Rectal sheath hematoma has been a well-known clinical entity from the ruin of the ancient Greece. It is relatively rare, however, to encounter this abdominal disorder in the clinical setting. Furthermore, the initial symptoms of rectus sheath hematoma are often similar to those of acute abdominal disorders. Therefore, the majority of the patients with rectus sheath hematoma have been treated with operative procedures because of the difficulty of a differential diagnosis from other abdominal disorders. We recently treated a 74-year female diagnosed with rectus sheath hematoma with the anticoagulants after an episode of cerebral infarction. From the findings of the physical examinations, ultrasound, and computed tomography, we could correctly diagnose, and could treat her with completely conservative methods without any invasive techniques. It is stressed that it is important to recognize this entity of rectus sheath hematoma when patients are examineed, after complaining of acute abdominal pain and with evidence abdominal masses in the clinical setting

Ishikawa, Masashi

Miki, Hisatsugu

Miyauchi, Takayuki

Tokushima University Institutional Repository

INTRODUCTIONRectus sheath hematoma produced by a tear inthe epigastric vessels or the muscle fibers of therectus abdominis is a well-described clinical entity (1).It is difficult to differentiate rectus sheath hematomafrom other abdominal diseases which show acuteabdomen symptoms or abdominal masses, therefore,a definite diagnosis has typically been performedafter surgical procedures in the majority of cases (1 -3).With the current advances in imaging, such as ul-trasound (US) and computed tomography (CT),proper diagnose can be made before surgery (4-10).The present study examined a patient with rectussheath hematoma under anticoagulant therapy aftercerebral infarction, which were correctly diagnosedusing US and CT of the abdomen. She was treatedconservatively without any invasive techniques.CASE REPORTA 74-year-old female was admitted to our hospitalon 9th February, 2001, complaining of acute painaffecting the right upper abdomen. Symptoms de-veloped suddenly following a coughing spell dueto bronchitis 7 days prior to admission. The patienthad a history of cerebral infarction, and had beentreated with anticoagulant therapy with ticlopidinehydrochloride at a dosage of 200 mg/day. On ad-mission, the patient’s general condition was stable,however, because of the radiation of the upperabdominal pain, she had problems walking. Herblood pressure was 98/67 mmHg ; pulse rate, 72beats per minute and regular ; respiration, 12 ; tem-perature ; 36.8℃ ; white blood cell count, 11,900cells/mm3 ; hematocrit, 39.8% ; hemoglobin, 12.6mg/dl ;platelets count, 67.4×104 cells/mm3 ; total bilirubin,0.26 mg/dl ; GOT, 22 IU/liter ; GPT, 35 IU/liter ; alp,396 IU/liter ; BUN, 11.1mg/dl ; creatinine, 0.76mg/dl ;Rectus sheath hematoma in an elderly woman underanti-coagulant therapyTakayuki Miyauchi, Masashi Ishikawa and, Hisatsugu MikiDepartment of Surgery, National Kochi Hospital, Kochi, JapanAbstract : Rectal sheath hematoma has been a well-known clinical entity from the ruinof the ancient Greece. It is relatively rare, however, to encounter this abdominal disorderin the clinical setting. Furthermore, the initial symptoms of rectus sheath hematoma areoften similar to those of acute abdominal disorders. Therefore, the majority of the patientswith rectus sheath hematoma have been treated with operative procedures because ofthe difficulty of a differential diagnosis from other abdominal disorders. We recently treateda 74-year female diagnosed with rectus sheath hematoma with the anticoagulants afteran episode of cerebral infarction. From the findings of the physical examinations, ultrasound,and computed tomography, we could correctly diagnose, and could treat her with completelyconservative methods without any invasive techniques. It is stressed that it is importantto recognize this entity of rectus sheath hematoma when patients are examineed, aftercomplaining of acute abdominal pain and with evidence abdominal masses in the clinicalsetting. J. Med. Invest. 48 : 216-220, 2001Keywords : Rectus sheath hematomaReceived for publication May 1, 2001 ; accepted June 13,2001.Address correspondence and reprint requests to : TakayukiMiyauchi, M.D., Ph.D., Department of Surgery, National KochiHospital, 1-2-25, Asakura-Nishi-machi, Kochi 780-8503, Japanand Fax : +81-88-843-6385.CASE REPORTThe Journal of Medical Investigation Vol. 48 2001２１６bleeding time, 1 minute 30 seconds ; prothorombinactivity 80%, hepaplastin test, 113.3% ; thrombo test,125.1%. Examination disclosed the presence of atender mass under the right arcus costalis. Thebulging of the mass was prompted by standing,and the size of the mass was 4.5cm by 7.5cm.Medially, the mass did not extended beyond themidline. Laterally, the border of the lateral marginof the mass was at the lateral border of the rectusabdominis muscle. On palpation, the mass had nofluctuation and no localized fever, however, the patientcomplained of mild tenderness. The physical findingsof the abdomen, in addition to the presence of themass, showed no sign of peritoneal irritation andthe bowel sound was normal.On US, the mass was revealed clearly within theright rectus abdominis muscle. The size was 4.97×2.44 cm transversely (Fig. 1A). The echo level waslow echoic, including the partial heterogeneoussite, and the border of the mass was relatively welldemarcated from the muscle. The anterior surfaceof the mass was contacted to the high echoic thinlayer in accordance with the anterior sheath. Pos-teriorly, two hyper-echoic layers in accordance withthe posterior sheath and the peritoneum, were wellrevealed. Those two layers protruded to the peritonealcavity although they were well demarcated fromthe intra-abdominal cavity (Fig. 1B). The gallbladderand the liver showed no sign of the disorder orconnection to the mass, and, no fluid collectionwas observed.The findings of CT also showed marked swell-ing of the right rectus muscle. The mass was spindleshaped, and the density of CT was high, otherwise,in part, heterogeneously low. Themass had a relativelyclear demarcation from the muscle tissue, and ex-tended from the right costal arc to the level of theumbilicus. The longitudinal length of the mass wasgreater than 11cm (Fig. 2A). Medially, the massdid not extend beyond the linea alba. Laterally, themass was relatively well discriminated by thesemilunar line, although the high density regionsextended, in part, to the subcutaneous layer, theexternal oblique muscle, and the preperitoneal fatlayer. The mass was revealed as a markedly highdensity layer (Fig. 2B). Intra-abdominal disorderswere not found as well as the findings of US. Fromtheseobservations, we diagnosed the patient withrectus sheath hematoma, and determined to treather conservatively because the hematoma was re-stricted locally in the right upper quadrant and thesize of the hematoma showed no sign of increasing.The patient was rest in bed for four days, onlybeing permitted to walk to her private room. Theanti-coagulant therapy was stopped. On the thirdday, a mild blue ecchymosis was observed in theFig. 1. Ultrasound showes a low echoic mass inthe right rectus abdominis muscle (Fig.1A), andthe two hyper-echoic layers in accordance withthe posterior sheath of the rectus abdominis andthe peritoneum (Fig.1B). Symbol↓indicates theposterior sheath of the rectus abdominis muscle,and Symbol↑indicates the peritoneum.Fig. 2. Plain CT shows a high density mass inthe rectus abdominismuscle, which is spindle shaped(Fig.2A). The high density mass does not extendbeyond the linea alba (Symbol↑), and Laterally,the high density area extends to the subcutaneouslayer, the external obliquemuscle, and the preperitonealfat layer (Symbol▽) (Fig.2 B).２１７The Journal of Medical Investigation Vol. 48 2001lateral abdomen, however, the patient complainedof no symptoms of peritoneal irritation and the sizeof the hematoma did not enlarge. On the eleventhday, the findings of CT showed a marked decreasein the size of the hematoma. The maximum breadthof the right rectus abdominis muscle, includingthe hematoma, was 2.8 cm. The density was stilllow, including the heterogeneously high densityarea, which suggested the formation of a clot. Thedemarcation of the hematoma was clear, comparedwith that on admission (Fig. 3). The pain duringwalking gradually decreased, and the palpation ofthe hematoma also gradually disappeared. On thenineteenth day, the anti-coagulant therapy was againstarted with panardin at a dosage of 200 mg/day.On the twenty-second day, the findings of USshowed a further decrease in the size of the hematoma,3.5cm by 2.8cm. The demarcation from the rectusmuscle tissue was very clear, the echo density wasalmost homogenously low, and the border betweenthe hematoma and the posterior sheath becamemore clear (Fig. 4). The patient was discharged onthe twenty-fifth day.DISCUSSIONRectus sheath hematoma is due to a rupture ofthe fibers of the rectus abdominis muscle or to atear in one of the epigastric vessels with hemorrhageinto the sheath of the rectus muscle(1-3),and hasbeen termed as a rupture of the rectus muscle,spontaneous rupture of the epigastric artery, spon-taneous hematoma of the abdominal wall, and spon-taneous hematoma of the rectus sheath (8).Hemorrhage within the rectus sheath may occurin a variety of conditions (1-3, 5) : 1) Sudden muscularcontraction, such as coughing, sneezing, suddenexertion, or strenuous exercise, 2) Direct traumaor surgical procedures, 3) Pregnancy, labor, andthe puerperium, 4) Cardiovascular diseases suchas arteriosclerosis, and congestive heart failure, 5)Degenerative diseases of the muscle associatedwith infections such as typhoid, pneumonia, influenza,leukemia, and cancer, 6) Blood dyscrasia includingiatrogenic cause from administration of anticoagulants,7) Overextension of the rectus muscle associatedwith obesity, abdominal aortic aneurysm, ascites,and tumor, 8) idiopathic. Teske et al. (1) reportedthat more than half of his cases were classified asidiopathic.The present patient complained of right hypo-chondralgia and a palpable mass in the right upperabdomen after a spell of coughing due to bronchitis,and she had been treated with the anticoagulantmedication. It is suggested that the contraction ofthe rectus abdominis muscle occurred abruptly,following a spell of severe coughing, which mighthave caused a tear in the muscle fiber or the epigastricvessels. She might have had disorders of the vesselwall because of her history of cerebral infarction,Fig. 3. Plain CT findings of the mass of the right rectusabdominis muscle are markedly decreased in size on theeleventh day.Fig. 4. Ultrasound shows a marked decrease in the mass, andthe echo density is almost homogenously low. Symbol↑showsthe anterior rectas sheath, and Symbol↓shows the posteriorrectus sheath.T. Miyauchi et al. Rectus sheath hematoma２１８and the anticoagulants could have easily acceleratedbleeding.Teske et al. (1) reported that from about 100cases of rectus sheath hematoma it occurred muchmore frequently in females than in males, and theratio was about 3:1. The age ranged from seventeento eighty-three years, while the average age was46.8 years, and they also suggested that it mayoccur at any age during adult life.According to the clinical symptoms, the onset isoften acute and there is usually a sharp, persistent,nonradiating pain in one of the abdominal quadrants(1-3). In the majority, a palpable, non-pulsating, tenderabdominal mass is present in the sitting and supinepositions (1 - 5). Titone et al. (2) reported that a palpable,non-pulsating tender abdominal mass was presentin 92% of 50 cases. A mass, which is above thesemicircular line, is palpable especially becausethe upper portion above the semicircular line isconfined by the posterior sheath, and themass shouldnot extend beyond the midline of the abdomen orthe lateral border of the sheath. In contrast, Bogatzet al. (11) reported that because of the lack of aposterior sheath of the rectus abdominis, the hematomain the lower portion of the rectus sheath mightextend laterally beyond the margin of the rectussheath, medially across the midline, showing signsof peritoneal irritation, causing a prominent protrusionof the mass into the abdominal cavity, and actuallyrupture into the peritoneal cavity, which causesgeneralized peritonitis. The symptoms directly relateto the size and the location of the hematoma andthe degree of peritoneal irritation of the anteriorabdominal wall. Several studies have reported thata hematoma occurs most frequently in the rightlower quadrants (1-3). Teske et al. (1) reported thatthe rectus sheath hematoma occurred 49% in theright lower quadrant, 22% in the left lower, 9% inthe right upper and 7% in the left upper. In mostcases the hematoma did not extend beyond themiddleor the lateral margin of the rectus (1).Many previous studies reported that differentialdiagnosis was very difficult because a hematomain the abdominal wall had been mistaken for otherconditions or lesions of the abdomen and pelvis. Themost common misdiagnoses were : appendicitis,twisted ovarian cyst, idiopatic or postincisional stran-gulated hernia, intestinal obstruction, and malignanttumors of the abdomen (1-3).The majority of patients previously underwentneedle aspiration to intake a definite diagnosis (4,9). However, Jones et al. (3) warned that when theblood is dispersed through the muscle, aspirationis not productive, or, if the preperitoneal space isfilled with blood, the positive aspiration might leadto an erroneous diagnosis of hemoperitoneum. Itis suggested that the needle aspiration might causerisks of enlargement of the hematoma, especially insuch cases as the present patient under anticoagulanttherapy.The recent advances in imaging techniques hasmarkedly improved the rate of correct diagnosisfor this disease. Several studies have emphasizedthe utility of US for the diagnosis of a hematomabecause it is a rapid and noninvasive examinationthat requires no ionizing radiation or contrast materials.Acutely ill patients can be examined painlessly withoutspecial preparation. US scans may be made in anyplane or body section with the patient in any position(5-7, 9). Wyatt et al. (7) described the features ofultrasound findings : (1) a mass located in theanatomical structure of the rectus sheath. Abovethe semicircular line, the mass is limited laterally bythe semi-lunar line and medially by the linea alba.Below this level, since the sheath communicatesposteriorly, the mass may project across the midlineor extend inferiorly and posteriorly towards the bladder,(2) The mass may be echo free if the blood is in aliquid state. If much liquid is present, the massmay contain echoes, (3) a mass on the transversescan, the mass may appear round, oval, or spindleshaped-above the semicircular line but usuallyspindle-shaped below it.Several studies reported the advantage of CT inthe diagnosis for rectus sheath hematoma (4, 8-10,12). According to the findings of CT, Sakamoto etal. (12) previously reported that a hematoma is imagedas a high density or heterogenous mass in accordancewith the rectus abdominis muscle, and the hematomais clearly demarcated because the circumferenceof the hematoma is slightly enhanced by contrastmedium. Cocke et al. (8) reported that CT is anaccurate noninvasive method for evaluating thepresence, nature, location, size, and extent of ab-dominal masses. Hirai et al. (9) reported that thecombination of US and CT was more effective thanUS only, and the rate of the correct diagnosis was93%, compared with 60% by US alone.In the present case we performed an image ex-amination, using both US and CT. By US the patientshowed the classical findings, and we could neglectother disorders of the abdominal cavity, which oftenrequire emergent treatment with surgical procedures.However, the hematoma was relatively large in this２１９The Journal of Medical Investigation Vol. 48 2001case, and the US image could not detect an exten-sion of the hematoma. CT provided effective infor-mation according to the anatomical extension ofthe entire hematoma.According to the treatment, many patients weretreated by operative procedures because of the difficultyof correct diagnosis preoperatively (1-3, 5). Joneset al. reported that surgical treatment was requiredto establish the diagnosis, control the hemorrhage,evacuate the hematoma and repair the defect ifpossible (3). In contrast, several studies have reportedthe beneficial effect of conservative treatments, suchas the use of sedatives, compress, ice bags, andbed rest (2, 5). Kumazawa (4) recently reportedthat the application of surgical treatment shouldbe restricted to those cases that showed severeperitoneal irritation, revealed a local protrusion ofthe peritoneum, and, in which the hematoma wasso big that is not expected to be easily absorbed.In general, the prognosis is favorable and relapseis rare (4, 9, 10). The present patient also showeda favorable clinical course by the conservativetreatment alone.In conclusion, we reported an elderly female patientwith rectus sheath hematoma, who was treated withanticoagulants. We could attain a correct diagnosisusing US and CT, and could treat her conservatively.US was especially useful in the evaluation of thechanges in the rectus sheath hematoma with time.It is stressed that it is important to take the anamnesisin detail and perform a careful palpation of the abdomen,taking this rare entity into consideration, whenpatients complain of acute abdominal pain and anabdominal mass is identified in the clinical setting.REFERENCES1. Teske JM: Hematoma of the rectus abdominismuscle. Report of a case and analysis of 100cases from the literature. Am J Surg 71 : 689-695, 19462. Titone C, Lipsius M, Krakauer JS : Spontaneoushematoma of the rectus abdominis muscle:Critical review of 50 cases with emphasis onearly diagnosis and treatment. Surgery 72 : 568-572, 19723. Jones TW, Merendino KA, Wasbington S : Thedeep epigastric artery : Rectusmuscle syndrome.Am J Surg 103 : 159-169, 19624. KumazawaH : Two cases of rectus sheath hematoma.Surgical Therapy (in Japanese) 81 : 377-379, 19995. Spitz HB, Wyatt GM : Rectus sheath hematoma.J Clin Ultrasound 5 : 413-416, 19776. Kaftori JK, Rosenberger A, Pollack S, Fish JH :Rectus sheath hematoma : Ultrasonographicdiagnosis. Am J Roentogenol 128 : 283-285, 19777. Wyatt GM, Spitz HB : Ultrasound in the diagnosisof rectus sheath hematoma. JAMA 241 : 1499-1500, 19798. Cocke JE,MacCartyRL,FoulkWT : Rectus sheathhematoma. Diagnosis by computed tomographyscanning. Mayo Clin Proc 56 : 757-761, 19819. Hirai K, Tanaka M, Nagashima M, Tsunemi S,Matsumoto S, UmeharaM : Three cases of rectussheath hematoma. J Clinical Surgery (in Japanese)55 : 853-856, 198510. Iwasaki Y : A case of rectus sheath hematomacomplicating an attach of bronchial asthma.Jpn J Allergol (in Japanese) 43 : 721-723, 199411. Rogatz P, Bubin IL : Hematoma of the rectusabdominis muscle. New York State J Med 54 :675-679, 195412. Sakamoto K, Funato T, Ichihashi M, Tarao M,Goto A : A case report of non-traumatic rectussheath hematoma. J Jpn Surg Assoc (in Japanesewith English abstract) 61 : 1223-1227, 1992T. Miyauchi et al. Rectus sheath hematoma２２０

Rectus sheath hematoma in an elderly woman under anti-coagulant therapy

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Rectus sheath hematoma in an elderly woman under anti-coagulant therapy

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