Diagnosis

Rectus sheath hematoma

Usually a self-limiting bleeding into the rectus sheath from damage to the epigastric arteries or from a direct tear of the rectus muscle.

Also known as: Rectus hematoma

Etiology

Cause [qju][fii]

Pathophysiology [ecs]

  1. The blood supply to the rectus abdominis muscles originates from the superior and inferior epigastric arteries

  2. The inferior epigastric artery:

    • Lacks the protection of a posterior rectus sheath until it reaches the arcuate line

    • Subjected to relative movement from muscle contractions along its pathway

  3. Injury to an epigastric artery or its perforating branches within the rectus muscle

    • Bleeding into the enveloping fascial sheath

    • Increases the pressure in the rectus compartment:

      • Pain

      • Anemia

Risk factors

Epidemiology

Incidence per 100.000 [wa9][qju][7ia][sam][fii][fit]

Epidemiology chart for Incidence

Symptoms & findings

Symptoms

Anorexia, Carnett's sign, Chills, Confusion, Constipation, Cullen's sign, Diaphoresis, Diarrhea, Fever, Fothergill's sign, Hyperesthesia, Hypoactive bowel sounds, Hypotension, Nausea, Pallor, Tachycardia, Tachypnea, Tenesmus, Vomiting, Weakness

Clinical findings

Anemia, Decreased hematocrit, Elevated Creatine Kinase, Leukocytosis

Anamneses

Anticoagulation, Surgery, Trauma

Localized findings

Pain
Radiates
Abdomen
Onset
Acute (minutes)Subacute (hours)
Pattern
Constant
Provoked by
Activity
Quality
CrampingSharp
Severity
Moderate (4-7)Severe (8-10)
Rash
Radiates
Right flankLeft flankRegio Umbilicalis
Lesion type
EcchymosesHematoma
Color
Red
Swelling
Radiates
Abdomen
Onset
Subacute (hours)
Pattern
ConstantIncreasing

Approach

Treatment

  1. Conservative treatment with observation: [tyk][7ia][fii][fit]

    • Hemodynamic monitoring

    • Intravenous fluids

    • Blood transfusion

    • Analgesia

    • Rest

    • Reversal of anticoagulation

  2. Endovascular coil embolisation [pzb]

  3. Surgery: Rarely needed

    • Fasciotomy

    • Evacuation of hematoma

    • Hemostasis

Differential diagnoses

Abdominal aortic aneurysm, Abdominal compartment syndrome, Abruptio placentae, Acute mesenteric ischemia, Acute pancreatitis, Aortic dissection, Appendicitis, Cholecystitis, Cholelithiasis, Diverticulitis, Femoral hernia, Gastritis, Gastroenteritis, Gastrointestinal obstruction, Incisional hernia, Inguinal hernia, Intussusception, Ovarian torsion, Ruptured aortic aneurysm, Ruptured ectopic pregnancy, Ruptured ovarian cyst, Ulcer disease, Umbillical hernia, Urinary retention, Urinary tract infection

References

[1] http://reference.medscape.com/article/776871 (2014-01-02); [Medscape]

[2] Hatjipetrou A, Anyfantakis D, Kastanakis M. Rectus sheath hematoma: a review of the literature. Int J Surg. 2015 Jan;13:267-271.

[3] Allen M, Sevensma KE. Rectus Sheath Hematoma. [Updated 2023 Jan 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519033/

[4] Andreassen KH, Olesen TE, Jacobsen PT. Spontant rectushaematom [Spontaneous rectal hematoma]. Ugeskr Laeger. 1996 Apr 15;158(16):2254-7.

[5] Klingler PJ, Wetscher G, Glaser K, Tschmelitsch J, Schmid T, Hinder RA. The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders. Surg Endosc. 1999 Nov;13(11):1129-34.

[6] Cherry WB, Mueller PS. Rectus sheath hematoma: review of 126 cases at a single institution. Medicine (Baltimore). 2006 Mar;85(2):105-110.

[7] Fitzgerald JE, Fitzgerald LA, Anderson FE, Acheson AG. The changing nature of rectus sheath haematoma: case series and literature review. Int J Surg. 2009 Apr;7(2):150-4.

[8] Gunasekaran K, Rajasurya V, Devasahayam J, Singh Rahi M, Chandran A, Elango K, Talari G. A Review of the Incidence Diagnosis and Treatment of Spontaneous Hemorrhage in Patients Treated with Direct Oral Anticoagulants. J Clin Med. 2020 Sep 15;9(9):2984.

[9] Spiliopoulos S, Festas G, Theodosis A, Palialexis K, Reppas L, Konstantos C, Brountzos E. Incidence and endovascular treatment of severe spontaneous non-cerebral bleeding: a single-institution experience. Eur Radiol. 2019 Jun;29(6):3296-3307.

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