• bowel obstruction
• warfarin
• rectus sheath haematoma

A rectus sheath haematoma caused by rupture of epigastric vessels is an uncommon condition that can occur spontaneously especially in patients who are being anticoagulated. It may present in a number of ways, most commonly with abdominal pain and a palpable abdominal mass. Depending on site, it can mimic acute abdominal conditions, for example, appendicitis¹ and splenic rupture.²

This unusual presentation of large bowel obstruction occurred in a 75 year old women taking long term anticoagulation treatment for atrial fibrillation. She presented with a 24 hour history of abdominal pain, distension, and absolute constipation. On examination she had generalised tenderness and a palpable 10×10 cm mass in the left iliac fossa. On admission INR was 3.4 and Hb 8 g/dl. An abdominal radiograph showed grossly dilated loops of large bowel (fig 1). An ultrasound scan and gastrograffin enema were inconclusive. Computed tomography was performed and a diagnosis of obstruction secondary to external compression by an abdominal wall haematoma was made (fig 2). Conservative treatment proved successful in permitting resolution of obstructive symptoms within 48 hours.

Diagnosis of rectus sheath haematoma should be suspected in patients taking anticoagulation treatment presenting with a palpable mass, abdominal pain, and anaemia.³ A review of the literature shows computed tomography to be the most accurate imaging technique in the diagnosis of rectus sheath haematomas.³

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Figure 1

Abdominal radiograph showing large bowel obstruction.

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Figure 2

Computed tomography of abdomen illustrating rectus sheath haematoma.