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Rectus Sheath Hematoma: a Diagnostic Dilemma Shaista Aziz Siddiqui

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Rectus Sheath Hematoma: a Diagnostic Dilemma Shaista Aziz Siddiqui CASE REPORT Rectus Sheath Hematoma: A Diagnostic Dilemma Shaista Aziz Siddiqui ABSTRACT Rectus sheath hematoma can present as an acute abdominal condition. A case presented as an obstetrical emergency, which was initially suspected as pregnancy-associated degenerating uterine fibroid and emergency laparotomy was performed under the belief of sudden abruption placenta or ruptured uterus. This patient was found to be misdiagnosed upon both the clinical and ultrasound examination and was subsequently discovered to have a rectus sheath hematoma at the time of surgery. Key words: Rectus sheath hematoma. Pregnancy. Acute abdominal pain. INTRODUCTION rebound tenderness. Her haemoglobin was 13 g/dl; haematocrit and platelets count were 37% and Rectus sheath hematoma (RSH) is an uncommon and 203,000/mm3 respectively. Blood biochemistry profile often clinically misdiagnosed cause of abdominal pain.1 was within normal limits and CTG (cardiotocography) It is the result of bleeding into the rectus sheath from was reactive. Ultrasound abdomen showed single alive damage to the superior or inferior epigastric arteries or fetus with fundal placenta and no evidence of their branches or from a direct tear of the rectus muscle. retroplacental hematoma but there was an avascular We report a case presenting with a diagnostic dilemma hypoechoic area on the right side of uterine wall. and was misdiagnosed as degenerating uterine Opinion was taken from surgical colleagues to rule out leiomyoma, abruption of placenta and ruptured uterus. surgical cause of pain, and a probable diagnosis of degenerating uterine leiomyoma was made, she was CASE REPORT kept under sedation and observation. Early morning at A 37 years old patient, 5th gravida with term pregnancy 6:00 am the severity of pain increased and CTG showed presented to emergency department in the evening with unprovoked deep decelerations. Her pulse was 110 b/m complaints of bouts of severe cough for 3 days and and blood pressure dropped to 90/60 mmHg. On sudden onset of right hypochondrium and right loin abdominal examination abdomen was tender and a pain few hours prior to admission. She complained 4 x 6 cms size swelling was noticed in the paraumblical of palpitation and cold sweating, but there was no region. Due to sudden tachycardia, hypotension, CTG nausea, vomiting or change of bowel habits. The fetal changes and paraumblical swelling a possible diagnosis movements were satisfactory. She had all full term of abruption placenta or ruptured uterus was made and normal vaginal deliveries in the past and her last born emergency laparotomy and caesarean section was child was 5 years old. performed. On opening the abdomen a large hematoma was found over the rectus muscles extending upto Her past medical and surgical history was not contributory subcoastal region. After delivering an alive 3.8 kg male and she denied the use of anticoagulant and antiplatelet baby, hematoma was evacuated and surgical repair of agents. On examination, her respiratory rate was 16 the torn epigastric artery and ruptured rectus abdominis breaths per minute, pulse rate was 86 beats per minute muscles was done by general surgeon. Two pints of and blood pressure was 134/84 mmHg. On abdominal blood was transfused to stabilize her condition. She examination, the height of fundus corresponded to made an uneventful recovery and was discharged home term; lie of the fetus was longitudinal with cephalic on third postoperative day. presentation and fetal heart rate was in the normal range. The paraumblical region was tender on touch, DISCUSSION otherwise her gravid obese abdomen was soft with no Rectus sheath hematoma is a well-described entity with a reported incidence of misdiagnosis as high as 93%,1 Department of Obstetrics and Gynaecology, Royal Commission as happened in this patient. It occurs 2-3 times more Medical Centre, Saudi Arabia. often in women than men.1,2 The higher incidence in Correspondence: Dr. Shaista Aziz Siddiqui, 4-G, 2/13, women is presumably due to the lower muscle mass as Nazimabad No. 4, Karachi. compared with men.1 RSH may occur due to trauma, E-mail: [email protected] blood dyscrasia, degenerating muscular disease, anti- Received October 27, 2009; accepted June 18, 2010. coagulant therapy, pregnancy, or spontaneous rupture of 828 Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (12): 828-829 Rectus sheath hematoma: a diagnostic dilemma epigastric vessel or the rectus muscle. Acute paroxysmal if the patient is unresponsive to initial fluid resuscitation. coughing, asthmatic attacks, bronchitis or influenza is Caesarean delivery is performed for fetal indications. the precipitating event in 56% of the cases.3 Rectus RSH has been associated with 50% rate of fetal sheath hematoma usually occurs in the lower abdominal demise.1,5 wall with the following anatomical considerations. Firstly The treatment of RSH comprises rest, analgesia, in the lower abdomen below the linea semilunaris there discontinuation of any anticoagulation therapy, blood is only weak tranversalis fascia and peritoneum support and blood products transfusions (if needed) and clinical the rectus and inferior epigastric vessels posteriorly.2 Secondly the branches of inferior epigastric pierce the observation. Surgical procedure may be used for rectus abdominis and are firmly attached to it.2 Thirdly diagnostic purpose as well as in controlling continued the rectus muscle is usually crossed by three transverse haemorrhage or intraperitoneal rupture. In general intersections, with the lowermost segment being the surgical procedures consist of clot evacuation, ligation of longest; hence muscle shortening and contractures are all bleeding vessels and closed suction drainage.9,10 greatest at this level. Rectus sheath hematoma is an unusual though not rare Three types of RSH can be distinguished by way of the cause of a painful abdominal mass that may present severity of haemorrhage as delineated on CT scan. to the gynaecologist. A careful history and physical Type-1 RSH are unilateral hematoma contained within examination and a high degree of suspicion when the muscles. Type-II RSH are bilateral hematomas performing ultrasound examination will assist in making or hematomas not contained within the muscle the correct diagnosis. Although spontaneous haemorrhage sheath. Type-lII RSHs enter the prevesicular space or into the sheath of the rectus abdominis muscle is peritoneum.4 RSH can occur during all stages of uncommon in pregnancy, rectus sheath hematoma pregnancy and in early postpartum period. Rectus should be considered in patients who present with an sheath hematoma is more common in multiparous acute onset of abdominal pain in the latter half of females. The most common precipitant factor in pregnancy or in the immediate postpartum period. pregnancy is coughing reported in 73% of patients. The second most common precipitant is labour observed in REFERENCES 18% of patients.5-7 1. Brotzman GI. Rectus sheath hematoma: a case report. J Fam Prac RSH has been mistaken for many common acute 1991; 33:194-7. abdominal diseases such as appendicitis, incarcerated 2. Thia EW, Low JJ, Wee HY. Rectus sheath hematoma mimicking intestinal hernias, urinary obstructions, acute cholecystitis, an ovarian mass. Internet J Gynaecol Obstet 2003; 2. mesenteric vascular insult or dissecting aneurysms. 3. Fukuda T, Sakamoto I, Kohzaki S, Uetani M, Mori M, Fujimoto T, In pregnancy, RSH has been misdiagnosed as ovarian et al. Spontaneous rectus sheath hematoma; clinical and r torsion or ruptured uterus, abruption placenta or adiological features. Abdom Imag 1996: 21:58-61. degenerating uterine leiomyoma. An incorrect initial 4. Benson M. Rectus sheath hematomas simulating pelvic diagnosis is associated with increased rate of exploratory pathology: the ultrasound appearances. Clin Radiol 1982; 33: laparotomy, premature cesarean delivery and perinatal 651-5. death.8 5. Chang W, Knight WA, Werdehoff SG, Blomkains AL. Rectus sheath hematoma [Internet]. [updated 2007 Nov 28]. Availabale A careful history and clinical examination is required to from: http://emedicine.medscape.com/article/776871-overview elicit the risk factors and precipitant events. Imaging techniques like ultrasound in one series was 100% 6. Humphrey R, Carlan SJ, Greenbaum L. Rectus sheath hematoma in pregnancy. 2001; 29:306-11. sensitive.2 But on ultrasound, tumours may be confused J Clin Ultrasound with abdominal wall tumours. While failure rate of 7. Casey RG, Mahmood MS, Carroll K, Hurley M. Rectus sheath hematoma: an unusual diagnosis. 2000; 93:90-2. ultrasound in another series has been reported to be Irish Med J < 30%.6 In the patients with non-diagnostic findings on 8. Klingler PJ, Wetscher G, Glaser K, Tschmelitsch J, Schmid T, sonography, CT scanning may be used to make the Hinder RA. The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders. definitive diagnosis, to prevent unnecessary exploratory Surg Endosc 1999; 13:1429-34. laparotomy. MRI is also a reliable tool for diagnosis of RSH in non-pregnant patients. Conservative management 9. Ozaras R, Yilmaz MH, Tahan V, Uraz S, Yigitbasi R, Senturk H. Spontaneous hematoma of the rectus abdominis muscles: a is preferred in pregnant patients. rare cause of acute abdominal pain in the elderly. Acta Chir Beig Surgery is advised if RSH ruptures into peritoneum, if 2003; 103:332-3. complicating infection is present or if the patient is 10. Khan Z. Rectus sheath hematoma presenting as acute abdomen. haemodynamically unstable. Surgery may also be required Pak J Surg 2007; 23:105-2. GGGGG*GGGGG Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (12): 828-829 829.
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