eMedicine Specialties > Emergency Medicine > Gastrointestinal

Rectus Sheath Hematoma: Follow-up

Author: Wan-Tsu Chang, MD, Staff Physician, Department of Emergency Medicine, University of Cincinnati
Coauthor(s): William A Knight IV, MD, Assistant Professor, Department of Emergency Medicine, University of Cincinnati School of Medicine; Steven G Werdehoff, MD, Consulting Staff, Department of Emergency Medicine, Huntsville Emergency Physicians Group; Andra L Blomkalns, MD, Associate Professor, Vice Chair - Academic Affairs, Department of Emergency Medicine, University of Cincinnati School of Medicine
Contributor Information and Disclosures

Updated: Jul 1, 2009

Follow-up

Further Outpatient Care

  • Patients should be educated regarding the expected duration of symptoms related to the type of rectus sheath hematoma (RSH) present. This will provide reasonable expectations related to need for pain control and work limitations. Patients can follow up with their primary care physicians or surgeons for pain control as the hematoma resolves.

Transfer

  • Transfer of patients with rectus sheath hematoma is rare but may be appropriate in smaller hospitals without intensive care capabilities when treating patients that are hemodynamically unstable. The transferring physician should contact an accepting surgeon while continuing aggressive resuscitation. Patients with types I and II rectus sheath hematomas typically should not require transfer.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose rectus sheath hematoma (RSH)
  • Failure to obtain a surgical consultation for patients with large or expanding hematomas, for patients who are hemodynamically unstable, for those requiring transfusions, or for those undergoing anticoagulation therapy
  • Failure to reverse anticoagulation in patients with expanding hematomas, symptomatic anemia, or hemodynamic instability
  • Failure to maintain adequate anticoagulation in patients at high risk for intravascular thrombosis with small stable rectus sheath hematomas
  • Failure to provide fluid resuscitation and transfusion with packed red blood cells if indicated by hemodynamics, comorbidities, or significant anemia

Special Concerns

  • Anticoagulation
    • Hemorrhage is a frequent and occasionally lethal complication of anticoagulation. The rectus sheath is a common source of bleeding in patients undergoing anticoagulation therapy. Anticoagulation is the most common predisposing factor to rectus sheath hematoma.
    • The incidence of rectus sheath hematoma has been increasing secondary to the widespread use of anticoagulation drugs and LMWHs in particular. These patients usually present with larger hematomas that sometimes require reversal of anticoagulation.
    • In patients with small hematomas, a clinical decision can be made to not interrupt anticoagulation therapy.
    • In patients with renal insufficiency treated with LMWH, reduced renal clearance may result in drug accumulation, thus the dose must be adjusted accordingly.14
    • All patients with rectus sheath hematoma who are undergoing anticoagulation therapy require admission to ensure that the hematoma is stable and to restart anticoagulation therapy as appropriate.
  • Elderly
    • Age is a predisposing factor for rectus sheath hematoma. The protection provided by the anatomy of the rectus sheath may be compromised by decreased muscle. Age-related changes from arteriosclerosis or hypertension may render vessels more susceptible to injury.
    • The greater incidence of rectus sheath hematoma in elderly people may also reflect the increased use of anticoagulation therapy in this group. In Berna's 2000 case series of 12 patients with rectus sheath hematoma and who were undergoing anticoagulation therapy, the average age was 68 years, with a range of 49-83 years.4
    • The presentation of rectus sheath hematoma is more likely to be atypical in elderly persons. Abdominal pain may not be present. Rectus sheath hematoma has been reported in elderly patients with chief symptoms of dyspnea, confusion, and urinary retention.
    • Elderly patients are more likely to have significant comorbidities, to be debilitated, or to be undergoing anticoagulation therapy, resulting in a more complicated course.
  • Pregnancy
    • Rectus sheath hematoma has occurred during all stages of pregnancy and in the early postpartum period. Occurrence during labor is easily understood. Postpartum rectus sheath hematoma is less understood, but it may be due to muscle stretching during pregnancy, labor, and delivery that leaves the rectus muscles more susceptible to mild trauma, such as a cough.
    • Rectus sheath hematoma in pregnancy is more common in multiparous females. According to Humphrey et al who in 2001 reviewed the 69 reported cases of rectus sheath hematoma in pregnancy found by a Medline search, the mean parity was 5.1, with a range of 1-12. The mean gestational age at the time of diagnosis was 32 weeks.15 The typical presentation is cough or mild trauma with acute abdominal pain occasionally accompanied by hypovolemic shock with a painful swelling on one side of the uterus. The most common precipitant in pregnancy is coughing, reported in 73% of patients. The second most common precipitant is labor, observed in 18% of patients.
    • In pregnancy, rectus sheath hematoma has been misdiagnosed as uterine rupture, placental abruption, ovarian torsion, and degenerating uterine leiomyomas. An incorrect initial diagnosis is associated with increased rates of exploratory laparotomy, cesarean delivery, premature delivery, and perinatal death.
    • Ultrasonography is the diagnostic test of choice in pregnant patients. In the event of nondiagnostic findings on sonography, CT scanning may be used to make the definitive diagnosis to prevent unnecessary exploratory laparotomy.
    • Nonsurgical management is preferred in the pregnant patient. Surgery is advised if a rupture into the peritoneum occurs, if complicating infection is present, or if the patient is hemodynamically unstable and unresponsive to initial fluid resuscitation. Cesarean delivery is performed for fetal indications. Rectus sheath hematoma has been associated with a 50% rate of fetal demise.
 


More on Rectus Sheath Hematoma

Overview: Rectus Sheath Hematoma
Differential Diagnoses & Workup: Rectus Sheath Hematoma
Treatment & Medication: Rectus Sheath Hematoma
Follow-up: Rectus Sheath Hematoma
Multimedia: Rectus Sheath Hematoma
References
[ CLOSE WINDOW ]

References

  1. Teske JM. Hematoma of the rectus abdominis muscle: report of a case and analysis of 100 cases from the literature. Am J Surg. 1946;71:689-95.

  2. Berna JD, Garcia-Medina V, Guirao J, Garcia-Medina J. Rectus sheath hematoma: diagnostic classification by CT. Abdom Imaging. Jan-Feb 1996;21(1):62-4. [Medline].

  3. Klingler PJ, Wetscher G, Glaser K, et al. The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders. Surg Endosc. Nov 1999;13(11):1129-34. [Medline].

  4. Berna JD, Zuazu I, Madrigal M, et al. Conservative treatment of large rectus sheath hematoma in patients undergoing anticoagulant therapy. Abdom Imaging. May-Jun 2000;25(3):230-4. [Medline].

  5. Fothergill WE. Hematoma in the abdominal wall simulating pelvic new growth. Br Med J. 1926;1:941-2.

  6. Kaftori JK, Rosenberger A, Pollack S, Fish JH. Rectus sheath hematoma: ultrasonographic diagnosis. AJR Am J Roentgenol. Feb 1977;128(2):283-5. [Medline].

  7. Zainea GG, Jordan F. Rectus sheath hematomas: their pathogenesis, diagnosis, and management. Am Surg. Oct 1988;54(10):630-3. [Medline].

  8. Fukuda T, Sakamoto I, Kohzaki S, et al. Spontaneous rectus sheath hematomas: clinical and radiological features. Abdom Imaging. Jan-Feb 1996;21(1):58-61. [Medline].

  9. Unger EC, Glazer HS, Lee JK, Ling D. MRI of extracranial hematomas: preliminary observations. AJR Am J Roentgenol. Feb 1986;146(2):403-7. [Medline].

  10. Herzan FA. Roentgenologic diagnosis of rectus sheath hematoma. Am J Roentgenol Radium Ther Nucl Med. Oct 1967;101(2):397-405. [Medline].

  11. Monsein LH, Davis M. Radionuclide imaging of a rectus sheath hematoma caused by insulin injections. Clin Nucl Med. Aug 1990;15(8):539-41. [Medline].

  12. Osinbowale O, Bartholomew JR. Rectus sheath hematoma. Vasc Med. Nov 2008;13(4):275-9. [Medline].

  13. Levy JM, Gordon HW, Pitha NR, Nykamp PW. Gelfoam embolization for control of bleeding from rectus sheath hematoma. AJR Am J Roentgenol. Dec 1980;135(6):1283-4. [Medline].

  14. Denard PJ, Fetter JC, Zacharski LR. Rectus sheath hematoma complicating low-molecular weight heparin therapy. Int J Lab Hematol. Jun 2007;29(3):190-4. [Medline].

  15. Humphrey R, Carlan SJ, Greenbaum L. Rectus sheath hematoma in pregnancy. J Clin Ultrasound. Jun 2001;29(5):306-11. [Medline].

  16. Adeonigbagbe O, Khademi A, Karowe M, et al. Spontaneous rectus sheath hematoma and an anterior pelvic hematoma as a complication of anticoagulation. Am J Gastroenterol. Jan 2000;95(1):314-5. [Medline].

  17. Barry TL, Butt J, Awad ZT. Spontaneous rectus sheath hematoma and an anterior pelvic hematoma as a complication of anticoagulation. Am J Gastroenterol. Nov 2000;95(11):3327-8. [Medline].

  18. Bene J, Lassman D, Solomon SA. Rectus sheath haematoma in elderly patients: a diagnostic challenge. Age Ageing. Jul 1998;27(4):512-4. [Medline].

  19. Brotzman GL. Rectus sheath hematoma: a case report [corrected]. J Fam Pract. Aug 1991;33(2):194-7. [Medline].

  20. Casey RG, Mahmoud M, Carroll K, Hurley M. Rectus sheath haematoma: an unusual diagnosis. Ir Med J. May 2000;93(3):90-2. [Medline].

  21. Cervantes J, Sanchez-Cortazar J, Ponte RJ, Manzo M. Ultrasound diagnosis of rectus sheath hematoma. Am Surg. Oct 1983;49(10):542-5. [Medline].

  22. Chatzipapas IK, Magos AL. A simple technique of securing inferior epigastric vessels and repairing the rectus sheath at laparoscopic surgery. Obstet Gynecol. Aug 1997;90(2):304-6. [Medline].

  23. Chi CH, Chen KW, Shin JS, Wu MH. Spontaneous rectus sheath hematoma: ED diagnosis and management. Am J Emerg Med. Nov 1995;13(6):671-3. [Medline].

  24. Cordero OC, Baldonado RT, Conte SJ, Lopez FA. Rectus sheath hematoma: cause of pelvic pseudotumor. Urology. May 1974;3(5):577-80. [Medline].

  25. Costello J, Wright J. Rectus sheath haematoma: 'a diagnostic dilemma?'. Emerg Med J. Jul 2005;22(7):523-4. [Medline].

  26. Cullen TS. Hemorrhage into or beneath the rectus muscle simulating an acute abdominal condition. Bull Johns Hopkins Hosp. 1937;61:317-48.

  27. Ducatman BS, Ludwig J, Hurt RD. Fatal rectus sheath hematoma. JAMA. Feb 18 1983;249(7):924-5. [Medline].

  28. Edlow JA, Juang P, Margulies S, Burstein J. Rectus sheath hematoma. Ann Emerg Med. Nov 1999;34(5):671-5. [Medline].

  29. Gocke JE, MacCarty RL, Foulk WT. Rectus sheath hematoma: diagnosis by computed tomography scanning. Mayo Clin Proc. Dec 1981;56(12):757-61. [Medline].

  30. Graham JM, Kozak JA, Reardon MJ. Rectus sheath hematoma after anterior lumbar fusion. Spine. Dec 1991;16(12):1377. [Medline].

  31. Hamilton JV, Flinn G Jr, Haynie CC, Cefalo RC. Diagnosis of rectus sheath hematoma by B-mode ultrasound: a case report. Am J Obstet Gynecol. JUN 15 1976;125(4):562-5. [Medline].

  32. Hildreth DH. Anticoagulant therapy and rectus sheath hematoma. Am J Surg. Jul 1972;124(1):80-6. [Medline].

  33. Hopper KD, Smazal SF Jr, Ghaed N. CT and ultrasonic evaluation of rectus sheath hematoma: a complication of anticoagulant therapy. Mil Med. May 1983;148(5):447-9. [Medline].

  34. Hough DR, Schneider HE. Rectus sheath hematoma with pain relief after ultrasound: case report. Mil Med. Nov 1983;148(11):885-6. [Medline].

  35. James RF. Rectus sheath haematoma. Lancet. May 21-27 2005;365(9473):1824. [Medline].

  36. Khan MI, Medhat O, Popescu O. Rectus sheath haematoma (RSH) mimicking acute intra-abdominal pathology. N Z Med J. 2005;118:1217. [Medline].

  37. Klingler PJ, Oberwalder MP, Riedmann B, DeVault KR. Rectus sheath hematoma clinically masquerading as sigmoid diverticulitis. Am J Gastroenterol. Feb 2000;95(2):555-6. [Medline].

  38. Lee TM, Greenberger PA, Nahrwold DL, Patterson R. Rectus sheath hematoma complicating an exacerbation of asthma. J Allergy Clin Immunol. Aug 1986;78(2):290-2. [Medline].

  39. Linsk JA. Rectus sheath hematoma. Mayo Clin Proc. May 1982;57(5):329. [Medline].

  40. Lohle PN, Puylaert JB, Coerkamp EG, Hermans ET. Nonpalpable rectus sheath hematoma clinically masquerading as appendicitis: US and CT diagnosis. Abdom Imaging. Mar-Apr 1995;20(2):152-4. [Medline].

  41. Luhmann A, Williams EV. Rectus sheath hematoma: a series of unfortunate events. World J Surg. Nov 2006;30(11):2050-5. [Medline].

  42. Luyx C, Vanpee D, Douala C, Gillet JB. Acute dyspnea in a woman with swelling of the left leg treated with low molecular weight heparine. Am J Emerg Med. May 2001;19(3):223-4. [Medline].

  43. Maharaj D, Ramdass M, Teelucksingh S, et al. Rectus sheath haematoma: a new set of diagnostic features. Postgrad Med J. Dec 2002;78(926):755-6. [Medline].

  44. Manier JW. Rectus sheath hematoma. Am J Gastroenterol. May 1972;57(5):443-52. [Medline].

  45. Moreno Gallego A, Aguayo JL, Flores B, et al. Ultrasonography and computed tomography reduce unnecessary surgery in abdominal rectus sheath haematoma. Br J Surg. Sep 1997;84(9):1295-7. [Medline].

  46. Noseda A, Bellens R, Van Gansbeke D, Gangji D. Rectus sheath hematoma mimicking acute splenic disease. Am J Gastroenterol. Sep 1983;78(9):566-8. [Medline].

  47. Perry CW, Phillips BJ. Rectus sheath hematoma: review of an uncommon surgical complication. Hosp Physician. 2001;37:35-7.

  48. Richardson SB. Rupture of the right rectus abdominis muscle from muscular efforts: operation and recovery, with remarks. Am J Med Sci. 1857;33:41-5.

  49. Rimola J, Perendreu J, Falco J, Fortuno JR, Massuet A, Branera J. Percutaneous arterial embolization in the management of rectus sheath hematoma. AJR Am J Roentgenol. Jun 2007;188(6):W497-502. [Medline].

  50. Scott WW Jr, Fishman EK, Siegelman SS. Anticoagulants and abdominal pain. The role of computed tomography. JAMA. Oct 19 1984;252(15):2053-6. [Medline].

  51. Sheehan V. Spontaneous haematoma of the rectus abdominis muscle in pregnancy. Br Med J. Nov 10 1951;4740:1131-2. [Medline].

  52. Thia EWH, Low JJH, Wee HY. Rectus Sheath Haematoma Mimicking An Ovarian Mass. The Internet Journal of Gynecology and Obstetrics. 2003;2:1.

  53. Titone C, Lipsius M, Krakauer JS. "Spontaneous" hematoma of the rectus abdominis muscle: critical review of 50 cases with emphasis on early diagnosis and treatment. Surgery. Oct 1972;72(4):568-72. [Medline].

  54. Torpin R. Hematoma of the rectus abdominis muscle in pregnancy. Am J Obstet Gynecol. 1943;46:557-66.

  55. Trias A, Boctor M, Echave V. Ultrasonography in the diagnosis of rectus abdominis hematoma. Can J Surg. Sep 1981;24(5):524-5. [Medline].

  56. Vanpee D, Gillet JB. Rectus sheath hematoma. Ann Emerg Med. Jul 2000;36(1):78-9. [Medline].

  57. Wyatt GM, Spitz HB. Ultrasound in the diagnosis of rectus sheath hematoma. JAMA. Apr 6 1979;241(14):1499-500. [Medline].

  58. Young JR, Cressman M, O'Hara PJ. Rectus sheath hematoma: diagnosis by computed tomography. Arch Intern Med. May 1981;141(6):820. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

rectus sheath hematoma, abdominal wall hematoma, epigastric artery rupture, rectus muscle, rectus muscle tear, rectus sheath hematoma symptoms, rectus sheath hematoma treatment, rectus sheath hematoma, causes, pelvic pseudotumor, RSH, abdominal pain, hypovolemic shock, hematoma, anticoagulation 

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Wan-Tsu Chang, MD, Staff Physician, Department of Emergency Medicine, University of Cincinnati
Wan-Tsu Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

William A Knight IV, MD, Assistant Professor, Department of Emergency Medicine, University of Cincinnati School of Medicine
William A Knight IV, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Emergency Medicine Residents Association, Society for Academic Emergency Medicine, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Steven G Werdehoff, MD, Consulting Staff, Department of Emergency Medicine, Huntsville Emergency Physicians Group
Steven G Werdehoff, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Andra L Blomkalns, MD, Associate Professor, Vice Chair - Academic Affairs, Department of Emergency Medicine, University of Cincinnati School of Medicine
Andra L Blomkalns, MD is a member of the following medical societies: American College of Emergency Physicians, American Heart Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St. Barnabas Hospital
Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Fred Harchelroad, MD, FACMT, FAAEM, FACEP, Chair, Department of Emergency Medicine, Director of Medical Toxicology - Allegheny General Hospital, Associate Professor, Department of Emergency Medicine, Drexel University College of Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.