Rectus sheath hematoma is a rare but well-known problem. Exercise, pregnancy, subcutaneous injection of insulin, abdominal surgery and severe coughs can be predisposing factors of hemorrhage in the mentioned muscle sheath. Here, we will discuss a case of rectus sheath hematoma in a 28 year-old female patient who presented to emergency department with complaint of abdominal pain and improved in 1 week with palliative care

Maleki-Verki, Mohammadreza

Motamed, Hasan

English

Journals Portal, Shahid Beheshti University of Medical Sciences

Emergency. 2018; 6 (1): e28CASE REPORTRectus Muscle Hematoma as a Rare Differential Diagnosisof Acute Abdomen; a Case ReportMohammadreza Maleki Verki1, Hassan Motamed1∗1. Emergency Medicine Department, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.Received: April 2018; Accepted: May 2018; Published online: 1 May 2018Abstract: Rectus sheath hematoma is a rare but well-known problem. Exercise, pregnancy, subcutaneous injection ofinsulin, abdominal surgery and severe coughs can be predisposing factors of hemorrhage in the mentionedmuscle sheath. Here, we will discuss a case of rectus sheath hematoma in a 28 year-old female patient whopresented to emergency department with complaint of abdominal pain and improved in 1 week with palliativecare.Keywords: Rectus abdominis; hemorrhage; abdomen, acute; emergency service, hospital; ultrasonography© Copyright (2018) Shahid Beheshti University of Medical SciencesCite this article as: Maleki Verki M, Motamed H. Rectus Muscle Hematoma as a Rare Differential Diagnosis of Acute Abdomen; a Case Report.Emergency. 2018; 6 (1): e28.1. IntroductionRectus sheath hematoma is a rare but well-known problem(1, 2). Exercise, pregnancy, subcutaneous injection of insulin,abdominal surgery and severe coughs can be predisposingfactors of hemorrhage in the mentioned muscle sheath (1-6).Acute abdominal pain and mass are among the most impor-tant clinical manifestations of rectus sheath hematoma thatcan be mistaken for cases such as appendicitis, abscesses andabdominal wall tumors, hernias, and diverticular diseases aswell as gynecologic and urinary tract diseases in differentialdiagnosis (7, 8). Here, we will discuss a case of rectus sheathhematoma in a 28 year-old female patient who presented toemergency department with complaint of abdominal painand improved in 1 week with palliative care.2. Case reportThe patient is a 28 year-old female who presented to theemergency department with acute abdominal pain since 2hours before. Abdominal pain in the patient was under theumbilicus and on both sides of the central line of the ab-domen or linea alba, localized, and without diffusion to aspecial point. The pain was not related to eating but would∗Corresponding Author: Hassan Motamed; Emergency Department,Golestan Hospital, Golestan, Farvardin Avenue, Ahvaz, Iran. Tel:+989123169951 Email: hasan_motamed@yahoo.comworsen with walking and change in position. As the patientsaid, the pain had manifested suddenly following the secondsession of working out while she was doing sit-ups and shecould not continue exercising. The patient did not mentioncomplaints of nausea or vomiting, urinary symptoms such asburning or frequent urination, vaginal discharge or history ofdirect trauma to the abdomen. Her menstrual cycle was reg-ular and she reported the time of her last menstruation as 20days before. She had a history of consuming Accutane druguntil 2 months before due to acne. She did not mention anyhistory of bleeding disorders in herself or her family.Vital signs of the patient on admission to the emergency de-partment were: blood pressure, 100/80 mmHg, heart rate 90per minute, respiratory rate 10 per minute, oxygen saturation98% at room temperature and sublingual temperature of 37◦C.Abdominal examination indicated localized bilateral tender-ness under the umbilicus, without rebound and no mass wassensed. There was no sign of bruise, scar, or skin lesions onthe abdomen. Examination of other organs and gynecologicexamination had no pathologic finding. Coagulation, bloodand urine tests were normal and serum ÎšHCG was negative.In the ultrasonography performed on the patient, 2 hetero-genic hypo-echo regions were seen. One was 9×22×23 mil-limeters in size (approximate volume of 2.5 cc) in the rightrectus muscle and the other with approximate dimensions of4×25×45 (approximate volume of 3 cc) in the left rectus mus-cle 13 mm from the skin surface with the approximate dis-This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).Downloaded from: www.jemerg.comM. Maleki Varaki and H. Motamed 2Figure 1: Ultrasonography view of hematoma in rectus muscle sheath of the patienttance of 10 cm under the umbilicus, which suggested rectushematoma (figure 1).No other ultrasonography abnormality was detected in theappendix, ovaries and vagina. Finally, the patient was dis-charged from the emergency department with diagnosis ofrectus muscle hematoma and with prescription of oral anal-gesics and order to rest. 1-week follow up of the patientrevealed gradual pain relief during the initial 48 hours andcomplete relief within a week.3. DiscussionRectus muscle sheath hematoma occurs due to rupture ofupper and lower epigastric arteries and their branches orrupture of the rectus muscles themselves (9). Sudden musclestrain and change in position without direct trauma are usu-ally predisposing factors of bleeding in muscle sheath (10). Inmost cases, rectus muscle hematomas are self-limiting andare conservatively absorbed via rest and use of analgesics(11). When a patient is hemodynamically unstable, the sizeof hematoma is increasing or rupture has happened in theperitoneum, there is a need to consult the surgery service(1, 12, 13). Anyway, the important point is to have this dif-ferential diagnosis in mind along with other pathologies ofacute abdomen and especially hernia, patients affected withwhich usually present with similar history. Abdominal ultra-sonography as an available bedside tool is also very helpful inthis case under the condition that the operator also looks forsurface pathologies having this differential diagnosis in mind(14). Like other diseases, accurate history taking along withclinical suspicion will lead to finding the key to the mysterymore rapidly.4. Appendix4.1. AcknowledgementsAll the staff members of the emergency department ofGolestan Hospital, Ahvaz, Iran are thanked for their cooper-ation.4.2. Authors contributionAll the authors of this article met the criteria of authorshipbased on the recommendations of the international commit-tee of medical journal editors.4.3. Conflict of interestHereby, the authors declare that there is no conflict of interestregarding the present study.4.4. Funding and supportNone.References1. Cherry WB, Mueller PS. Rectus sheath hematoma: re-view of 126 cases at a single institution. Medicine.2006;85(2):105-10.2. Maharaj D, Ramdass M, Teelucksingh S, Perry A,Naraynsingh V. Rectus sheath haematoma: a new setof diagnostic features. Postgraduate medical journal.2002;78(926):755-6.This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).Downloaded from: www.jemerg.com3 Emergency. 2018; 6 (1): e283. Linhares MM, Lopes Filho GJ, Bruna PC, Ricca AB, SatoNY, Sacalabrini M. Spontaneous hematoma of the rectusabdominis sheath: a review of 177 cases with report of 7personal cases. International surgery. 1999;84(3):251-7.4. Buckingham R, Dwerryhouse S, Roe A. Rectus sheathhaematoma mimicking splenic enlargement. Journal ofthe Royal Society of Medicine. 1995;88(6):334-5.5. Zainea GG, Jordan F. Rectus sheath hematomas: theirpathogenesis, diagnosis, and management. The Ameri-can surgeon. 1988;54(10):630-3.6. James RF. Rectus sheath haematoma. Lancet (London,England). 2005;365(9473):1824.7. Edlow JA, Juang P, Margulies S, Burstein J. Rectussheath hematoma. Annals of emergency medicine.1999;34(5):671-5.8. Lohle PN, Puylaert JB, Coerkamp EG, Hermans ET. Non-palpable rectus sheath hematoma clinically masquerad-ing as appendicitis: US and CT diagnosis. Abdominalimaging. 1995;20(2):152-4.9. Riaz A, Phylactides L, Smith F, Cheng K, Law N, Hamil-ton H. Spontaneous rectus sheath haematoma mim-icking an enlarged urinary bladder. Hospital Medicine.2000;61(10):739-.10. Berna J, Garcia-Medina V, Guirao J, Garcia-Medina J. Rec-tus sheath hematoma: diagnostic classification by CT.Abdominal imaging. 1996;21(1):62-4.11. Zainea G, Jordan F. Rectus sheath hematomas: theirpathogenesis, diagnosis, and management. The Ameri-can surgeon. 1988;54(10):630-3.12. Smithson A, Ruiz J, Perello R, Valverde M, Ramos J,Garzo L. Diagnostic and management of spontaneousrectus sheath hematoma. European Journal of InternalMedicine. 2013;24(6):579-82.13. Salemis NS, Gourgiotis S, Karalis G. Diagnostic evalu-ation and management of patients with rectus sheathhematoma. A retrospective study. International Journalof Surgery. 2010;8(4):290-3.14. Klingler P, Wetscher G, Glaser K, Tschmelitsch J, SchmidT, Hinder R. The use of ultrasound to differentiate rec-tus sheath hematoma from other acute abdominal disor-ders. Surgical endoscopy. 1999;13(11):1129-34.This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).Downloaded from: www.jemerg.com

Rectus Muscle Hematoma as a Rare Differential Diagnosis of Acute Abdomen; a Case Report

Mohammadreza Maleki-Verki

Hasan Motamed

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Rectus Muscle Hematoma as a Rare Differential Diagnosis of Acute Abdomen; a Case Report

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