Rectus Sheath Hematoma Clinical Presentation

Common historical features of rectus sheath hematoma (RSH) include acute abdominal pain, fever, nausea, and vomiting. The nonspecific nature of these symptoms combined with the low incidence of the disorder lead to difficulty in considering this diagnosis. Rectus sheath hematoma should be included in the differential diagnosis of every patient who presents with abdominal pain.

Specific symptoms

• Constitutional: Fever and chills are common symptoms in rectus sheath hematoma. Symptoms of hypovolemic shock with weakness, confusion, pallor, and diaphoresis can develop in patients with a large rectus sheath hematoma.
• Abdominal pain: The most common presenting symptom is acute abdominal pain. The onset of pain may be sudden, but more often, it develops over a period of several hours. The pain is typically sharp and severe, with an associated palpable abdominal mass. Pain is usually worse with movement and is often unilateral. Constant pain with episodic abdominal cramping is also a frequent symptom. In atypical cases, the pain may develop insidiously, making the abdominal mass difficult to differentiate from an abdominal wall neoplasm.
• Gastrointestinal/urologic: Anorexia, nausea, vomiting, diarrhea, constipation, tenesmus, and bladder irritability are all compatible with the diagnosis of rectus sheath hematoma. The severity of symptoms is related to the degree of peritoneal irritation.
• Precipitating factors: The clinician needs to have rectus sheath hematoma in the differential, or the diagnosis will be easily overlooked. A careful history should include directed questions regarding surgical procedures, occult blunt trauma, coughing, sneezing, constipation (straining at the stool), or exercise. In patients with certain medical problems, questions about recent asthma exacerbations, bronchitis, or upper respiratory tract infections may prove helpful. Rectus sheath hematoma must always be considered in abdominal pain patients on anticoagulants.

Vital signs

A low-grade fever is common in rectus sheath hematoma. The hematoma can be large enough to compromise intravascular volume, with resultant signs of hypovolemic shock including hypotension, tachycardia, and tachypnea.

Abdominal examination

Typically, the abdominal examination reveals a palpable, painful, firm, nonpulsatile abdominal mass corresponding to the rectus sheath. The mass may be bilobar with a central groove. The mass does not move with respiration. Because the hematoma is deep to the subcutaneous tissue and rectus muscles, the mass is not always palpable, particularly in obese patients. In 2000, Berna et al's case series reported a palpable mass detected in 8 of 12 patients.^[4] Hyperesthesia of the overlying skin is not uncommon. Bowel sounds may be absent. Signs of local peritoneal irritation with rebound tenderness and involuntary guarding may be present. This finding is most often seen in infra-umbilical hematomas due to the thin transverse fascialis serving as the only barrier between a hematoma and the peritoneum. Rarely, a hematoma may rupture into the peritoneum, causing a chemical peritonitis or even abdominal compartment syndrome.

The Fothergill sign is useful in determining whether an abdominal mass is part of the abdominal wall or whether it is in the abdomen. It is elicited by voluntary contraction of the rectus muscles by the patient lifting either his or her head or legs while in the supine position. With this action, rectus sheath hematomas become fixed, more painful, and more tender, while intra-abdominal masses become less distinct and less tender. The Fothergill sign may be inconclusive in patients who are obese or pregnant. As described by Fothergill in 1926^[5] :

This patient complains of pain and the medical man finds the swelling. The trouble is that he seldom knows how long the swelling has been present…The main point is the recognition that these swellings are part and parcel of the abdominal wall. This is generally made by noting that they can still be felt when the recti are in action, and that they become fixed as the muscles contract

The Carnett sign is an additional test to assist in differentiating between abdominal wall and intra-abdominal pathology. It is performed by having the patient lie supine and tensing the abdominal musculature by raising either the head or the shoulder off the table. A positive sign is elicited if abdominal tenderness is increased or unchanged while tensing the abdomen. This indicates an abdominal wall process. A negative sign, or decreased abdominal tenderness while tensing the abdomen, suggests intra-abdominal pathology. Previous studies have demonstrated this sign to be fairly sensitive but not specific for abdominal wall pathology.

The Cullen sign of periumbilical ecchymosis is associated with retroperitoneal or abdominal wall hemorrhage. In rectus sheath hematoma, ecchymosis appears after 2-5 days. The ecchymosis uncommonly extends into the flanks.

See the image below.

The Grey-Turner sign is another manifestation of retroperitoneal hemorrhage. This finding of flank ecchymosis was initially described in hemorrhagic pancreatitis, and along with the Cullen sign, it is not specific for retroperitoneal or abdominal wall hemorrhage.

Pelvic examination

The pelvic examination may reveal a mass anterior to the vagina and above the pubis. The pelvic examination may be misleading, particularly in those cases that demonstrate unilateral adnexal tenderness and mass.

Several risk factors of rectus sheath hematoma (RSH) can be obtained in the history. In most cases of rectus sheath hematoma, one or more precipitating factors can be found. Reports of spontaneous rectus sheath hematoma exist, but more likely, in these cases, the precipitating factor was not appreciated. Anticoagulation is the most frequent predisposing factor, and severe coughing is the most important inciting factor.

• Anticoagulation: Rectus sheath hematoma is a well-recognized complication of anticoagulant therapy. Anticoagulation can be a predisposing factor, or it can directly cause rectus sheath hematoma by accidental intramuscular injection of LMWHs. Heparin-induced immune microangiopathy has been proposed as a mechanism of the pathogenetic process. Rectus sheath hematoma secondary to anticoagulation may have greater morbidity and mortality because of increased hemorrhage volume. Even when coagulation factors are within the therapeutic range, a substantial risk of hemorrhage still exists.
• Coughing: Rectus sheath hematoma can occur after bouts of severe coughing, explaining its association with asthma, tuberculosis, influenza, pertussis, and other respiratory infections.
• Pregnancy: Rectus sheath hematoma is associated with pregnancy in the gravid state, during labor, and in the early postpartum period.
• Previous abdominal surgery: Abdominal operations predispose to rectus sheath hematoma because surgical scars redirect the shearing forces on muscle contraction, placing more stress on the epigastric vessels.
• Recent abdominal surgery: Excessive retraction or inadequate hemostasis can cause rectus sheath hematoma that may become evident up to 4 weeks after the procedure.
• External trauma: The nature of the trauma can be trivial. Tight contraction of the recti in anticipation of a blow predisposes to rectus sheath hematoma formation.
• Vigorous uncoordinated rectus muscle contraction: Rectus sheath hematoma has been observed in a healthy man leaping over a ditch and in a woman rising from a chair to adjust a curtain rod. In a similar manner, sports activities and exercises, such as golf, tennis, skiing, and weightlifting, have caused rectus sheath hematoma. Activities with significant Valsalva effort, such as coughing, sneezing, straining from constipation, urination, and sexual intercourse, have been implicated in rectus sheath hematoma.
• General medical conditions: General medical conditions that predispose to rectus sheath hematoma can be categorized as those causing damage to blood vessels; those causing failure of coagulation; or as anomalous conditions, such as endometriosis in the rectus sheath. Vascular conditions of hypertension, arteriosclerosis, and collagen vascular disease are associated with rectus sheath hematoma. Disorders of coagulation associated with RSH include leukemia, myeloproliferative disorders, hemophilia, and blood dyscrasias.
• Unusual: Case reports have also described rectus sheath hematoma related to acupuncture and follicle aspiration for in vitro fertilization. Minor surgical procedures such as diagnostic or therapeutic paracentesis have also been shown to cause rectus sheath hematoma.^[6] In addition to LMWH injections, rectus sheath hematoma has also been seen in any abdominal wall medication injections (eg, insulin).^[7] These unusual causes underscore the importance in obtaining a thorough history from the patient.