Hernia

, Volume 19, Issue 3, pp 509–512

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

Authors

    • Primary Health Care Centre of Kissamos
  • M. Kastanakis
    • First Department of SurgerySaint George General Hospital of Chania
  • G. Petrakis
    • First Department of SurgerySaint George General Hospital of Chania
  • E. Bobolakis
    • First Department of SurgerySaint George General Hospital of Chania
Original Article

DOI: 10.1007/s10029-013-1186-4

Cite this article as:
Anyfantakis, D., Kastanakis, M., Petrakis, G. et al. Hernia (2015) 19: 509. doi:10.1007/s10029-013-1186-4

Abstract

Purpose

Rectus sheath hematoma (RSH) represents an unusual abdominal wall pathology, frequently confounded as acute abdomen, with high mortality rates reported especially among elderly patients. The purpose of this retrospective study was to delineate characteristics of the patients diagnosed with RSH at the First Surgery Department of the Saint George General Hospital of Chania, Greece over a 5-year period.

Methods

Seven patients with a median age of 62 years (range 51–85) were included in the study. Clinical features, demographics, management and outcome are summarized.

Results

The most common predisposing risk factor was anticoagulation. Acute onset abdominal pain and painful palpable abdominal mass, located more often on the right lower abdominal quadrant, were the most frequent initial symptoms. Management was mostly conservative [6 (85.7 %)] with disruption of anticoagulation, analgesia and bed rest. Blood transfusion was performed in hemodynamic compromised patients [2 (28.5 %)]. One patient was not appropriately diagnosed. On admission, the patient presented severe hemodynamic compromise and for this reason underwent emergency explorative laparotomy. The majority of the patients [6 (85.7 %)] experienced an uncomplicated clinical recovery and were discharged home after a mean hospital stay of 10 days (range 7–12).

Conclusions

Surgeons as well as primary care physicians have to be aware of the clinical diagnostic tests and include the condition in the differential diagnosis of acute onset abdominal pain. Prompt recognition will prevent unnecessary surgical intervention and potential complications.

Keywords

Rectus sheath hematomaDiagnosisManagement

Introduction

Rectus sheath hematoma (RSH) is a rare abdominal wall condition occurring from the accumulation of blood within the rectus abdominis muscle sheath secondary to either an epigastric vessel disruption or a musculature tear [1]. Common factors that predispose to the RSH formation include anticoagulant treatment, abdominal trauma, obesity, hypertension and increase abdominal pressure from coughing, straining or pregnancy [1]. Due to its non-specific clinical expression at onset, RSH is often misdiagnosed as acute abdomen leading to explorative laparotomy with secondary adverse health outcomes [2]. Remarkably, high mortality rates reaching up to 20 % have been reported, especially among elderly fragile patients [3].

Methods

We retrospectively analyzed clinical and demographical characteristics of the patients with RSH diagnosed at our department from January 1999 to January 2004. Details about management, duration of hospitalization and outcome are also reported. Seven patients, 6 females (85.7 %) and 1 male (14.3 %), were diagnosed with RSH, with a mean age of 62 years (range 51–85). Initial diagnostic suspicion was raised by the presence of acute abdominal pain with, or a palpable abdominal mass, predisposing conditions such as anticoagulation therapy and the existence of positive clinical signs during abdominal examination suggestive for RSH. More specifically, Fothergill’s and Carnett’s signs were performed.

Fothergill’s sign is considered a useful and reliable diagnostic tool in the evaluation of abdominal tenderness by assisting differentiation of intra-abdominal mass from a mass that arises in the abdominal wall [4]. The patient being in a supine position was asked to lift the head and touch the chest using the chin [4]. In a patient with RSH, during tension of the abdominal rectus muscle, the abdominal mass will remain palpable and fixed [4]. In case of intra-abdominal pathology, abdominal mass will become impalpable [4].

Carnett’s sign, first described in 1926 [5], is considered positive when abdominal pain or tenderness remains constant or increases when the abdominal wall muscles are tensed by asking patient to lift the head and shoulders from the pillow. Negative Carnett’s sign (decreased abdominal tenderness while tensing the abdomen) is suggestive for intra-abdominal pathology [5].

Results

Two of the patients with a diagnosis of acute abdomen were referred by their general practitioners. The most common predisposing risk factor was anticoagulation therapy. Four of the patients (57.1 %) were receiving low molecular weight heparin (LMWH). From those receiving LMWH, three patients suffered from previous deep vein thrombosis, while one underwent a hip replacement surgery. Two of the patients (28.5 %) were under treatment with oral vitamin K antagonist (acenocoumarol) due to aortic valve replacement and atrial fibrillation, respectively. One patient suffered from chronic kidney disease and hematoma was formatted secondary to a vigorous contraction of the abdominal musculature due to persistent coughing. A schematic presentation of the main clinical and demographic features of the patients appears in Table 1.
Table 1

Schematic presentation of the characteristics of the patients with RSH

No. (n)

Gender

Age [mean 62 (51–85)]

Size (cm)

Clinical manifestation at admission

Location

Clinical signs at admission

1

F

51

5 × 8 × 7

Palpable mass

Left lower Q

+ Fothergill sign

2

M

51

6 × 3 × 6.5

Abdominal pain/palpable mass

Right lower Q

+ Carnett sign/+ Fothergill sign

3

F

65

4 × 2.5 × 8

Abdominal pain

Right lower Q

+ Carnett sign

4

F

83

Abdominal US was inconclusive

Abdominal pain

Left lower Q

Rebound tenderness/+ Carnett sign

5

F

50

4.3 × 2.6 × 6.7

Abdominal pain/palpable mass

Right lower Q

+ Carnett sign/+ Fothergill sign

6

F

49

9.2 × 7.7 × 11

Abdominal pain

Right lower Q

Rebound tenderness/+ Carnett sign

7

F

85

10 × 8 × 9

Abdominal pain/palpable mass

Right lower Q

+ Carnett sign/+ Fothergill sign

F female, M male, Q quadrant

The most frequent presenting symptom was acute onset, sharp abdominal pain with progressive severity [6 (85.7 %)] followed by a palpable abdominal wall mass [4 (57.1 %)]. With regard to location, in all seven cases symptoms were presented in the lower abdominal quadrants with a predominance in the right lower abdominal quadrant [5 (71.4 %)]. A positive Carnett sign was present in the majority of cases [6 (85.7 %)]. Fothergill sign was positive in 4 cases (57.1 %). Local peritoneal irritation with rebound tenderness on palpation was present in 2 cases (28.5 %). Remarkably, 48–72 h after admission, 4 cases (57.1 %) presented periumbilical ecchymosis (Cullen sign).

Definitive diagnosis was confirmed by abdominal computerized tomography (CT) in 5 cases (71.4 %). Although abdominal US established the diagnosis in one case, in another case it was negative and failed to determine the cause of acute abdomen. Treatment consisted of conservative intra-hospital management in stable patients with discontinuation of anticoagulants, fluid resuscitation, bed rest and analgesic medication [6 (85.7 %)]. Two patients (28.5 %) underwent blood transfusion due to a significant decrease in hemoglobin and hematocrit levels, 12–48 h from admission. One patient with a previous history of chronic renal failure was admitted to the emergency department with severe hemodynamic instability. Accurate diagnosis was not possible with the ultrasound imaging and due to the continuous drop of hemoglobin and of hematocrit levels, the patient was operated with emergency explorative laparotomy. Intraoperatively, we identified a large hematoma involving the left rectus sheath with extension into the pelvic cavity. The hematoma was successfully evacuated and the abdominal pressure was relieved. No bleeding vessels were detected during surgery. The patient was transported to the Intensive Care Unit and died 9 h after, from cardiac arrest secondary to myocardial infarction. The remaining six patients had a normal clinical recovery without any complications during their hospital stay. The mean value of the hospital stay was 10 days (range 7–12). A follow-up CT abdominal scan has been also performed and revealed total remission of the hematomas.

Discussion

Consistent with our findings, a female gender predilection in the 5th decade of life has been reported [1]. With regard to location, in alignment with our analysis, although RSH may develop in any abdominal quadrant, occurrence in the lower abdominal quadrants is more common [1]. This could be attributed to the supportive deficit of the posterior wall of the rectus abdominis muscle below the linea semilunaris [1].

RSH is a well-known disorder described by Hippocrates and Galen with the first case reported in the United States by Richardson in 1857 [6]. Diagnosis at the early phases is often obscure [7]. It can mimic a variety of acute surgical abdomen conditions making diagnosis challenging [1]. Appendicitis, ovarian cyst, strangulated hernia, intestinal obstruction are some of the conditions included in the differential diagnosis of RSH [1].

Careful clinical assessment by taking a detailed medical history combined with the use of bedside diagnostic tests may allow prompt recognition of this abdominal wall pathology and avoid unnecessary surgical intervention [1, 7]. Abdominal CT and US are the most frequently used imaging investigations to differentiate between RSH and intra-abdominal disorders [8]. However, CT is considered the most sensitive diagnostic modality for the confirmation of diagnosis, especially in uncertain cases where abdominal US is inconclusive [1, 8]. Furthermore, CT may provide additional information on the activity of hemorrhage [8].

On the basis of CT findings, the condition is classified into three subtypes [9]. Type I hematoma is mild, unilateral, occurs within the muscle and does not require hospital admission [9]. They usually resolve without therapy within a month. Type II hematoma is located intramuscular but bleeding extends between the muscle and the transversalis fascia [9]. It may be unilateral or bilateral. Patients with type II hematoma usually require short hospitalization for close observation [9]. Type III hematoma occurs between the muscle and the transversalis fascia in the peritoneum, and in the prevesical space [9]. This type often mimics acute abdomen and is associated with anticoagulant therapy [9]. Management often requires blood transfusion; the patient is discharged within 1 week while complete resolution occurs in more than 3 months [9].

Therapeutic strategy of the RSH will be influenced by parameters such as dimension of the RSH, patients’ comorbidities and potential complications [10]. Follow-up of the patients with RSH usually does not reveal any problem [10]. The majority of RSH follows a favorable course and resolves spontaneously after conservative management [10]. 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]. This non-interventional approach represents currently the treatment of choice [1] and consists of disruption of anticoagulation, analgesics, bed rest [8], compression of the hematoma [1], application of icepacks [1] and control of the predisposing risk factors [1]. Reversal of anticoagulation with or without antiplatelet therapy and intravenous fluid resuscitation with blood transfusion in haemodynamically unstable patients should be performed under the guidance of an expert hematologist [8]. It has been reported that, in general, 2–6 units of packed red blood cells are required [14].

If the conservative management fails to control active bleeding and the patients become hemodynamically compromised, invasive management with radiological embolization of the bleeding vessels represents the next step and should be performed without delay [8, 10]. The use of coil embolization [15] and gelfoam [16] has been also reported [10]. In case that the previously reported radiological embolization is not successful and the patient continues to be unstable, open surgical approach represents the last option and consists of hematoma evacuation and ligation of the bleeding vessels [8, 10]. Surgical drainage of the clot is discouraged since this may cause continuous bleeding by reducing a potential tamponade effect [8]. This is only indicated on the suspicion of abdominal compartment syndrome [8]. Careful abdominal administration of LMWH as well as trocar insertion under direct visualization during laparoscopic operation is considered important preventive measures to avoid the formation of RSH [17].

Conclusions

RSH, although well-documented cause of abdominal pain, is frequently misdiagnosed as acute intra-abdominal condition leading to unnecessary surgical intervention with subsequent high mortality-related burden among elderly patients. Its incidence is expected to rise due to the increase of the elderly population and the widespread use of anticoagulation [10]. For this reason, awareness of the clinical and radiological diagnostic modalities may allow for early diagnosis and appropriate non-interventional management [10], preventing potential complications.

Since life-threatening conditions rarely allow diagnostic revisions, we highlight the necessity of a high index of clinical suspicion on behalf of surgeons and primary care physicians when they encounter elderly patients with sudden-onset progressive abdominal pain receiving anticoagulation therapy.

Conflict of interest

DA declares no conflict of interest, MK declares no conflict of interest, GP declares no conflict of interest, EB declares no conflict of interest, No grant and/or honorarium and/or travel support is declared by all the authors.

Copyright information

© Springer-Verlag France 2013