Giant rectus sheath hematoma

Abstract

Background: Rectus sheath hematoma (RSH) is an uncommon entity associated with predisposing factors such as anticoagulation. It may mimic more frequent abdominal conditions and its accurate diagnosis is important to focus on the correct treatments and improve morbidity and mortality. Case presentation: An elderly patient with shock, abdominal pain, palpable abdominal mass, and anemia was suspected of having a large RSH by point-of-care ultrasound (POCUS), which was then confirmed by computed tomography. Surgery was performed, markedly improving his clinical status. Conclusions: POCUS has a good sensitivity for the diagnosis of RSH and it is also an excellent tool for patient follow-up.

Rectus Sheath Hematoma Causing Bladder Outlet Obstruction

“…Type 2 hematomas are intramuscular with blood between the muscle and the transversalis fascia, can be unilateral but are usually bilateral, and no blood is found in the prevesical space. With type 3 hematomas, as discussed in this case, blood is seen between the transversalis fascia and the muscle, in the peritoneum, which can dissect into prevesical space [2][3][4][5][6][7][8][9][10][11]. Unlike types 1 and 2, type 3 has a higher prevalence of a hematocrit effect, requiring blood transfusion as there is no sheath below the arcuate line to contain the hematoma and this reduces the compressive force of the sheath [6][7][8][9][10][11].…”

“…The rupture may be caused by external trauma to the abdominal wall, iatrogenic trauma from surgery, or the rectus muscle vigorously contracting from coughing, vomiting, or straining at the stool [1][2][3][4][5][6]. Hematomas originating below the arcuate line are caused by damage to the inferior epigastric artery and its branches [7][8][9][10]. These hematomas are more prone to bleed, and are more likely to shift across the midline descending into prevesicular space [9][10][11].…”

“…Hematomas originating below the arcuate line are caused by damage to the inferior epigastric artery and its branches [7][8][9][10]. These hematomas are more prone to bleed, and are more likely to shift across the midline descending into prevesicular space [9][10][11].…”

“…There are three types of RSH based on CT scan findings [9][10][11]. If the hematoma is intramuscular as well as unilateral and does not dissect along the fascial planes, it is classified as type 1.…”

“…If RSH is small and present, it usually is accompanied by an abdominal bulge which can be painful [3][4][5]. Some can dissect into the pelvis, and if large enough, can cause pressure symptoms [5][6][7][8][9][10][11]. It is unusual for them to cause bladder outlet obstruction.…”