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Rectus Sheath Haematoma is a relatively rare presentation in the context of acute Accident and Emergency presentations. Correct diagnosis and subsequent management depend on sound clinical acumen and history taking with appropriate use of diagnostic aides in order to avoid prolonged and inappropriate management of such cases. We present an interesting case of a young fit male whose history alone suggested the diagnosis despite an initial diagnostic dilemma.
A fit 18 year old male rugby player presented to Accident and Emergency Department with a 4 hour history of acute onset progressive right lower quadrant abdominal pain. Such pain, described as sharp in nature and exacerbated by pelvic movement and coughing, was initially noticed during a rigorous exercise programme on a rowing machine. He was normotensive, afebrile with a pulse rate of 86 bpm (average).
Examination revealed quite a marked degree of abdominal guarding and rigidity particularly in the right lower quadrant. Nothing else remarkable was in evidence on further examination. Subsequent investigation revealed normal Fbc, Bioprofile, and plain radiographic studies of the abdomen. The patient remained in extremis and treated accordingly with incremental doses of intravenous opiate analgesia. A provisional diagnosis of acute appendicitis was made and admission arranged for surgical management.
Despite refractory presentation a decision was made to continue with supportive symptomatic management. The patient showed symptomatic improvement with conservative management (intravenous fluids and analgesia).
‘Next-day’ ultrasound abdomen revealed a large Rectus Sheath Haematoma. The patient quickly improved and was discharged the following day on oral analgesia as required.
Appropriate advice was issued regarding sports, exercise, and training.
Rectus Sheath Haematoma, as an acute abdominal presentation,1 is relatively uncommon. Reported rates vary,2 but current literature suggests a female:male preponderance of 2–3:1 in the 50 to 60 year old age group (however, equal distribution in the younger age groups is noted despite different aetiology). Overall incidence is not quantified owing to rarity of presentation.
Rectus Sheath Haematoma is an accumulation of blood in the anterior Rectus abdominis muscle. Primary causation is due to either epigastric vessel rupture or muscle body tear. This may occur in any abdominal quadrant but typically sub - umbilical due to Rectus Abdominis posterior wall supportive deficit below the level of the linea semilunaris (weak transversalis fascia and peritoneum being the essential supportive framework for Rectus Abdominis) and relative infrastructural rigidity (firm adherence of inferior epigastric penetration arteries to rectus abdominis). As in our case, intense, perhaps unaccustomed, muscular exertion induced labile contractile muscle lengths and shear forces in a plane opposite to epigastric penetration vessels resulting in immediate haematoma formation.
Predisposing factors associated with Rectus Sheath Haematoma formation are varied and include hypertension, arteriosclerosis, old age, obesity, direct abdominal trauma, anticoagulant therapy, previous abdominal surgery, pregnancy and acute intra-abdominal pressure fluctuations (straining, coughing, exertion) – the latter illustrating male predominance, as in our index case.
Interestingly, one series reported a case related to intramuscular administration of low molecular weight sub-cutaneous heparin.3
Clinical presentation is often non-specific5 – pain and swelling/mass in any one of the four abdominal quadrants (left upper quadrant being the site of least frequency in reported series) – typically the lower quadrants being the sites of most frequent occurrence.4 Pain, often in isolation of mass/swelling, is usually of acute onset, of moderate severity with signs suggestive of peritoneal irritation. The presence of an associated mass is often highly suggestive, particularly if right sided and is considered diagnostic if extends to midline. Some series’ have quoted associated signs – notably Fothergill’sGrey Turner’s, Cullen’s, and dysuria/urinary frequency – depending on breach of peritoneum but these are typically associated with delayed presentation beyond 48 hours.
Supportive data may occasionally include a mild leucocytosis, a low grade pyrexia or a corroborative drop in haemoglobin (clearly extent related), however, these are considered unusual.
Diagnostic conclusion is usually successful with a combination of clinical awareness and radiographic imaging – Ultrasound or Computed Tomography. Ultrasound is usually the investigation of choice due to high sensitivity rates (approaching 100% in most series), time/cost efficacy and radiation safety protocol. Classical ultrasonographic appearances range from sonolucent (early stage) to sonodense (late stage) appearance with time from initial injury.
Computed Tomography is considered more sensitive an investigation and useful in cases of inconclusive ultrasound but due to issues relating to time/resource management is less commonly employed. Magnetic Resonance Imaging has been less employed and is considered as sensitive as the aforementioned. Should the diagnosis continue to prove elusive, more invasive methods such as diagnostic needle aspiration and laparotomy have been suggested, however, the former has not received much acclaim due to reasons relating to sepsis propagation.1
A conservative non interventional approach to diagnosis/management has received acceptance most recently. Such approach, of course, advocates analgesia, serial clinical assessment, bedrest, haematoma compression, icepack application, and managing the predisposing cause. Clearly, haemodynamic compromise necessitates operative intervention - clot evacuation and vessel ligation via laparotomy or laparoscopic6 approach is usual. Levy et al7 reported successful interventional outcome with Gelfoam embolization however this method has not received much acclaim.
Rectus Sheath Haematoma may prove to be a diagnostic dilemma; differential diagnoses would have to include ovarian pathology (torsion, cyst), appendicitis, intestinal pathology (obstruction, neoplasia, perforation) and strangulated herniae.
As our case demonstrates, reasonable prolonged conservative management (in the context of clinical awareness and corroborative diagnostic exclusion) should negate the need for intervention in the case of Rectus Sheath Haematoma assuming haemodynamic stability.