Expanding refractory rectus sheath hematoma: a therapeutic dilemma

Abstract

Rectus sheath hematoma (RSH) is a rare pathology. RSH is often misdiagnosed because its symptoms vary. Conservative management, including bed rest, analgesia, and intravenous fluid replacement, has long been the standard treatment for RSH, and problematic cases are rarely described (1). We report a case of two expanding refractory RSHs without evidence of active bleeding on contrast-enhanced computed tomography (CECT) and angiography. The patient was successfully treated by empiric transcatheter arterial embolization (TAE) of the inferior epigastric artery. Case reportAn 87-year-old woman with a history of hypertensive cardiovascular disease was admitted because of an acute cerebral infarction. She was initially treated with aspirin and dipyridamole. On the day of admission, she developed an excessive cough secondary to recurrent choking episodes. A nasogastric tube was then inserted to facilitate feeding. Antiplatelet agents were discontinued because material with a coffeeground appearance was present in the nasogastric effluent on the second day after admission. An upper gastrointestinal panendoscopy confirmed that she had active gastric ulcers. Her hemoglobin level was 13.3 g/dL. On the eighth day after admission, she experienced a paroxysm of coughing that lasted several minutes and was followed by severe abdominal pain and hypotension (blood pressure, 93/44 mmHg). Physical examination revealed a large tender mass in the lower left quadrant of the abdomen and the absence of rebound tenderness or muscular rigidity. Her hemoglobin level decreased to 8.3 g/dL, but her platelet count and coagulation profile were normal. Urgent CECT of the abdomen and pelvis revealed a 9.8×7.2×10.3 cm left RSH and a 3.2×2.3×5.9 cm right RSH. Ecchymosis developed in the periumbilical region and expanded into the bilateral inguinal regions by the thirteenth day after admission. Despite conservative treatment and transfusion of four units of erythrocyte, the size of the masses gradually increased, and persistent hemodynamic instability was present by the twenty-fourth day after admission. A repeat CECT scan was conducted on suspicion of continued bleeding and expanding hematomas. The left RSH measured 10.5×8.2×13 cm, extending into the pelvis, and the left inferior epigastric artery was engorged; the right RSH measured 4.5×2.8×7 cm (Figs. 1 and 2). Interventional radiology was conducted because of the patient's instability and poor response to conservative treatment. On angiography with selective catheterization of the left external iliac artery, the main trunk and branches of the vessel appeared normal, and there was no obvious contrast extravasation (Fig. 3). Because of the engorged left inferior epigastric artery and the patient's vigorous tussive efforts, the risk of microhemorrhage and coughinduced intermittent bleeding could not be disregarded. Consequently, INTERVENTIONAL RADIOLOGY CASE REPORT Expanding refractory rectus sheath hematoma: a therapeutic dilemmaGuo-Shiang Tseng, Guo-Shiou Liau, Hann-Yeh Shyu, Shi-Jye Chu, Fu-Ch...

Rectus sheath hematoma in a single secondary care institution: a retrospective study

“…The patients present a stable hemodynamic state without any serious complications [10]. However, hypovolemic shock [10,11], abdominal compartment syndrome [11], muscle necrosis [10,12], myocardial infarction [10] and death [10,11,13] are some of the potential complications of RSH. Management of RSH is mostly conservative [8,10].…”

Rectus sheath hematoma due to cough in an elderly patient under antiplatelet therapy

“…Superior and inferior epigastric veins are located along the posterior rectus sheath. As a result of the rupture of these vessels or rectus abdominis, muscle rectus sheath hematoma occurs (3). Above the arcuate line, the aponeuroses of the external oblique and the internal oblique muscles invest the rectus sheath anteriorly, and the apeneuroses of the transversalis and the internal oblique muscles invest the rectus sheath posteriorly.…”

Ultrasound-guided percutaneous drainage of a traumatic abdominal wall hematoma in the emergency department

“…Less common causes and risk factors are cough attacks, physical exercise, [2,3] intra-abdominal injections, over 50 years old, and pregnancy. [4,5] RSH is a collection of blood that occurs between the rectus sheath of the abdominal wall due to disruption of epigastric (inferior or superior) vessels or rectus muscle. Sometimes clinical manifestations of RSH are not specific and they require a complete clinical evaluation to make an appropriate diagnosis.…”