Diagnostic and management of spontaneous rectus sheath hematoma

• Published in: European journal of internal medicine Vol. 24; no. 6; pp. 579 - 582
• Main Authors: Smithson, Alex, Ruiz, Jessica, Perello, Rafael, Valverde, Marta, Ramos, Javier, Garzo, Luïsa
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier B.V 01.09.2013
• Subjects: Abdominal pain; Abdominal Pain - etiology; Aged; Aged, 80 and over; Anticoagulants - adverse effects; Cohort Studies; Embolization; Embolization, Therapeutic; Epigastric Arteries; Female; Hematoma - complications; Hematoma - diagnosis; Hematoma - therapy; Humans; Hypertension - complications; Internal Medicine; Male; Middle Aged; Rectus Abdominis - diagnostic imaging; Rectus sheath hematoma; Retrospective Studies; Spontaneous; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography; Rectus sheath hematoma; Abdominal pain; Embolization; Spontaneous
• ISSN: 0953-6205; 1879-0828
• DOI: 10.1016/j.ejim.2013.02.016

Abstract Background Spontaneous rectus sheath hematoma is an uncommon and often misdiagnosed cause of abdominal pain. The aim of this study is to describe our experience in their management. Methods Retrospective analysis of the characteristics and outcomes of the spontaneous rectus sheath hematomas diagnosed over the last 12 years was conducted. Results 24 patients were included (66% women; mean age: 74 years; range: 54–87). All cases presented predisposing factors mainly anticoagulant therapy in 21 (87.5%) patients, hypertension in 19 (79.1%) and abdominal surgery in 12 (50%) cases. Eighteen (75%) referred triggering factors like coughing being the most common one, present in 17 (70.8%) patients. The main clinical findings were abdominal pain in 21 (87.5%) cases and the existence of an abdominal mass in 20 (83.3%). The diagnosis was confirmed by abdominal ultrasonography and/or computerized tomography in 23 (95.8%) patients. Nineteen cases (79.1%) responded to conservative management while 5 (20.8%) required interventional treatment, which consisted in an arteriography with selective embolization of the epigastric arteries in all cases. Four (80%) of the patients needing interventional treatment were receiving low molecular weight heparin. Nine (37.5%) patients developed hypovolemic shock and 1 (4%) died. Conclusions Spontaneous rectus sheath hematomas should be considered in the differential diagnosis of abdominal pain, particularly in elderly women under anticoagulant therapy with onset of symptoms after a bout of cough. Most cases respond to conservative management, although those related to low molecular weight heparin might require interventional treatment; arteriography with selective embolization of the epigastric arteries is the first therapeutic option.