Rectus Sheath Hematoma (RSH)is a rare condition that frequently affect elderly women on anticoagulant therapy. Risk factors include trauma, surgery, cough, iatrogenic, renal or blood disorders.Most patients present a painful mass at the moment of admission, accompanied of a drop of hemoglobin level. Although the vast majority of cases are self-limiting, and managedwith conservative treatment (anticoagulation reversal, fluid replacement, blood transfusion, analgesics), there is still a minority of cases that will present hemodinamicallyinestability and will need selective embolisation or even surgery.US and CT are useful imaging techniques, especially intravenous contrast CTthat will select patients for embolisation.Management is a dilemma, and decision of when reintroducing anticoagulation can convert into a challenge.There is a lack of consensus and guidelines about how to manage this entity, and most of literatureconsist of series of case reports.We report a case of giant rectus sheath hematoma that caused abdominal compartment syndrome and required two embolisation and surgery. This is a peculiar case because although rectus sheath hematoma has been reported, previously, as cause of abdominal compartment syndrome, this is an uncommon presentation and few cases reported in the English literature.
Rectus Sheath Hematoma (RSH)is an un common entity in clinical practice. It typically appearsinelderly patients on anticoagulant therapy, as a result of trauma, surgery, pregnancy, paroxysmal coughing and other medical disorders. They are more frequent in women and locatedon infraumbilicalregion. It represents less than 2% of the total cases of abdominal pain collected in the Emergency Department [1-5].RSHusually presents as a painful massassociated with a significant decrease in hemoglobin levels. Occasionally, they may raise a problem in differential diagnosis. Computed Axial Tomography (CT)and Abdominal Ultrasound (US)are useful diagnostic techniques [1-5].Most of them are a self- limiting process that respond to non-aggressivetreatment. However, some cases will need selective embolisation or surgery [6,7].
We reporta case of giant RSH in an80-year-old woman that was on anticoagulant therapy. The peculiarity of this case is that RSH caused abdominal compartment syndrome and required drain and two selective embolisation. Abdominal compartment syndrome produced by RSH has been previously described in the literature, although it is a rarity.
A 80 yearoldfemalewitha medical history of arterial hypertension, rheumatic valvulopathy with mechanical mitral prosthesis and tricuspid annuloplasty, severe pulmonary hypertension and atrial fibrillation. She was on anticoagulant therapy(acenocumarol) and had been admitted two months earlier to our center due to lower leg hematomas. As a result, at the moment of admission, she was on Low-Molecular-Weight Heparin (LMWH).The patient presented witha 12-hour history of diffuse abdominal pain, nausea, abdominal distension and mass effect.
On physicalexamination, she was hemodynamically stable with tenderness and palpable abdominal mass on the hypogastrium. Blood tests revealed: hemoglobin level 10 g/dL, hematocrit 34%, platelet 177.000/UL, Activated Partial Tromboplastin Time (APTT) 28.9 sec and International Normalized Ratio (INR) 1.07.
Under the suspicion of a RSH, Computed Tomography Angiography (CTA) was performed. It showed a 20 X 25 size rectus sheath hematoma withactive bleeding signs (Figure 1).
While the patient was in the Emergency Department, her hemoglobin level plummeted from 10 to6 g/dl accompanied byhypotension and tachycardia. Intravenous fluid replacement, red blood cell and fresh frozen plasma transfusion were started. At that moment, the patient was moved to the Intensive Care Unit, where she was stabilized.Since there was an active bleeding, a therapeutic angiography with embolisation of the left inferior epigastric artery was carried out.In the following days, the patient developed an abdominal compartment syndrome with 23 mm Hg of intra- abdominal pressure, and acute renal failure due to giantpreperitoneal hematoma.She underwent urgent surgery. A small infraumbilicallaparotomy allowed to get into Retzius space. A damaged rectus muscle was found, so epigastric vessels couldn’t be identified. Clot evacuation and packing were performed. Then, 24 hours later, it was removed and no active bleeding found.In the next 72h hours, the hemoglobin level dropped from 11 to 8g/dl. A repeated CT showed active bleeding signs, and another embolisations of the left inferior epigastric artery was realized (Figure 2 and 3).
In recent years, the use of anticoagulant drugsin elderly, has caused an increasing numberof Rectus Sheath Hematoma (RSH).RSH constitutes the most common non-neoplastic disorder occurring in Rectus Abdominis Muscles (RAM) .The ancients already described this entity, and Hippocratesand Galenmentionedit in their treatises. Later, in 1857, Richardson reported the first case in the modern literature. [2,3,4].In 1946, Teske analyzed a series of 100 cases of hematoma of the anterior rectus abdominis muscle .According to Klinger et al. a RSH is discovered in 1.8% of patients who undergo ultrasonographyfor acute abdominal disorder .They mostly affect women in their sixth and seventh decades of life [2,3,6].On contrary, Kingler in his 23 patient serie reported a slightly predilection formen .RSH is caused by a tear of rectus abdominis musclesor epigastric vessels. There are two epigastric vessels: the superior epigastric artery (terminal branch of internal thoracicartery)and inferior epigastric artery (branch of external iliac artery). Most frequently, RSH is located below the arcuate line of Douglas, where posterior surface of RAMis only covered by a weak transversalis fascia and peritoneum.(Figure 4).
According to Nikolao, 70% of RHSs occur in the lower abdomen . However, above arcuate line, aponeurotic expansions of external oblique, internal oblique and transversalis musclespass anteriorly and posteriorly the RAMs,and form a thick sheath that grants contention.They appear most commonly in the right side [2-6,9](Figure 5).
Several risk factors have been associated to RSH, among them, the most common is anticoagulant therapy that is also related to increasingmortality. Overall mortality rate of RSH is,approximately, 4%. However, in patients under anticoagulant therapy, it reachesaround 25% [1,5].Other causes of RSH are abdominal direct trauma, iatrogenic (procedures such as paracentesis, percutaneous drain, laparoscopic…etc.), Valsalva effort (coughing)pregnancy,elderly (weak RAMs contribute to formationof RHS) andmedical conditions as hypertension, atherosclerosis, vasculitis, renal or blood disorders… Cough constitutes the most frequent precipitating factor [1-3,5].They usually present as a painful mass inelderly patientson anticoagulant medications. Pain occurs in 85-97% of patients, it appears suddenly and can mimic acute intra-abdominalconditionssuch as appendicitis, perforated ulcer, intestinal obstruction, strangulated hernia, ectopic pregnancy…etc[1,3,5,8,10].In 1926, two clinical signs were described. Fothergill’s sign occurs when a palpable mass in the abdominal walldoes not cross the middle line. Carnett’s sign is positivewhenat tensingabdominal wall, tenderness increases. However, in case of intra-abdominalprocess, the fact of lifting head and shoulders decreases the pain due toprotection of abdominal wall [3,6,11].
US is the first-line imagining choice, and it reaches a sensitivity of 70-90%. However, CT is considered the gold standardwith a sensitivity of 100%. It allows to exclude other abdominal processes. Furthermore, itdetermines the size of hematoma and signs of active bleeding when realized with intravenous contrast, and identifiescasesthat will be candidates to selective embolisation.
In 1996, Berna proposed a classification based on CT findings:
-Type I: unilateral hematoma that does not require hospitalization, mild, and intramuscular
-Type II: moderate intramuscular hematoma that requires hospitalization, unilateralor bilateral.
-Type III: severe hematoma on anticoagulated patients that extendsinto peritoneum and prevesical space and requires blood transfusion . The vast majority of RSHs are self-limitingand conservative treatment is successful in most cases. Non- surgical management consists of suspension of anticoagulants, blood transfusion, rest and antibiotic.Reversal of anticoagulation is usually needed and consist of intravenous vitamin K; prothrombin complex concentrates or fresh frozen plasma .
However, we emphasize that the main data to decide the correct treatmentis the hemodynamic stability of the patient. When hemodynamic instability is present, selective embolisation or surgery should be considered. In addition, enlarging hematomas should undergo embolisation[2,3,12].Surgery consist of ligation of vessels or drainage of the hematoma .We report a case of a giant RSH that caused abdominal compartment syndromeand, although initially selective embolisation was successful, the patient required surgery because of the high intra-abdominal pressure. A 3 cminfraumbilical incision was performed and middle line opened, the giant hematoma was drained but no bleeding vessel identified, although a diffuse bleeding was present and a packing performed. Two days later, packing was removed and no signs of bleeding identified. However, threedays later,the hemoglobin plummeted,and a second embolisation was carried out. This is a rare case where a second embolisation was needed.
RSH is a rare cause of abdominal compartment syndrome, and althoughdescribed in the literature, is a rare presentation. When it occurs, surgery is mandatory to reduceintra-abdominal pressure.When anticoagulationreversal has been required, a critical issueis to determine the adequate time toreintroduce anticoagulant therapy. The fact that most patients with RHSneed anticoagulationfor life-threading conditions(mechanical valves, auricular fibrilation…etc) makes it challenging. It is commonly accepted to continue with anticoagulant therapy once the patient is hemodynamicallystable. In addition, Villa et al. recommend a repeated contrast-enhanced CT in patients under anti-coagulation .In our case, once patient was hemodynamically stable, anticoagulation was initiatedLMWHs require special concern because of the high number of cases of severe RSH due to injection technique. On this way, the deltoid region could be a safer alternative .
To summarize, RSH occurs mostly in anticoagulated elderlyon infraumbilical location. US and CT are useful tools and allow to identify patients that will benefit of selective embolisation.Although,most cases are self-limiting, and nonaggressivetreatment will be effective, some patients will present active bleeding and hemodynamicallyinestability;under these circumstances, selective embolisation shouldbe performed, and finally,surgery considered. The fact that RSH happens in patients with life-threadingpathologies make the management a challenge.
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Figure 1: CTA showed a 20 X 25 cm size rectus sheath hematoma with active bleeding signs.
Figure 2: A repeated CT showed active bleeding signs and rest of hematoma.
Figure 3: embolisations of the left inferior epigastric artery.
Figure 4: Below arcuate line posterior surface of RAM is only covered by a weak transversalis fascia and peritoneum.
Figure 5: Above arcuate line, aponeurotic expansions of external oblique, internal oblique and transversalis muscles pass anteriorly and posteriorly the RAMs.
Citation: Minaya Bravo AM, Medina Quintana RE, Mendoza Moreno F, Garcia Mahillo JC (2017) Giant Rectus Sheath Hematoma Causing Abdominal Compartment Syndrome: Review and Management. J Surg 2017: JSUR-148.