The first evidence of a rectus sheath hematoma is
|A||anorexia and nausea without vomiting|
|B||bluish discoloration of the skin|
|C||development of an abdominal wall mass|
|D||sudden sharp abdominal pain|
a. The terminal branches of the superior and inferior epigastric arteries course deep to the posterior aspect of the left and right rectus pillars and penetrate the posterior rectus sheath.
b. Injury to these vessels or to any of the network of collateralizing vessels within the rectus sheath and muscles can result in a rectus sheath hematoma.
c. Although there may be a history of significant blunt trauma, less-obvious events also have been reported to cause this condition, such as sudden contraction of the rectus muscles with coughing, sneezing, or any vigorous physical activity.
d. Spontaneous rectus sheath hematomas have been described in the elderly and in those on anticoagulation therapy.
e. Patients frequently describe the sudden onset of unilateral abdominal pain that may be confused with lateralized peritoneal disorders such as appendicitis.
g. Fothergill's sign is a palpable abdominal mass that remains unchanged with contraction of the rectus muscles and is classically associated with rectus hematoma.
h. A hemoglobin/hematocrit level and coagulation studies should be obtained.
i. Computed tomography is the most definitive study for establishing the correct diagnosis and excluding other intra-abdominal disorders.
k. Small, unilateral, and contained hematomas may be observed without hospitalization.
l. The need for a red blood cell or coagulation factor transfusion is determined by the clinical circumstances.
m. Emergent operative intervention or angiographic embolization is required infrequently.
n. Surgical therapy consists of evacuation of the hematoma and ligation of any bleeding vessel identified.
o. It is more common in women than men and in older than younger individuals.
p. In young women, rectus sheath hematomas have been associated with pregnancy.
q. The most common symptom associated with rectus sheath hematomas is the sudden onset of abdominal pain, which may be severe and is often exacerbated by movements requiring contraction of the abdominal wall.
r. Abdominal wall ecchymosis, including periumbilical ecchymosis (Cullen's sign) and blue discoloration in the flanks (Grey Turner's sign), may be present if there is a delay from the onset of symptoms to presentation.
s. The pain and tenderness associated with this process may be severe enough to suggest peritonitis.
t. In most instances, patients with rectus sheath hematomas may be successfully managed with rest and analgesics and, if necessary, blood transfusion.
u. Progression of the hematoma necessitates angiographic embolization of the bleeding vessel or, uncommonly, operative evacuation of the hematoma and hemostasis