Abstract
Purpose
Non-traumatic spontaneous hematoma of the rectus abdominal muscle is not considered a critical condition. Nevertheless, it can be a serious complication in some patients due to continuous and/or consistent bleeding. The most frequent cause of spontaneous rectus muscle hematoma is the anticoagulation therapy. The natural history of rectus muscle hematoma usually leads to a positive outcome and can be spontaneously self-limited only by conservative therapy. Nevertheless, in some patients, despite a correct and early medical therapy, the continuous bleeding requests a more radical handling. Up to now, the surgical hematoma evacuation and the bonding of blood vessels were considered the most appropriate treatment, while at present, the percutaneous management by means of selective catheters and embolization of the bleeding vessel is considered to be the most used option. Our purpose is to report our experience in the endovascular spontaneous rectus muscle bleeding treatment in the elderly patients.
Materials and methods
From the data base and medical reports of the hospital, we selected 144 medical reports. We focused on those cases that showed the following criteria: patients with rectus muscle hematoma undergoing anticoagulation therapy and/or non-traumatic spontaneous hematoma and with persistent bleeding revealed on CT examination despite a pharmacological treatment aimed to timely reverse coagulopathy. These criteria were found in 18 patients: 15 females and 3 males, with a median age of 73 (range 64–81). In all patients, the diagnosis had been confirmed by an abdominal CT in emergency setting, performed before and after contrast medium intravenous administration. Because of clinical conditions, all patients had been moved on the angiographic room for diagnostic arteriography and embolization. The criteria for this treatment were hemodynamic instability and the continuous bleeding despite the correct medical therapy.
Results
CT imaging detected rectus muscle hematoma in 18/18 patients and active bleeding in 7/18 patients. Selective catheterization was applied to all 18 patients; arteriographic study confirmed the information of the CT study in all of the seven patients. The inferior epigastric artery was the main cause of the bleeding in all 18 patients. In 14 patients, one single vessel was responsible for the bleeding, while in the other four patients, more than one vessel were involved: In two patients, we also found the involvement of the superior epigastric artery; while the other two patients showed also the involvement of the deep iliac circumflex artery. The material for embolization was compatible coils with micro-catheters in 17/18 patients, and glue for 1/18 patient.
Conclusions
Patients with large rectus muscle hematoma, which have not yet recovered with conservative therapy, should then consider undergoing endovascular treatment. This procedure is highly recommended in patients with other coexisting pathologies that could eventually lead to a fatal outcome. It is difficult to determine when surgery is necessary when there is very poor data provided by scientific literature review, so the decision to use surgery can be suggested when embolization is unsuccessful or when it is necessary to evacuate a complex huge fluid mass in peritoneal cavity.
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References
Verhagen HJ, Tolenaar PL, Sybrandy R (1993) Hematoma of the rectus abdominis muscle. Eur J Surg 105(6):335–338
Cherry B, Mueller P (2006) Rectus sheath hematoma. Review of 126 cases at a single institution. Medicine 85:105–110
Ozucelik D, Yucel N, Emet M et al (2005) Spontaneous rectus sheath hematoma presenting with acute abdominal pain: a case series and review of the literature. Ann Saudi Med 25:250–254
Edlow JA, Juang P, Margulies S et al (1999) Rectus sheath hematoma. Ann Emerg Med 34:671–675
Adeonigbabe O, Khademi A, Karowe M, Gualtieri N, Robilotti J (2000) Spontaneous rectus sheath hematoma and an anterior pelvic hematoma as a complication of anticoagulation. Am J Gastroenterol 95(1):314–315
Levine MN, Raskob G, Landefeld S, Kearon C (2001) Hemorrhagic complication of anticoagulant treatment. Chest 119(suppl):108S–121S
Berna JD, Zuazu I, Madrigal M, Garcia-Medina V, Fernandez C, Guirado F (2000) Conservative treatment of large rectus sheath hematoma in patients undergoing anticoagulant therapy. Abdom Imaging 25(3):230–234
Zainea GG, Jordan F (1988) Rectus sheath hematomas: their pathogenesis, diagnosis and management. Am Surg 54:630–633
Titone C, Lipsius M, Krakauer S (1972) Spontaneous hematoma of the rectus abdominis muscle: critical review of 50 cases with emphasis on early diagnosis and treatment. Surgery 72:568–572
Zack JR, Ferral H, Postoak D, Wholey M (2001) Coil embolization of rectus sheath hemorraghe. J Trauma 51:793–795
James RF (2005) Rectus sheath hematoma. Lancet 365:1824
Cavagna E, Carubia G, Schiavon F (2000) Correlazioni anatomo radiologiche negli ematomi dei muscoli retti dell’addome. Radiol Med 99:432–437
Abrams HL, Baum S, Pentecost MJ (1997) Abram’s angiography: vascular and interventional radiology, 4th edn. Little Brown, Boston
Lambroza A, Tighe MK, DeCosse JJ, DAnnenberg AJ (1995) Disorders of the rectus abdominis muscle and sheath: a 22 year experience. Am J Gastroenterol 90:1313–1317
Barbaros E, Turkbey M, Murat C et al (2007) An unusual complication of carotid stenting: spontaneous rectus sheath hematoma and its endovascular management. Diagn Interv Radiol 13:46–48
Fitzgerald JE, Fitzgerald LA, Anderson FE et al (2009) The changing nature of rectus sheath hematoma: case series and literature review. Int J Surg 7:150–154
Lohle PN, Puylaert JB, Coerkamp EG, Hennans FT (1995) Non palpable rectus sheath hematoma clinically masquerading as appendicitis: US and CT diagnosis. Abdom Imaging 20(2):152–155
Riaz AA, Phyactides L, Smith F, Heng KS, Law NW, Hamilton HE (2000) Spontaneous rectus sheath hematoma mimicking an enlarged urinary bladder. Hosp Med 61(10):739
Humphrey R, Carlan SJ, Greenbaum L (2001) Rectus sheath hematoma in pregnancy. J Clin Ultrasound 29:306–311
Landefeld CS, Beyth RJ (1993) Anticoagulant related bleeding: clinical epidemiology, prediction and prevention. Am J Med 93:315–328
Raven MC, Hoffman RS (2005) Images in emergency medicine. Acute left sided rectus sheath hematoma. Ann Emerg Med 46(6):558–562
Jonhson RC, Fligelstone LJ, Boyce DF, Salaman JR (1994) Rectus sheath hematoma: diagnosis is essential. Br J Clin Pract 48(5):269–270
Berna Serna JD, Sanchez Garre J, Madrigal M et al (2005) Ultrasound therapy in rectus sheath hematoma. Phys Ther 85(4):352–357
Berna JD, Garcia V, Guirao J, Garcia J (1996) Rectus sheath hematoma: diagnostic classification by CT. Abdom Imaging 21(1):62–64
Moreno Gallego A, Aguayo JL, Flores B et al (1997) Ultrasonography and computed tomography reduce unnecessary surgery in abdominal rectus sheath hematoma. Br J Surg 84:1295–1297
Todd AW (2001) Inadvertent puncture of the inferior epigastric artery during needle biopsy with fatal outcome. Clin Radiol 2001(56):989–1002
Segev Y, Orron D, Alon R et al (1994) Pseudoaneurysm of the inferior epigastric artery mimicking abdominal wall hematoma. J Ultrasound Med 13:483–484
Lam E, McLafferty R, Taylor LJ et al (1998) Inferior epigastric artery pseudoaneurysm: a complication of paracentesis. J Vasc Surg 28:566–569
Pellegrin A, Stocca T, Belgrano M et al (2013) Preoperative vascular mapping with multislice CT of deep inferior epigastric artery perforators in planning breast reconstruction after mastectomy. Rad Med 118:732–743
Kapan S, Turhan A, Alis H et al (2008) Rectus sheath hematoma: three cases reports. J Med Case Rep 2:22
Berna JD, Zuazu I, Madrigal M et al (2000) Conservative treatment of large rectus sheath hematoma in patients undergoing anticoagulant therapy. Abdom Imaging 25:230–234
Zainea GG, Jordan F (1988) Rectus sheath hematomas: their pathogenesis, diagnosis and management. Am Surg 54:630–633
Titone C, Lipsius M, Krakauer S (1972) Spontaneous hematoma of the rectus abdominis muscle: critical review of 50 cases with emphasis on early diagnosis and treatment. Surgery 72:568–572
Basile A, Medina JG, Mundo E, Medina Garcia VG, Leal R (2004) Transcatheter arterial embolization of concurrent spontaneous hematomas of the rectus sheath and psoas muscle in patients undergoing anticoagulation. Cardiovasc Interv Radiol 27:659–662
Rimola J, Perendreu J, Falco J et al (2007) Percutaneous arterial embolization in the management of rectus sheath hematoma. A J R 188:497–502
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Pieri, S., Agresti, P., Buquicchio, G.L. et al. Endovascular management of the rectus muscle hematoma. Radiol med 120, 951–958 (2015). https://doi.org/10.1007/s11547-015-0516-2
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DOI: https://doi.org/10.1007/s11547-015-0516-2