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Rectus Sheath Hematoma Clinical Presentation

  • Author: Wan-Tsu Wendy Chang, MD; Chief Editor: Steven C Dronen, MD, FAAEM  more...
 
Updated: Nov 02, 2014
 

History

Common historical features of rectus sheath hematoma (RSH) include acute abdominal pain, fever, nausea, and vomiting. The nonspecific nature of these symptoms combined with the low incidence of the disorder lead to difficulty in considering this diagnosis. Rectus sheath hematoma should be included in the differential diagnosis of every patient who presents with abdominal pain.

Specific symptoms

Constitutional

Fever and chills are common symptoms in rectus sheath hematoma. Symptoms of hypovolemic shock with weakness, confusion, pallor, and diaphoresis can develop in patients with a large rectus sheath hematoma.

Abdominal pain

The most common presenting symptom is acute abdominal pain. The onset of pain may be sudden, but more often, it develops over a period of several hours. The pain is typically sharp and severe, with an associated palpable abdominal mass. Pain is usually worse with movement and is often unilateral. Constant pain with episodic abdominal cramping is also a frequent symptom. In atypical cases, the pain may develop insidiously, making the abdominal mass difficult to differentiate from an abdominal wall neoplasm.

Gastrointestinal/urologic

Anorexia, nausea, vomiting, diarrhea, constipation, tenesmus, and bladder irritability are all compatible with the diagnosis of rectus sheath hematoma. The severity of symptoms is related to the degree of peritoneal irritation.

Precipitating factors

The clinician needs to have rectus sheath hematoma in the differential, or the diagnosis will be easily overlooked. A careful history should include directed questions regarding surgical procedures, occult blunt trauma, coughing, sneezing, constipation (straining at the stool), or exercise. In patients with certain medical problems, questions about recent asthma exacerbations, bronchitis, or upper respiratory tract infections may prove helpful. Rectus sheath hematoma must always be considered in abdominal pain patients on anticoagulants.

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Physical

Vital signs

A low-grade fever is common in rectus sheath hematoma. The hematoma can be large enough to compromise intravascular volume, with resultant signs of hypovolemic shock including hypotension, tachycardia, and tachypnea.

Abdominal examination

Typically, the abdominal examination reveals a palpable, painful, firm, nonpulsatile abdominal mass corresponding to the rectus sheath. The mass may be bilobar with a central groove. The mass does not move with respiration. Because the hematoma is deep to the subcutaneous tissue and rectus muscles, the mass is not always palpable, particularly in obese patients. In 2000, Berna et al's case series reported a palpable mass detected in 8 of 12 patients.[4]

Hyperesthesia of the overlying skin is not uncommon. Bowel sounds may be absent. Signs of local peritoneal irritation with rebound tenderness and involuntary guarding may be present. This finding is most often seen in infra-umbilical hematomas due to the thin transverse fascialis serving as the only barrier between a hematoma and the peritoneum. Rarely, a hematoma may cause extraperitoneal compression of the abdominal cavity and cause abdominal compartment syndrome, or even rupture into the peritoneum, causing a chemical peritonitis.

The Fothergill sign is useful in determining whether an abdominal mass is part of the abdominal wall or whether it is in the abdomen. It is elicited by voluntary contraction of the rectus muscles by the patient lifting either his or her head or legs while in the supine position. With this action, rectus sheath hematomas become fixed, more painful, and more tender, while intra-abdominal masses become less distinct and less tender. The Fothergill sign may be inconclusive in patients who are obese or pregnant. As described by Fothergill in 1926[5] :

This patient complains of pain and the medical man finds the swelling. The trouble is that he seldom knows how long the swelling has been present…The main point is the recognition that these swellings are part and parcel of the abdominal wall. This is generally made by noting that they can still be felt when the recti are in action, and that they become fixed as the muscles contract

The Carnett sign is an additional test to assist in differentiating between abdominal wall and intra-abdominal pathology. It is performed by having the patient lie supine and tensing the abdominal musculature by raising either the head or the shoulder off the table. A positive sign is elicited if abdominal tenderness is increased or unchanged while tensing the abdomen. This indicates an abdominal wall process. A negative sign, or decreased abdominal tenderness while tensing the abdomen, suggests intra-abdominal pathology. Previous studies have demonstrated this sign to be fairly sensitive but not specific for abdominal wall pathology.

The Cullen sign of periumbilical ecchymosis is associated with retroperitoneal or abdominal wall hemorrhage. In rectus sheath hematoma, ecchymosis appears after 2-5 days. The ecchymosis uncommonly extends into the flanks.

See the image below.

The Cullen sign, periumbilical ecchymosis, in a pa The Cullen sign, periumbilical ecchymosis, in a patient with a rectus sheath hematoma.

The Grey-Turner sign is another manifestation of retroperitoneal hemorrhage. This finding of flank ecchymosis was initially described in hemorrhagic pancreatitis, and along with the Cullen sign, it is not specific for retroperitoneal or abdominal wall hemorrhage.

Pelvic examination

The pelvic examination may reveal a mass anterior to the vagina and above the pubis. The pelvic examination may be misleading, particularly in those cases that demonstrate unilateral adnexal tenderness and mass.

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Causes

Several risk factors of rectus sheath hematoma (RSH) can be obtained in the history. In most cases of rectus sheath hematoma, one or more precipitating factors can be found. Reports of spontaneous rectus sheath hematoma exist, but more likely, in these cases, the precipitating factor was not appreciated. Anticoagulation is the most frequent predisposing factor, and severe coughing is the most important inciting factor.

Anticoagulation

Rectus sheath hematoma is a well-recognized complication of anticoagulant therapy. Anticoagulation can be a predisposing factor, or it can directly cause rectus sheath hematoma by accidental intramuscular injection of LMWHs. Heparin-induced immune microangiopathy has been proposed as a mechanism of the pathogenetic process. Rectus sheath hematoma secondary to anticoagulation may have greater morbidity and mortality because of increased hemorrhage volume. Even when coagulation factors are within the therapeutic range, a substantial risk of hemorrhage still exists.[6]

Coughing

Rectus sheath hematoma can occur after bouts of severe coughing, explaining its association with asthma, tuberculosis, influenza, pertussis, and other respiratory infections.[6]

Pregnancy

Rectus sheath hematoma is associated with pregnancy in the gravid state, during labor, and in the early postpartum period.

Previous abdominal surgery

Abdominal operations predispose to rectus sheath hematoma because surgical scars redirect the shearing forces on muscle contraction, placing more stress on the epigastric vessels.

Recent abdominal surgery

Excessive retraction or inadequate hemostasis can cause rectus sheath hematoma that may become evident up to 4 weeks after the procedure.

Chronic kidney disease

In a study by Sheth et al involving 115 hospitalized patients with a confirmed diagnosis of rectus sheath hematoma, 58.3% of them had chronic kidney disease of stage 3 or higher.[6]

Steroid/immunosuppressive therapy

In the above-mentioned study by Sheth et al, 41.7% of the patients were undergoing steroid/immunosuppressive treatment.[6]

External trauma

The nature of the trauma can be trivial. Tight contraction of the recti in anticipation of a blow predisposes to rectus sheath hematoma formation.[6]

Vigorous uncoordinated rectus muscle contraction

Rectus sheath hematoma has been observed in a healthy man leaping over a ditch and in a woman rising from a chair to adjust a curtain rod. In a similar manner, sports activities and exercises, such as golf, tennis, skiing, and weight lifting, have caused rectus sheath hematoma. Activities with significant Valsalva effort, such as coughing, sneezing, straining from constipation, urination, and sexual intercourse, have been implicated in rectus sheath hematoma.

General medical conditions

General medical conditions that predispose to rectus sheath hematoma can be categorized as those causing damage to blood vessels; those causing failure of coagulation; or as anomalous conditions, such as endometriosis in the rectus sheath. Vascular conditions of hypertension, arteriosclerosis, and collagen vascular disease are associated with rectus sheath hematoma. Disorders of coagulation associated with RSH include leukemia, myeloproliferative disorders, hemophilia, and blood dyscrasias.

Unusual

Case reports have also described rectus sheath hematoma related to acupuncture and follicle aspiration for in vitro fertilization. Minor surgical procedures such as diagnostic or therapeutic paracentesis have also been shown to cause rectus sheath hematoma.[7] In addition to LMWH injections, rectus sheath hematoma has also been seen in any abdominal wall medication injections (eg, insulin).[8] These unusual causes underscore the importance in obtaining a thorough history from the patient.

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Contributor Information and Disclosures
Author

Wan-Tsu Wendy Chang, MD Fellow in Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine

Wan-Tsu Wendy Chang, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Society of Critical Care Medicine, Neurocritical Care Society

Disclosure: Nothing to disclose.

Coauthor(s)

Andra L Blomkalns, MD Associate Professor, Vice Chair - Academic Affairs, Department of Emergency Medicine, University of Cincinnati School of Medicine

Andra L Blomkalns, MD is a member of the following medical societies: American College of Emergency Physicians, American Heart Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

William A Knight IV, MD Assistant Professor, Department of Emergency Medicine, Assistant Professor, Department of Neurosurgery, Division of Neurocritical Care, University of Cincinnati College of Medicine

William A Knight IV, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine, Society of Critical Care Medicine, Emergency Medicine Residents' Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Genentech, Inc.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Fred Harchelroad, MD, FACMT, FAAEM, FACEP Attending Physician in Emergency Medicine, Excela Health System

Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Jerry R Balentine, DO, FACEP, FACOEP Vice President, Medical Affairs and Global Health, New York Institute of Technology; Professor of Emergency Medicine, New York Institute of Technology College of Osteopathic Medicine

Jerry R Balentine, DO, FACEP, FACOEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, American College of Osteopathic Emergency Physicians, American Association for Physician Leadership, American Osteopathic Association

Disclosure: Nothing to disclose.

Acknowledgements

Steven G Werdehoff, MD Consulting Staff, Department of Emergency Medicine, Huntsville Emergency Physicians Group

Steven G Werdehoff, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References
  1. Teske JM. Hematoma of the rectus abdominis muscle: report of a case and analysis of 100 cases from the literature. Am J Surg. 1946. 71:689-95.

  2. Berna JD, Garcia-Medina V, Guirao J, Garcia-Medina J. Rectus sheath hematoma: diagnostic classification by CT. Abdom Imaging. 1996 Jan-Feb. 21(1):62-4. [Medline].

  3. Klingler PJ, Wetscher G, Glaser K, et al. The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders. Surg Endosc. 1999 Nov. 13(11):1129-34. [Medline].

  4. Berna JD, Zuazu I, Madrigal M, et al. Conservative treatment of large rectus sheath hematoma in patients undergoing anticoagulant therapy. Abdom Imaging. 2000 May-Jun. 25(3):230-4. [Medline].

  5. Fothergill WE. Hematoma in the abdominal wall simulating pelvic new growth. Br Med J. 1926. 1:941-2.

  6. Sheth HS, Kumar R, DiNella J, Janov C, Kaldas H, Smith RE. Evaluation of Risk Factors for Rectus Sheath Hematoma. Clin Appl Thromb Hemost. 2014 Oct 7. [Medline].

  7. Ko SB, Choi HA, Malhotra R, Lee K. Giant rectus sheath hematoma after therapeutic paracentesis resulting in hemodynamic instability in the intensive care unit. Hosp Pract (Minneap). Jun 2010. 38(3):52-5. [Medline].

  8. Auten JD, Schofer JM, Banks SL, Rooney TB. Exercise-induced bilateral rectus sheath hematomas presenting as acute abdominal pain with scrotal swelling and pressure: case report and review. J Emerg Med. Apr 2010. 38(3):e9-12. [Medline].

  9. Kaftori JK, Rosenberger A, Pollack S, Fish JH. Rectus sheath hematoma: ultrasonographic diagnosis. AJR Am J Roentgenol. 1977 Feb. 128(2):283-5. [Medline].

  10. Zainea GG, Jordan F. Rectus sheath hematomas: their pathogenesis, diagnosis, and management. Am Surg. 1988 Oct. 54(10):630-3. [Medline].

  11. Fukuda T, Sakamoto I, Kohzaki S, et al. Spontaneous rectus sheath hematomas: clinical and radiological features. Abdom Imaging. 1996 Jan-Feb. 21(1):58-61. [Medline].

  12. Unger EC, Glazer HS, Lee JK, Ling D. MRI of extracranial hematomas: preliminary observations. AJR Am J Roentgenol. 1986 Feb. 146(2):403-7. [Medline].

  13. Herzan FA. Roentgenologic diagnosis of rectus sheath hematoma. Am J Roentgenol Radium Ther Nucl Med. 1967 Oct. 101(2):397-405. [Medline].

  14. Monsein LH, Davis M. Radionuclide imaging of a rectus sheath hematoma caused by insulin injections. Clin Nucl Med. 1990 Aug. 15(8):539-41. [Medline].

  15. Osinbowale O, Bartholomew JR. Rectus sheath hematoma. Vasc Med. 2008 Nov. 13(4):275-9. [Medline].

  16. Levy JM, Gordon HW, Pitha NR, Nykamp PW. Gelfoam embolization for control of bleeding from rectus sheath hematoma. AJR Am J Roentgenol. 1980 Dec. 135(6):1283-4. [Medline].

 
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Anatomy of the rectus sheath.
The Cullen sign, periumbilical ecchymosis, in a patient with a rectus sheath hematoma.
Rectus sheath hematoma of the right rectus muscle. Image courtesy of Dr David Gordon.
Note how the rectus sheath hematoma becomes bilobar as it dissects inferiorly (same patient as in the previous image). Image courtesy of Dr David Gordon.
Ultrasound image of a rectus sheath hematoma presenting as a tender, unilateral abdominal mass. D Maharaj, M Ramdass, S Teelucksingh, A Perry and V Naraynsingh; Rectus sheath haematoma: a new set of diagnostic features. Postgraduate Medical Journal 2002;78:755-756. Reproduced with permission from the BMJ Publishing Group.
 
 
 
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