Rectus sheath hematomas (RSH) are generally caused by damage to the inferior epigastric artery. They are rare causes of abdominal pain or acute anemia due to blood loss, but they are an important diagnostic consideration because they can be cryptic and potentially fatal. Clinical Findings: An 85-year-old female who was admitted to the hospital for 10 days with a myasthenia crisis was abruptly hypotensive with a tender abdominal mass in the left lower quadrant that subtly crossed the midline. She was on prophylactic anticoagulation during her hospitalization. The patient was initially stabilized with fluids and given one unit of packed red blood cells. Results from a computed tomography angiography of her abdomen and pelvis showed a type III RSH. She underwent a percutaneous embolization of her inferior epigastric artery via interventional radiology. Unfortunately, she did not recover and was transitioned to hospice, where she died 1 day after discharge. Conclusion: Classic teaching associates RSHs with systemic anticoagulation and a physical exam notable for a mass not crossing the midline. However, a wider range of presentations, including an abdominal mass that crosses the midline, can occur. Other important risk factors include frailty, immunosuppression, and possibly abdominal injections (particularly heparin).
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