Embolization of Hemorrhaging Rectus Sheath Hematoma

Abstract

A75-year-old man with multiple myeloma and history of pulmonary embolism on warfarin anticoagulation presented with three days of worsening abdominal pain after a fall. His exam demonstrated a tender, unilateral abdominal mass that remained palpable with tensing of the rectus sheath (Fothergill’s sign).1 Initial hemoglobin was 5.7 g/dL, platelets 47,000/mm3, and INR 1.74. Computed tomography revealed a large right-sided rectus sheath hematoma (Figs. ​(Figs.1A,1A, ​,B).B). Blood products were administered and anticoagulation was reversed. However, repeat hemoglobin was 4.9 g/dL. Emergent angiography identified a hemorrhaging branch of the right inferior epigastric artery (Fig. ​(Fig.1C,1C, black arrowhead and inset). One linear and two short coils were deployed achieving hemostasis (Fig. ​(Fig.1D,1D, white arrowheads). Surgical evacuation was performed three days later due to overlying skin necrosis. He recovered without further incident and was discharged without anticoagulation. Figure 1. Embolization of a large rectus sheath hematoma. Rectus sheath hematoma is an uncommon complication of anticoagulant therapy and usually self-tamponades. Conservative management includes anticoagulant reversal, fluids, and transfusion, if needed. Invasive measures are indicated if bleeding persists and compromises hemodynamic stability. Historically, surgical evacuation with vessel ligation was performed; however, percutaneous arterial embolization is a safe, effective, and less invasive alternative.2