Constipation-Induced Spontaneous Rectus Sheath Hematoma

Abstract

Rectus sheath hematoma (RSH) is a unique condition that is often misdiagnosed by clinicians in patients presenting with abdominal pain. RSH is an accumulation of blood within the abdominal rectus sheath muscle as a result of rupturing of the epigastric arteries supplying the rectus sheath muscle. RSH is difficult to diagnose because it presents with similar symptoms as other intra-abdominal pathologies. In severe cases, patients may also present with confusion, fever, chills, and vomiting. If left untreated RSH can lead to hypovolemic shock. Based on the CT scan results, RSH can also be sub classified further. An 83 year-old-female with a past medical history of HTN, Arthritis, Deep vein thrombosis (DVT), HTLV-1 associated myopathy and paraparesis, CVA with right hemiplegia, Umbilical Hernia since birth, and constipation; presented to the emergency department complaining of left sided abdominal pain for two weeks that has gradually worsened over time. The patient describes the pain as being dull at first and gradually becoming sharp, throbbing, and colicky in character. The pain is located diffusely over the left side of the abdomen. On abdominal examination, the left side of the abdomen was warm to touch relative to the right side. The patient also reports that the abdominal pain intensified while trying to pass stools. The patient denies any recent abdominal trauma or surgery that would increase the patient's risk for bleeding into the rectus sheath. A computed tomography (CT) scan without contrast was performed on the Abdomen/Pelvis to evaluate for the underlying pathology causing the presenting symptoms. The CT scan revealed a Left Rectus Sheath Hematoma, Rectal distention suggesting constipation. We would classify this patient as having a Type I RSH, since the hematoma did not cross midline and the patient was stable. The patient was treated with close observation in the hospital and a follow up CT scan showed no significant change in the hematoma. Rectus Sheath Hematoma is a rare clinical condition resulting in blood accumulation within the rectus sheath, whose presenting symptoms are commonly seen in other abdominal pathologies. This patient's chief complaint was left sided diffuse abdominal pain that intensified while straining to pass bowel movements. In conclusion, we feel clinicians should keep RSH as a differential when considering a case of abdominal pain with a history of chronic constipation in conjunction with anticoagulation therapy.