What are the signs and symptoms of rectus sheath hemorrhage?

Signs and Symptoms of Rectus Sheath Hematoma

Rectus sheath hematoma (RSH) typically presents with abdominal pain and a palpable abdominal mass, with the clinical presentation varying based on the severity and location of the bleeding.

Clinical Presentation

Common Signs and Symptoms

• Abdominal pain (present in 84% of cases) - typically acute onset and may be severe 1
• Palpable abdominal mass or swelling (present in 63% of cases) 1
• Tenderness over the rectus muscle 2
• Nausea and vomiting 2
• Difficulty with urination or incomplete voiding 2

Physical Examination Findings

• Visible swelling or mass in the abdominal wall, often unilateral 2
• Ecchymosis (bruising) of the abdominal wall may be present, though this is a late finding 1
• Positive Fothergill's sign - a mass in the abdominal wall that does not cross the midline and remains palpable when the patient tenses the rectus muscle by raising the head 3
• Positive Carnett's sign - increased pain when the patient tenses the abdominal muscles 3

Severity-Based Presentation

• Type I hematomas (mild): Confined to the muscle with minimal symptoms and no drop in hemoglobin 3
• Type II hematomas (moderate): Blood between muscle and fascia with moderate pain and possible hemoglobin drop 3
• Type III hematomas (severe): Blood extends to prevesical space and peritoneum with significant pain, hemodynamic instability, and marked hemoglobin drop 3

Complications and Severe Presentations

Hemodynamic Instability

• Hypotension and tachycardia in severe cases (particularly Type III hematomas) 2
• Lightheadedness or syncope due to blood loss 2
• Significant drop in hemoglobin levels requiring blood transfusion 1

Abdominal Compartment Syndrome

• Progressive abdominal distension 2
• Respiratory distress due to diaphragmatic elevation 2
• Elevated bladder pressure (>20-25 mmHg) 2
• Oliguria or anuria 2

Risk Factors and Associated Conditions

Major Risk Factors

• Anticoagulation therapy (present in 69% of cases) 1
• Advanced age (mean age 67.9 years) 1
• Female gender (64% of cases) 1
• Recent coughing, sneezing, or other abdominal strain (29% of cases) 1
• Nonsurgical abdominal trauma (48% of cases) 1

Other Contributing Factors

• Coagulopathies 4
• Abdominal injections (particularly low-molecular-weight heparin) 3
• Obesity 2
• Pregnancy 2

Diagnostic Considerations

Imaging Findings

• CT scan is the diagnostic modality of choice (diagnostic in 100% of cases) 3
• Ultrasound may show a hypoechoic mass in the rectus sheath 3
• CT angiography can identify active bleeding and is highly sensitive and specific 4

Laboratory Findings

• Decreased hemoglobin and hematocrit in moderate to severe cases 1
• Elevated INR or aPTT in patients on anticoagulation therapy 1

Clinical Pearls and Pitfalls

Important Clinical Pearls

• RSH should be considered in the differential diagnosis for elderly patients on anticoagulation who present with acute abdominal pain and a palpable mass 3
• The condition can mimic acute intraabdominal disorders, leading to unnecessary surgery if not correctly diagnosed 3
• Early diagnosis is essential to reduce morbidity and mortality, which can be as high as 12-30% in severe cases 4

Common Pitfalls

• Misdiagnosis as an intraabdominal emergency leading to unnecessary laparotomy 3
• Failure to recognize hemodynamic instability in larger hematomas 2
• Overlooking RSH in patients with vague abdominal complaints who are on anticoagulation 1

Management Considerations

• Conservative management is effective in 90% of cases 3
• Blood transfusion is typically required for Type III hematomas 3
• Surgical intervention or endovascular embolization may be necessary in approximately 8% of cases 1
• Mortality rate is approximately 1.6% directly attributable to RSH bleeding 1