UMEM Educational Pearls

Title: What's the Diagnosis? Written by Ali Farzad, MD

Posted: 7/15/2012 by Haney Mallemat, MD (Emailed: 7/16/2012) (Updated: 7/16/2012)
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Question

23 year-old female presents complaining of progressive right lower quadrant pain after doing "vigorous" pushups. CT abdomen/pelvis below. What’s the diagnosis? (Hint: it’s not appendicitis)

Answer

Answer: Rectus Sheath Hematoma

Rectus Sheath Hematoma (RSH)

Rectus muscle tear causing damage to the superior or inferior epigastric arteries with subsequent bleeding into the rectus sheath; uncommon cause of abdominal pain but mimics almost any abdominal condition.

May occur spontaneously, but suspect with these risk factors:

Coagulopathy (#1 cause); acquired (e.g., warfarin) or inherited disorder
Rectus muscle trauma
Vigorous or sudden contraction of rectus muscle
Increased intra-abdominal pressure from vigorous coughing
Pregnancy (gestation, labor, or post-partum)

Typically a self-limiting condition, but hypovolemic shock may result from significant hematoma expansion.

Hemodynamically stable (non-expanding hematoma): conservative treatment (rest, analgesia, and ice)
Hemodynamically unstable (expanding hematoma): treat with fluid resuscitation, reversal of coagulopathy, and transfusion of blood products.

References

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