Spontaneous Rectus Sheath Hematoma Research Articles

Bladder Perforation and Vesico-Haematoma Fistula: An Uncommon Complication of Rectus Sheath Haematoma.

Rectus sheath haematoma (RSH) has become increasingly common but is often underdiagnosed. Prompt diagnosis will avoid unnecessary investigations and procedures, resulting in early treatment and a better outcome. We described a case of a spontaneous RSH with intraperitoneal extension and formation of a vesico-haematoma fistula, which was initially misdiagnosed as a urinary tract infection. The diagnosis was made ten days after admission, when a CT scan showed an over-16 cm RSH with intraperitoneal extension, bladder perforation and a vesico-haematoma fistula. The patient was managed conservatively. RSH accounts for less than 2% of acute abdomen cases and is often unrecognised. Its presentation can mimic other intra-abdominal pathologies, and the diagnosis is often delayed or missed. Complications can arise from an RSH although it is generally viewed as a self-limiting condition. RSH has become increasingly common, and we would like to highlight the need to include abdominal wall pathologies in the initial differential diagnoses of acute abdomen to avoid delay in diagnosis. Rectus sheath haematoma has become increasingly common due to the use of anticoagulants.The presentation can be non-specific and mimic other intra-abdominal pathologies. Misdiagnosis or delayed diagnosis can result in complications and unnecessary invasive procedures.Abdominal wall pathologies including rectus sheath haematomas should be included in initial differentials of acute abdomen.

Nephrotic syndrome with rectus sheath hematoma: a case report

BackgroundRectus sheath hematoma is a rare presentation often associated with abdominal trauma and anticoagulant therapy. Here, we present a patient with severe rectus sheath hematoma accompanied by nephrotic syndrome who achieved significant clinical improvement without the need for invasive treatment.Case presentationA 72-year-old Japanese woman was referred to our hospital for the treatment of nephrotic syndrome. She was receiving steroid and anticoagulant therapy. Then she had abdominal pain and she was diagnosed with spontaneous rectus sheath hematoma by abdominal computed tomography. She received transfusion and was managed conservatively with bed rest, which led to improvement in abdominal pain.ConclusionDespite the absence of trauma history, rectus sheath hematoma should be considered in patients at risk of vascular failure, including those receiving anticoagulant or steroid therapy, those who are elderly, and those with nephrotic syndrome.

Spontaneous hematomas in COVID-19 patients. Literature review

A brief literature review presents the main classifications, clinical manifestations and methods of diagnosis of spontaneous retroperitoneal and rectus sheath hematomas in patients with COVID-19. The direct and indirect ultrasound criteria, stages of resolution and treatment strategy of the spontaneous hematomas are discussed

Spontaneous retroperitoneal and rectus sheath hematomas and their interventional therapy: a review

Retroperitoneal and rectus sheath hemorrhage (RRSH) has been described as a potentially fatal condition with mortality rates of up to 30 % due to the risk of exsanguination in combination with often nonspecific clinical symptoms. Patients at risk are > 65 years of age as well as those receiving anticoagulation/antiplatelet medicine. Classifications based on etiology consist of trauma, surgery, and/or underlying vascular pathologies, though spontaneous occurrences without precipitating factors have been reported and are expected to increase with the high number of patients undergoing anticoagulant therapy. Analysis, summary, and discussion of published review articles and expert recommendations. The most commonly described symptom during clinical examination is abdominal pain. However, depending on the volume loss, clinical symptoms may include signs of abdominal compartment and hemorrhagic shock. Computed tomography angiography (CTA) with high sensitivity and specificity for the presence of active bleeding plays an important role in the detection of RH and RSH. Therapy management is based on different pillars, which include surgical and interventional measures in addition to conservative measures (volume replacement, optimization of coagulation parameters). Due to its lower invasiveness with simultaneously high technical and clinical success rates, interventional therapy in particular has gained increasing importance. Diagnostic and therapeutic workup of the patients by an interdisciplinary team is essential for optimal patient care. In case of transcatheter arterial embolization, a standardized approach to the detection of bleeding sites within the vascular territory of the core hematoma appears to favorably influence success and patient outcome. · The clinical presentation of retroperitoneal and rectus sheath hematomas can be very heterogeneous and nonspecific. Quick diagnosis is essential due to the relatively high mortality rate (approx. 12-30 %).. · The main risk factors are age > 65 years and the intake of anticoagulants, the use of which has increased 2.5 times in the last 10 years. Coagulopathies, retroperitoneal masses, and hemodialysis are less common causes.. · Computed tomography angiography (CTA) has a high sensitivity and specificity for the presence of active bleeding and has replaced diagnostic subtraction angiography (DSA).. · Treatment should be performed in a multidisciplinary setting with the inclusion of internal medicine, radiology, and surgery. The main indications for embolization are the detection of active contrast extravasation on CTA and the presence of abdominal pain. In cases without active bleeding and with stable vital parameters, conservative treatment measures can be sufficient. Surgical treatment is often reserved for treatment-refractory bleeding with symptoms of abdominal compartment.. · A systematic standardized approach to the detection of bleeding on DSA seems to have advantages regarding technical and clinical success rates.. · Becker LS, Dewald CLA et al. Spontaneous retroperitoneal and rectus sheath hematomas and their interventional therapy: a review. Fortschr Röntgenstr 2024; 196: 163 - 175.

Does COVID-19 increase the incidence of spontaneous rectus sheath hematoma?

The COVID-19 pandemic started to affect Turkey in March 2020. In this study, we retrospectively investigated spontaneous rectus sheath hematoma (S-RSH) in patients with COVID-19 presenting with acute abdominal pain during the ongoing pandemic. The demographic characteristics, laboratory findings, length of hospital stay, and treatment processes of COVID-19 cases with S-RSH detected between March and December 2020 were recorded. The rectus sheath hematoma diagnosis of the patients was made using abdominal computed tomography, and the patients were followed up. Low-molecular-weight heparin treatment, which was initiated upon admission, was continued during the follow-up. S-RSH was detected in 13 out of 220 patients with COVID-19 who were referred to general surgery for consultation due to acute abdominal pain. The mean age of these patients was 78±13 years, and the female-to-male ratio was 1.6. Mechanical ven-tilation support was applied to three patients, all of whom were followed up in the intensive care unit. Two patients died for reasons independent of rectus sheath hematoma during their treatment. Among the laboratory findings, the activated partial thromboplastin time (aPTT) values did not deviate from the normal range. While there was no correlation between the international normalized ratio (INR) and aPTT (p>0.01), a significant correlation was found between INR and interleukin-6 (IL-6) (p<0.002). None of the patients required surgical or endovascular interventional radiology procedures. In the literature, the incidence of S-RSH in patients presenting with acute abdominal pain is 1.8%. However, in our series, this rate was approximately 3 times higher. Our patients' normal INR and aPTT values suggest that coagulopathy was mostly secondary to endothelial damage. In addition, the significantly higher IL-6 values (p<0.002) indicate the development of vasculitis along with the acute inflammatory process. S-RSH can be more commonly explained the high severity of vasculitis and endothelial damage due to viral infection.

Urological symptoms as the initial presentation of a spontaneous rectus sheath hematoma

Urological symptoms as the initial presentation of a spontaneous rectus sheath hematoma

Spontaneous rectus sheath hematoma associated with apixaban in an elderly gentleman with chronic obstructive airway disease – a case report

BackgroundRectus sheath hematoma (RSH) is a relatively uncommon cause of acute abdominal pain and can be mistaken as other surgical causes of acute abdomen. A diagnosis requires high index of suspicion especially in susceptible patients, for example, in patients on anticoagulation. While anticoagulation is the commonest risk factor for RSH, direct-acting oral anticoagulants have only been very recently implicated as a potential cause with fewer than ten cases reported in the literature.Case presentation.An 82-year-old Chinese man with chronic obstructive airway disease, ischemic heart disease, heart failure and atrial fibrillation on apixaban presenting with acute onset of lower abdominal pain. Physical examination showed peritoneal signs with tenderness and guarding over the lower quadrants with hypotension. Computed tomography (CT) of the abdomen confirmed a large rectus sheath hematoma (RSH) without active extravasation. He was given fluid resuscitation and was managed successfully with supportive treatment and cessation of apixaban. A follow-up CT two months later showed resolving hematoma and aspirin was resumed primarily for ischemic heart disease. The patient tolerated anti-platelet therapy without recurrence of RSH. The risk factors, treatment options, prognosis and issue related to anticoagulation resumption after an episode of RSH are discussed. Reported cases of RSH associated with direct-acting oral anticoagulants are reviewed.ConclusionsDirect-acting oral anticoagulant-associated rectus sheath hematoma is rare. With increasing use of direct-acting oral anticoagulants in multiple clinical settings, clinicians should remain vigilant of this potentially life-threatening bleeding complication when a patient presents with acute abdominal pain. Conservative treatment with cessation of anti-coagulant and supportive transfusion remains the mainstay of treatment.

INTRACTABLE COUGH CAUSING SPONTANEOUS RECTUS SHEATH HEMATOMA

TOPIC: Signs and Symptoms of Chest Diseases TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cough is a physiologic mechanism that causes airways to be cleared of foreign materials and excess secretions. The violent expiration is associated with rapid contraction of the diaphragm and the abdominal wall muscles leading to an increase in intraabdominal pressures. Longstanding untreated cough can lead to spontaneous abdominal wall hematomas. (1) CASE PRESENTATION: A 65-year-old gentleman presented to the Emergency Room with right lower quadrant abdominal pain of one-week duration. He had no past medical history. He was noted to have a persistent intractable cough for one month. Prior to the onset of cough, he had one week of loss of taste and smell, nasal congestion, nasal discharge and postnasal drip. According to him, the cough was so bad that he felt like he was going to burst. Although his family insisted, he did not get the cough evaluated. His vital signs were stable. Physical examination showed ecchymosis, a small palpable mass and tenderness in the right lower quadrant. Lung exam was unremarkable. Lab work unremarkable with normal platelet count and coagulation profile. Computed Tomography (CT) of the abdomen/pelvis showed an intramuscular vascular mass of 9 cm within the right rectus abdominis suggestive of a hematoma which was managed conservatively. Of note, he was not on any anticoagulants. On 1 month follow-up, he had complete resolution of abdominal pain, ecchymosis, mass and tenderness in the right lower quadrant. However, he continued to have a persistent cough for which he was referred to pulmonology. He visited the pulmonary clinic after 5 months of referral. At that time, he had become dependent on over-the-counter (OTC) oral decongestants and antihistamines. He had no reflux symptoms, no allergies, was a lifetime nonsmoker, employed as a banker and had a Labrador for 11 years. CT chest showed normal lung parenchyma. Pulmonary function tests revealed features of mild obstructive lung disease. His OTC medications were stopped and he was given a course of oral prednisone along with fluticasone and azelastine nasal spray with dramatic improvement and complete resolution of cough. DISCUSSION: Sustained cough results in over contraction and overstretching of abdominal muscles with an increase in intra-abdominal pressures. (2) Vigorous coughing plausibly generates shear forces high enough to tear superior and inferior epigastric vessels along the posterior aspect of long rectus muscle which results in rectus sheath hematomas. Almost 29% of spontaneous rectus sheath hematomas are the result of sustained cough the risk of which increases with the use of anticoagulants. (3) While these hematomas are conservatively managed, patients should undergo a thorough evaluation and treatment of cough to prevent its recurrence. CONCLUSIONS: This case highlights the potential of sustained vigorous cough to cause abdominal wall hematomas even in the absence of anticoagulants. REFERENCE #1: 1. Fuller RW, Jackson DM. Physiology and treatment of cough. Thorax. 1990;45(6):425-430. doi:10.1136/thx.45.6.425 REFERENCE #2: 2. Kodama K, Takase Y, Yamamoto H, Noda T. Cough-induced internal oblique hematoma. J Emerg Trauma Shock. 2013;6(2):132-134. doi:10.4103/0974-2700.110789 REFERENCE #3: 3. Cherry WB, Mueller PS. Rectus sheath hematoma: review of 126 cases at a single institution. Medicine (Baltimore). 2006;85(2):105-110. doi:10.1097/01.md.0000216818.13067.5a DISCLOSURES: No relevant relationships by Fady Jamous, source=Web Response No relevant relationships by Swaminathan Perinkulam Sathyanarayanan, source=Web Response

Perianal fistula in perineal phlegmon as a complication of spontaneous rectus sheath hematoma. A case report

The authors present a case of a 56-year-old female patient treated due to perineal phlegmon complicated with fistulas in the anal region and medial region of the right thigh. Imaging scans demonstrated the presence of numerous pus collections at various sites, but did not reveal the cause of phlegmon and fistulas. The patient was deemed eligible for an urgent surgery. The crypt-related etiology of fistulas was ruled out intraoperatively. The numerous pus collections and cutaneous fistulas were incised, cleansed and drained. Subsequently, treatment was continued using negative pressure wound therapy. The treatment led to wound healing. The retrospective analysis demonstrated that the most probable cause of phlegmon was spontaneous rectus sheath hematoma that had an atypical manifestation due to pathological obesity. Obesity, diabetes and delayed diagnosis led to the gravitational spread of phlegmon within the perineum, right groin and right thigh, and to the formation of cutaneous fistulas.

A Comparison of Drug Regimens and Analysis of Effective Factors for Blood Transfusion and Intervention in Spontaneous Rectus Sheath Hematomas

A Comparison of Drug Regimens and Analysis of Effective Factors for Blood Transfusion and Intervention in Spontaneous Rectus Sheath Hematomas

Spontaneous giant rectus sheath hematoma in patients with COVID-19: two case reports and literature review

IntroductionCoronavirus disease 2019, COVID-19, as a global public health emergency, has come with a broad spectrum of clinical manifestations and complications. In this study, we present a unique complication of this disease.Presentation of cases(A) A 65-year-old woman with a known case of COVID-19; on the second day of admission, the patient presented sudden tachycardia and hypogastric pain; on abdomen physical examination, a huge lower abdominal tender mass was noticed. (B) A 50-year-old woman with COVID-19, 4 days after admission, started complaining of tachycardia, pain, and mass in the lower abdomen. On abdomen physical examination, a huge lower abdominal tender mass was noticed. Both of the patients underwent an abdomen CT scan which confirmed a huge rectus sheath hematoma (RSH). Both of the patients underwent angioembolization of the inferior epigastric artery. The patient recovered completely and no evidence of further expansion was seen after 2 weeks of follow-up.DiscussionHemorrhagic issues in COVID-19 patients remain poorly understood. Physicians should discuss risks of RSH in patients where continuous anticoagulation therapy will be reinstated. With increased clinician awareness of the need for RSH screening in COVID-19 patients with acute abdominal pain, the interprofessional team of healthcare providers can maximize patient safety and reduce hospitalization time, especially in high-risk patients at risk for unnecessary surgery.ConclusionsThese two reports and literature review demonstrate the need of active surveillance for possible hemorrhagic complications in patients with COVID-19 infection.

Challenges in the Diagnosis and Management of Spontaneous Rectus Sheath Haematoma in Pregnancy: A Case Report

Challenges in the Diagnosis and Management of Spontaneous Rectus Sheath Haematoma in Pregnancy: A Case Report

CAN COMPUTED TOMOGRAPHY PREDICT WHETHER SPONTANEOUS RECTUS SHEATH HEMATOMAS ARE CAUSED BY COAGULOPATHY?

Spontaneous rectus sheath hematomas may occur spontaneously due to anticoagulant use and cough. Rectus sheath hematoma frequency increased with more use of anticoagulants. This study was aimed to evaluate the success of CT, which has a high sensitivity in detecting rectus sheath hematomas, in predicting whether spontaneous rectus sheath hematomas are caused by coagulopathy or not. Cases with rectus sheath hematoma in the radiology archive of our hospital were included in the study. Cases with a history of trauma, surgery, or abdominal injection were excluded from the study. Twenty-four cases evaluated as spontaneous rectus sheath hematoma were divided into two groups according to the international normalized ratio (INR) result as anticoagulant-related rectus sheath hematoma (14 cases) and non-anticoagulant-related rectus sheath hematoma (10 cases). Fluid cellular level in the hematoma (1), heterogeneity (2), localization at the infra-umbilical level (3) and stranding of subcutaneous fat tissue in the abdominal wall (4), were evaluated as anticoagulant-related rectus sheath hematoma CT findings. Hematoma at the supra-umbilical or umbilical level was considered as hematoma unrelated to anticoagulant use. Diagnostic accuracies were confirmed by laboratory results. Categorical data were compared with chi-square and numerical data using Mann–Whitney U test. While 17 (70.8 %) of the cases were female, only 7 (29.2%) were male. While rectus hematomas are mostly seen in isolation at the umbilical or supraumbilical level of the rectus muscle in the group with no anticoagulant use, it is mostly seen at the infra-umbilical level in the group with anticoagulant use (p = 0.001). Stranding in subcutaneous fatty tissue accompanying rectus hematoma is mostly seen in the group with anticoagulant use (p <0.001). Besides, the incidence of heterogeneity in hematoma due to anticoagulant use has increased (p = 0.035). No statistically significant difference was found between the two groups in terms of fluid cellular levels in the hematoma. In spontaneous rectus hematomas accompanied by coagulability, the hematoma is mostly localized at the infra-umbilical level. Also, subcutaneous fatty tissue stranding is more common.

EMERGENCIES IN CORONAVIRUS DISEASE CAUSED BY COVID-19 VIRUS

In 2019, the new coronavirus was identified as the cause of a disease originating from the city of Wuhan in China, now known as SARS-CoV-2. The World Health Organization declared COVID-19 a pandemic in March 2020. Some people may have only a few symptoms or may not have any symptoms at all. Some people may experience worsening symptoms, such as shortness of breath and pneumonia, about a week after the onset of symptoms, and some may experience systemic complications caused by COVID-19 infection. Many of these complications can be caused by a condition known as cytokine release syndrome or cytokine storm. Cytokines can significantly damage vital organ tissue, including the lungs, heart, and kidneys. The pathology of coronavirus disease (COVID-19) is exacerbated by the progression of thrombosis, disseminated intravascular coagulation (DIC), and cytokine storm. Signs and symptoms of an emergency may include: difficulty breathing, rapid, shallow breathing, persistent chest pain or pressure, somnolence, confusion, collapse, pale, gray or blue skin, lips or nails - depending on skin tone. In hospitalized patients, constant monitoring and monitoring of parameters that may indicate a certain complication in the disease requiring prompt timely treatment, is necessary. The following emergency conditions, complications in COVID-19 have been described in this paper: acute respiratory failure, ARDS, COVID-19 coagulopathy and DIC, septic shock, rhabdomyolysis, acute renal failure, acute hepatic failure, acute heart disease, myocarditis, MIS-C, emergency neurological diseases and spontaneous rectus sheath hematoma. Keywords: emergencies in COVID-19, cytokine storm, COVID-19 coagulopathy, COVID-19 complications, multisystem inflammatory syndrome in children, MIS-C. https://doi.org/10.55302/JMS2143064s

Risk Factors in the Development of Rectus Sheath Hematoma and Treatment Modalities.

Background: In this study,we aim to present the clinical features of patients with rectus sheath hematoma(RSH), as well as the condition's therapeutic management and results. Methods: The study included patients who were diagnosed with and received treatment for spontaneous RSH between the years 2010 and 2020. The demographic and clinical features of the patients, as well as follow-up parameters, were analyzed retrospectively. Results: Our study included 53 patients. The number of female patients was twice as many as the number of male patients. The median age was 65.7 +-14.68 years, and 63.3% of the patients were over the age of 65. The most frequently used anticoagulant was warfarin (30.1%), and it was most often used for heart diseases (54.7%). The international normalized ratio value at the time of admission to the hospital was 1.93+1.18, and the hemoglobin value was 11.2 gr/dl. The average hematoma diameter was 74 mm, and the most common stage was typeI (75.6%). Of the patients, 90.6% were followed up conservatively. The average duration of hospital stay was 15.1 days, and mortality occurred in eight patients during their hospital stay. Conclusion: Spontaneous RSH should be consideredfor elderly female patients who have used anticoagulants. Most patients are followed up medically, but mortality is still high.

Spontaneous Pelvic Hemorrhage and Rectus Sheath Hematoma due to Anticoagulant Overdose: A Case Report

Hemorrhagic events are common complications in patients receiving this continuous oral anticoagulation therapy A 75-year-old female patient applied to the emergency service with abdominal pain. The patient has coronary bypass surgery and she has been using warfarin since then. In physical examination she had tenderness in the lower quadrants of her abdomen. Her INR value was 9.11. Computed tomography showed pelvic hemorrhage and rectus sheath hematoma. Patient was treated conservatively with fresh frozen plasma. She was discharged without any complications 2 days after her application. Especially elderly patients should be informed about the side effects of anticoagulants.

Spontaneous rectus sheath hematoma due to prophylactic anticoagulation in a membranous nephropathy patient

Spontaneous rectus sheath hematoma due to prophylactic anticoagulation in a membranous nephropathy patient

Spontaneous rectus sheath hematoma– cause of acute abdomen in patients on anticoagulant therapy: two case reports

(Spontaneus) Rectus sheath hematoma ((S)RSH) is an accumulation of blood in the sheath of the rectus abdominis muscle, secondary to rupture of an epigastric vessel or muscle tear. It is defined as spontaneous in patients without history of abdominal trauma. It can be located supra- or infraumbilically. Although the exact incidence is unknown, Klingler et al. observed 23 cases (1.8%) of rectus sheath hematoma among 1257 patients evaluated by ultrasound for acute abdominal disorders. Ultrasonography can help in the diagnosis, but CT scan is most accurate in its ability to define the lesion. When diagnosed clinically, a conservative therapeutic program can usually be instituted. Only in cases of supportive management failure, progressive and large hematoma or uncontrollable hemodynamic patients, interventional management including surgery or less invasive newer techniques is indicated. Case presentation: We present two cases of SRSH in patients using oral anticoagulant agent (acenocoumarol). Their chief complaint was sudden onset of acute abdominal pain. On admission they were haemodynamically stable. After thorough clinical evaluation a suspicion for SRSH diagnosis was made and then confirmed by ultrasonography and CT. Both of them were successfully treated conservatively and discharged home in a good general condition. Conclusion: These two cases illustrate the accurate diagnosis of SRSH treated conservatively leading to optimal patient outcomes.

Spontaneous hematoma of the breast: What can we learn about the management of blunt force trauma of the female breast and spontaneous rectus sheath hematoma?

Spontaneous hematoma of the breast: What can we learn about the management of blunt force trauma of the female breast and spontaneous rectus sheath hematoma?

Spontaneous Rectus Sheath Hematoma: Factors Predictive of Conservative Management Failure.

To evaluate radiographic, laboratory, and clinical factors associated with conservative management (CM) failure in spontaneous rectus sheath hematoma (RSH). Retrospective review of 72 patients with spontaneous RSH between 2006 and 2017 was performed. Patients were initially managed conservatively and then divided into 2 groups based on decision to embolize. No differences were found between embolization (n= 32) and CM (n= 40) groups in age (67.5 vs 69.5 y; P= .79), sex (31% vs 38% male; P= .58), body mass index (27.7 vs 25.7 kg/m2; P= .20), or medical comorbidities. Univariate analyses compared initial hemoglobin level, change in hemoglobin level, coagulation parameters, transfusion requirements, hematoma volume, and active extravasation on computed tomographic (CT) angiography between groups. Multivariable logistic regression identified factors predictive of CM failure. A scoring system was then created to predict CM failure. CM failed in 32 of 72 patients. Multivariable regression identified active extravasation on CT angiography (P= .02), hematoma volume (P= .01), and packed red blood cell (pRBC) transfusion of ≥ 4 U (P= .03) as predictors of embolization. A scoring system using these factors along with maximum rate of hemoglobin decrease yielded a sensitivity of 100% and specificity of 98% in determining need for embolization. CM for RSH was more likely to fail in patients with active extravasation on CT angiography, larger hematoma volume, pRBC transfusion of ≥ 4 U, and higher rate of hemoglobin decrease. Using these parameters, a scoring system was created that achieved high sensitivity and specificity in identifying patients who would require embolization.