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BACKGROUND:Rectus sheath hematoma is a rare and frequently misdiagnosed cause of acute abdominal pain. In the management of the patients with rectus sheath hematoma, which are mostly with advanced age and comorbid diseases, positive results can be obtained by avoiding unnecessary surgical procedures with correct diagnosis and treatment approaches. The presented study aims to contribute to the lack of algorithms and optimal treatment strategies in the management of rectus sheath hematoma patients with the description of our experience in their management. METHODS:Patients who underwent treatment with the diagnosis of rectus sheath hematoma between May 2010 and July 2018 were retrospectively analyzed. Demographic characteristics, medical histories, physical and laboratory findings and imaging methods, treatment processes, complications, morbidity, mortality, length of hospitalization and long-term follow-up results were searched. Data were analyzed from patient files, hospital computer registry system and radiology archives. Data analysis was performed using Microsoft Excel and IBM-SPSS-Statistics-24. RESULTS:The mean age of the 31 patients was 63.03 years (24-85 years). The female/male ratio (21/10) was 2.1. The most common presenting sign or symptom was abdominal pain (100%), followed by abdominal wall mass in 25 patients (80.6%). Twenty-five patients (80.6%) were receiving some form of anticoagulation and antiplatelet therapy. Diagnosis was confirmed by Computed Tomography in 11 (45.4%), Ultrasonography in five (16.1%) and Computed Tomography with Ultrasonography in 15 (33.3%). Eight patients (25.8%) were evaluated as Type-1, 10 (32.2%) as Type-2 and 13 (41.9%) as Type-3. Mean International Normalized Ratio (INR) value of patients was 2.59. Bleeding was controlled by surgery in three cases (9.6%). The conservative approach was preferred in 28 cases (90.3%). 29 (93.5%) patients were discharged after an average hospital stay of 7.48 days (4-21). One patient died on the postoperative 5th day and other on the 14 th day of conservative treatment (6.45% mortality). The mortality rate of conservatively and surgically treated patients was 3.5% and 33.3%, respectively. CONCLUSION:Rectus sheath hematoma should be suspected in elderly patients using anticoagulants with acute abdominal pain, severe cough attacks and an umbilical palpable or radiologically supported mass. Computed Tomography and Ultrasonography should be performed in case of clinical suspicion. Early and correct diagnosis ensures successful conservative treatment and prevents unneces-sary surgical procedures. In the management of cases where clinician experience is at the forefront, we are hopeful that a new effective algorithm system and guidelines for the diagnosis will be identified after increasing the presentations of case series and experiences.

This case report presents a large left rectus sheath hematoma (RSH) case developed in a COVID-19 patient who had received no anticoagulant therapy before hospital admission. It discusses the patient’s diagnosis and treatment process. A 78-year-old woman was admitted to the ED with acute cough and shortness of breath. On CT scan, the pulmonary findings were consistent with COVID-19 pneumonia. Subcutaneous enoxaparin sodium was started to the patient, in accordance with the COVID-19 treatment guidelines applied in Turkey. On the ninth day after admission, her hemoglobin level decreased to 7.3 g/dL. At that point, her blood pressure was 84/52 mmHg, and her heart rate was 120 beats/min. There was a mass in the left lower quadrant on the physical exam. CT examination of the abdomen and pelvis showed a left inferior RSH approximately 9 cm wide. Enoxaparin sodium was stopped. Vital signs monitoring and fluid replacement were begun. One week after the diagnosis of RSH, a CT of the abdomen and pelvis was performed. The scan showed no significant increase in the size of the hematoma. On the 18 th day after admission, the patient was discharged because her hemoglobin value, which was 10.2 g/dL at that point, had not decreased, her vital signs were stable, and her treatment for COVID-19 was completed. From the moment of diagnosis to discharge, the patient required no interventional or surgical procedures.

A 43-year-old male patient without any additional disease, surgery or anticoagulant use admitted to the emergency department. After evaluation with computed tomography (CT), pulmonary findings were consistent with COVID-19 pneumonia. The patient was hospitalized and enoxaparin sodium 60 mg / 0.6 ml (two subcutaneous injections per day) was initiated for prophylactic purpose. In the 16th day after admission, his hemoglobin level decreased to 7.4 g/dL. On CT scan, a right flank hematoma reaching approximately 10 cm in width, starting from the subcostal level and continuing to the inguinal canal level, was seen. Anticoagulant therapy was stopped. Erythrocyte suspension (ES), totally 10 units, were given to keep the hemoglobin level above 7 g/dL. On the 32th day after admission, the patient was discharged because his hemoglobin value, which was 10.2 g/dL at that point, had not decreased, his vital signs were stable, and his treatment for COVID-19 was completed.

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