UMEM Educational Pearls


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: 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 the following 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 coughingPregnancy (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.


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