treatment pattern of a group of retrospectively identified RSH patients presented to our emergency departments (ED). Methods We retrospectively identified cases of RSH over a period of 3 years from two hospitals, Ege University School of Medicine Hospital and Izmir Bozyaka Training and Research Hospital. Both hospitals are tertiary referral centers. Patients' final diagnoses were defined by positive clinical and radiological findings. Clinical notes were reviewed and data were abstracted from patient charts and hospital information system. Results We identified 14 patients (7 male, 7 female; median age 59, range 22-85) admitted to ED with a final diagnosis. Cases were summarised in Table 1. All cases complained of abdominal pain at the location of haematoma. Four (29%) patients (cases 1, 3, 9 and 13) had haematomas on the left side while ten cases (81%) were on the right. Four (29%) of the cases stated that pain started after a few days of prolonged coughing and all cases denied trauma to the abdomen. Seven (50%) cases were using warfarin (for mitral valve replacement, cerebrovascular disease, coronary artery disease, pericardial haematoma after coronary artery bypass grafting operation) and 1 patient was using acetylsalicylic acid. Another case (case 8) had a bleeding disorder due to platelet dysfunction. All cases were haemodynamically stable at the time of presentation to ED. On physical examination, most patients (8/14, 57%) had signs of peritoneal irritation and the admission diagnosis was appendicitis in 4 cases (case 2, 4, 6, 10) and acute cholecystitis in one case (case 11). Three cases had only ultrasonography (USG) of the abdomen while the remaining cases also had computed tomography (CT) of the abdomen, which all showed localised haematoma of the rectus sheath. Ultrasonography of case 6 showed free fluid in the abdomen with similar findings on CT. CT of case 8 revealed free fluid in pelvis which was not determined on USG. Both were operated with paramedian incision, followed by evacuation of the haematoma and drainage of blood of 200 ml from the pelvic area. The rest of the cases were followed conservatively. All cases were admitted for treatment. Five of the patients with prior warfarin use had International Normalized Ratio (INR) values above the therapeutic range. They were treated with fresh frozen plasma with

3 Akay et al./rectus sheath haematoma 163 Table 1. The clinical characteristics of the 12 patients with rectus sheath haematoma Case Sex/ Risk Co- Antico- Coagulation Acute USG CT Treatment Blood FFP Outcome Age factors morbidity agulant use results abdomen resus resus APTT INR signs 1 M/48 Coughing Cerebrovascular None - Regular shaped, Not applied Symptomatic Discharged disease, unknown hypoechoic mass in the bleeding disorder left rectus muscle, consistent 2 M/22 Coughing None + Regular shaped, 3.2 x 4 cm Not applied Symptomatic Discharged sized, asymmetrical, heterogeneous haematoma in right rectus muscle 3 F/65 None + Enlargement of the left Regular shaped, Symptomatic Discharged rectus muscle 5.8 x 7cm sized, hypoechoic mass in left rectus muscle, consistent 4 M/45 Aspirin + 4 cm sized, heterogeneous Not applied Aspirin Discharged hypodense mass in right stopped, rectus muscle, consistent 5 F/46 Mitral valve Warfarin Cholelithiasis, 9 x 3 cm Cholelithiasis, Warfarin 1 4 Discharged replacement sized, heterogeneous 16 x 9 x 5 cm sized stopped unit units mass in the right in right rectus lower quadrant muscle expanding from paraumblical area to symphysis pubis 6 F/51 Mitral valve Warfarin Free fluid in Mass in right Warfarin 1 Discharged replacement the pelvis rectus muscle, stopped, unit free fluid in surgery the pelvis 7 M/59 HT, CHF, Warfarin x 2 cm sized Same as USG Warfarin 2 2 Discharged CABG haematoma in the right stopped units units rectus muscle 8 F/82 Polycythemia vera, None Cholelithiasis, 6 x 3 cm Same as USG Surgery Discharged thrombocyte sized haematoma in the and free fluid dysfunction right lower rectus muscle in the pelvis 9 M/62 Coughing COPD, CHF None - 13 x 5 cm sized haematoma Same as USG Symptomatic Discharged in the left rectus muscle 10 F/85 Mitral valve Warfarin x 5 cm sized haematoma Same as USG Warfarin 1 3 Discharged replacement in the right rectus muscle stopped, unit units 11 F/58 Coughing None + 4 x 3 x 9 cm sized, lobulated, Same as USG Symptomatic Discharged heterogeneous mass in the right upper quadrant consistent 12 M/85 CABG, Warfarin + 7 x 3 cm sized haematoma Same as USG Warfarin 1 1 Discharged pericardial in the right rectus muscle stopped, unit unit haematoma 13 F/55 Mitral valve Warfarin x 5 cm sized haematoma in Same as USG Warfarin 3 Discharged replacement the left lower rectus muscle stopped, units 14 M/51 Coughing COPD Warfarin - 3 x 4 cm sized haematoma Same as USG Symptomatic Discharged of the right rectus muscle APTT=activated partial thromboplastin time; CABG=coronary artery bypass graft; COPD=chronic obstructive pulmonary disease; INR=international normalized ratio; USG=ultrasonography

4 164 Hong Kong j. emerg. med. Vol. 18(3) May 2011 cessation of the warfarin. Only four patients required erythrocyte transfusion. In one patient, acetylsalicylic acid treatment was ceased until the resolution of haematoma. All the patients were discharged from the hospital with full recovery. Discussion Acute abdominal pain could be a common ED complaint and it accounted for 5% of patients admitting to ED. 4 Despite all efforts for diagnosing the underlying pathology, in 40% of cases the causes were never determined. RSH could be a rare and frequently misdiagnosed cause of abdominal pain and 1.8% of patients admitted to hospital due to abdominal pain had ultrasonographic evidence of RSH. 5 RSH is generally caused by the rupture of epigastric arteries or their smaller branches in the rectus sheath. Vigorous contractions, such as repeated Valsalva manoeuvre with coughing, strenuous activity and blunt trauma can cause trauma to vessels resulting in accumulation of blood in the rectus sheath. It was suggested because most people were right handed and more prone to right sided strain of muscle, therefore more RSH (60%) were reported to be on the right side. 6 In our series, 10 (71%) patients had RSH on the right side, consistent with other reports in the literature. Some authors suggested that increased muscle mass could provide a protection to trauma and its associated blood vessels in men. However, previous reports suggested a female predominance for RSH. 1,6 In our series, female to male ratio was 1:1. Consistent with other reports, our RSH patients tended to be older and more likely to have more risk factors such as anticoagulation therapy. In general, we regarded that RSH could be one of the differential diagnoses for the elderly people presenting to ED with unexplained abdominal pain. Risk factors of our patients included advanced age, coughing, previous aspirin or warfarin use and bleeding disorder. Limited data in the literature suggested that minor trauma, exertional abdominal straining, pregnancy and subcutaneous drug injection could be the risk factors. 7-9 Nine (64%) of our sample patients had warfarin, acetylsalicylic use or bleeding disorder as predisposing factor. Five (36%) patients had a history of strenuous coughing. A detailed history and physical examination should be done to look for RSH as the differential diagnosis of acute abdominal pain: (1) Fothergill's sign- the patient is asked to flex the head and a mass of abdominal origin will becomes fixed with a sensation of pain where an intra-abdominal mass will become impalpable; 10 (2) Carnett's test, pain is unchanged or increased with the same manoeuvre. Both tests have sensitivity of 40% in RSH patients. 11 Cullen's and Gray Turner's signs could be seen as late findings. RSH is graded into 3 categories where in grade 1 haematoma is intramuscular, unilateral and does not dissect along the fascia. 12 In grade 2, it is bilateral, and can dissect along the fascia leading to a drop in haemoglobin. A grade 3 haematoma dissects into extraperitoneal or intra-peritoneal spaces. Two of our patients had grade 3 haematomas. Both had acute abdominal signs with guarding in the right lower quadrant and free fluid in the pelvis, and had initial working diagnosis of acute appendicitis. Operations were performed and haematomas were evacuated with drainage of blood from the pelvic cavity. All patients had USG as the initial radiologic testing and 11 (79%) cases had abdominal CT as the additional radiologic study. RSH was missed by USG study in one case which only showed free fluid in the pelvis. In one patient, CT showed free fluid in the pelvis inconsistent with USG findings leading to surgery during which haematoma was evacuated. Treatment of RSH is basically supportive with reversal of anticoagulation therapy or correction of underlying bleeding disorder for the patients with non-expanding haematomas and stable haemodynamically status. Except for two patients who were operated, all were

5 Akay et al./rectus sheath haematoma 165 treated conservatively. Four of our patients required erythrocyte transfusion with an average of 1.25 units per patient, 6 patients required fresh frozen plasma transfusion with an average of 2.3 units per patient. Transfusion requirement and amount of product used was similar to those in other reports. 1 Two cases operated due to free fluid seen on imaging had full recovery. Operation requirement for RSH treatment per se was rare in the literature due to the benign course. Arterial embolisation could be useful in cases with expanding haematomas especially with haemodynamic instability or failed conservative therapy. 13 Complications reported in the literature include repeated RSH, hypovolaemic shock, obstructive uropathy, myocardial infarction, acute renal failure, partial small bowel ileus, abdominal compartment syndrome which are all rare. 1,2,14 Fatalities reported on elderly patients on anticoagulation therapy for various reasons, presenting with haemodynamic instability and unresponsive to invasive control of haematoma. 1,13,14 Unlike a recent case series in Turkey, 15 we did not have any mortality in our series. Conclusion RSH is a rare and potentially fatal cause of abdominal pain. Physicians should keep alert on attending patients with abdominal pain in the presence of a palpable mass, especially those of old age, of female gender, with comorbid conditions of COPD or on anti-coagulation therapy. Physical examination can mimic other conditions such as appendicitis, diverticulitis or tuboovarial pathologies. USG and abdominal CT are useful for imaging the haematoma. Conservative therapy with reversal of anti-coagulation therapy is usually sufficient for haemodynamically stable patients with nonexpanding haematomas but invasive procedures such as surgery or arterial embolisation is beneficial to the unstable patients. References 1. Cherry WB, Mueller PS. Rectus sheath hematoma, review of 126 cases at a single institution. Medicine (Baltimore) 2006;85(2): Luhmann A, Williams EV. Rectus sheath hematoma: a series of unfortunate events. World J Surg 2006;30(11): Zissin R, Gayer G, Kots E, Ellis M, Bartal G, Griton I. Transcatheter arterial embolisation in anticoagulant-related haematoma - a current therapeutic option: a report of four patients and review of the literature. Int J Clin Pract 2007; 61(8): Powers RD, Guertler, AT. Abdominal pain in the ED: stability and change over 20 years. Am J Emerg Med 1995; 13(3): Klingler PJ, Wetscher G, Glaser K, Tschmelitsch J, Schmid T, Hinder RA. The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders. Surg Endosc 1999;13(11): Teske JM. Hematoma of the rectus abdominis muscle: report of a case and analysis of 100 cases from the literature. Am J Surg 1946;71: Choi Y, Lee D. A case of rectus sheath hematoma caused by yoga exercise. Am J Emerg Med 2009:27(7):899.e Kayrak M, Bacaksiz A, Yazici M. Is enoxaparin injection from the abdominal wall safe in elderly people?: a fatal case of rectus sheath hematoma. Can Fam Physician 2008; 54(9): Ross DS. Hematoma of the rectus sheath. Occup Med 1976;26: Fothergill WE. Hematoma in the abdominal wall simulating pelvic new growth. Br Med J 1926;1(3413): Linhares MM, Lopes Filho GJ, Bruna PC, Ricca AB, Sato NY, Sacalabrini M. Spontaneous hematoma of the rectus abdominis sheath: a review of 177 cases with report of 7 personal cases. Int Surg 1999;84(3): Cervantes J, Sanchez Cortazar J, Ponte RJ, Manso M. Ultrasound diagnosis of rectus sheath hematoma. Am Surg 1983;49(10): Rimola J, Perendreu J, Falcó J, Fortuño JR, Massuet A, Branera J. Percutaneous arterial embolization in the management of rectus sheath hematoma. AJR Am J Roentgenol 2007;188(6): Toyonaga J, Tsuruya K, Masutani K, Maeda H, Nakamura K, Taniguchi M, et al. Hemorrhagic shock and obstructive uropathy due to a large rectus sheath hematoma in a patient on anticoagulant therapy. Intern Med 2009;48(24): Carkman S, Ozben V, Zengin K, Somuncu E, Karatas A. Spontaneous rectus shealth hematoma: an analysis of 15 cases. Ulus Travma Acil Cerrahi Derg 2010;16(6):532-6.