Rectus Sheath Hematoma

Rectus sheath hematoma is a rare condition where blood gathers in the sheath of the rectus abdominis muscle. This happens when the epigastric arteries or the muscle get damaged. It leads to sudden pain and swelling in the abdomen, making it hard to tell apart from other serious conditions.

This condition is usually not serious but can be a big problem for older people or those on blood thinners. It’s important to spot and treat it quickly to avoid more serious issues. This article will explore the anatomy, causes, symptoms, diagnosis, and treatment of this often misunderstood condition.

What is a Rectus Sheath Hematoma?

A rectus sheath hematoma is a painful condition. It happens when blood bleeds into the sheath of the rectus abdominis muscle. This muscle is in the abdominal wall, covered by a fibrous sheath. When this sheath is torn or injured, blood can collect.

These hematomas can be small or large. They need quick medical care.

Anatomy of the Rectus Abdominis Muscle

The rectus abdominis muscle runs vertically on each side of the belly. It has important features:

The muscle is in the rectus sheath. This sheath is made of the transversus abdominis, internal oblique, and external oblique muscles. It can tear and bleed, causing a hematoma.

Causes of Rectus Sheath Hematoma

Many things can cause a sheath bleed or tear. These include:

• Trauma to the abdominal wall
• Vigorous coughing or straining
• Anticoagulation therapy
• Pregnancy and postpartum period
• Abdominal surgery complications
• Underlying coagulopathies

Knowing about the anatomy and causes of rectus sheath hematoma is key. People on blood thinners or with past abdominal injuries should watch for signs of a hematoma.

Symptoms and Signs of Rectus Sheath Hematoma

The main symptom of a rectus sheath hematoma is acute abdominal pain. This pain is sharp and severe. It usually happens in the lower abdomen and might be worse on one side.

The pain gets worse when you move or cough. This makes it hard to find a comfortable spot.

People with this condition also notice abdominal swelling or a bulge. This swelling is more noticeable in big hematomas. A doctor might feel a firm area or an abdominal mass during an exam. This helps tell it apart from other problems inside the belly.

The symptoms can change based on the size and where the hematoma is. They also depend on the person’s health. Sometimes, you might see:

If you’re feeling these symptoms, you should see a doctor right away. A rectus sheath hematoma can look like other serious belly problems. Quick diagnosis and treatment are key to avoiding serious issues and getting better.

Risk Factors for Developing a Rectus Sheath Hematoma

Several factors can increase the risk of developing a rectus sheath hematoma. It’s important to know these risk factors. This helps identify who might be more at risk and how to prevent it.

Anticoagulation Therapy and Rectus Sheath Hematoma

Anticoagulation therapy is a big risk factor for rectus sheath hematoma. This therapy is used to prevent blood clots. Medications like heparin and warfarin can lead to abdominal muscle injury and hematomas. People on these medications should watch for signs of bleeding and tell their doctor if they notice any unusual pain or swelling.

The risk of anticoagulation complications is higher in some groups. This includes the elderly and those with kidney problems. It’s key to monitor anticoagulant levels closely to reduce bleeding risks.

Other Predisposing Factors

Other factors can also increase the risk of rectus sheath hematoma:

Knowing and addressing these risk factors can help prevent rectus sheath hematoma. People with several risk factors should be closely watched. They should also be taught about the signs and symptoms of this condition.

Diagnostic Imaging for Rectus Sheath Hematoma

Getting a quick and accurate diagnosis of a rectus sheath hematoma is key. Imaging techniques are vital for confirming the diagnosis and seeing how big the hematoma is. The main tools used are abdominal ultrasound and abdominal CT scan.

Ultrasound Imaging

Abdominal ultrasound is often the first choice because it’s easy to get, cheap, and doesn’t use radiation. It can spot a rectus sheath hematoma and tell you its size and where it is. But, it might not work as well for very obese people or those with big hematomas.

Computed Tomography (CT) Scanning

Abdominal CT scan is the top choice for finding out about rectus sheath hematomas. CT scans give detailed pictures that show the hematoma’s size, location, and how big it is. They can also find bleeding or other problems. Here’s a quick look at the good and bad of ultrasound and CT for checking rectus sheath hematomas:

Differential Diagnosis of Abdominal Wall Hematoma

When someone has sudden abdominal pain and a mass that can be felt, a rectus sheath hematoma might be suspected. But, other conditions can also cause similar symptoms. These include tumors, hernias, and abscesses in the abdomen.

Abdominal tumors, both good and bad, can feel like a mass in the belly. They can grow from muscle, fat, or connective tissue. Some examples are:

Abdominal hernias happen when something bulges through a weak spot in the belly. They can be seen or felt, more so when standing or straining. Common hernias include:

• Inguinal hernia
• Umbilical hernia
• Incisional hernia (after abdominal surgery)

An abdominal abscess is a pocket of pus in the belly due to infection. It can form in places like the appendix or after surgery. Symptoms include fever, belly pain, and a tender spot. Ultrasound or CT scans can tell the difference between an abscess and a rectus sheath hematoma.

In summary, while rectus sheath hematoma is a big cause of sudden belly pain and a mass, other conditions must also be thought of. A detailed check-up and imaging can tell apart rectus sheath hematoma from tumors, hernias, and abscesses. This helps in getting the right treatment quickly.

Grading and Classification Systems for Rectus Sheath Hematoma

Rectus sheath hematoma severity is graded and classified to guide treatment. The Berná and Klingler systems are key. They look at size, location, and how unstable the patient is.

The Berná system has three levels. It looks at the size and where the hematoma is in the abdominal wall. It helps decide if surgery is needed. Here are the grades:

The Klingler system has four levels. It uses CT scans and checks if the patient is stable. It helps figure out the risk of problems and how to manage them:

Getting the right classification is key for treatment. Lower-grade hematomas (Berná I-II, Klingler I-II) might just need watchful waiting. But higher-grade hematomas (Berná III, Klingler III-IV) might need more serious steps like angiographic embolization or surgery.

Conservative Management of Rectus Sheath Hematoma

Most cases of rectus sheath hematoma can be managed without surgery. The focus is on pain management and supportive care. This approach helps the hematoma to heal on its own while avoiding complications.

It’s important to keep a close eye on the hematoma. This ensures it doesn’t grow or cause more problems.

Pain Control and Activity Modification

Managing pain is a key part of treatment. Doctors often use acetaminophen and NSAIDs for mild to moderate pain. For more severe pain, opioids might be needed.

Rest and avoiding strenuous activities are also key. Patients should not lift heavy things or do activities that could make the bleeding worse. In some cases, bed rest is advised.

Discontinuation of Anticoagulation

If a patient is on anticoagulation therapy and gets a rectus sheath hematoma, they might stop taking the medication. The decision depends on the hematoma’s size and the patient’s risk of blood clots. Anticoagulation reversal agents, like protamine sulfate or vitamin K, are used for severe bleeding.

Choosing to stop anticoagulation is a careful decision. It should involve a team of healthcare professionals to balance the risks of bleeding and the need for anticoagulation.

Interventional Treatment Options for Rectus Sheath Hematoma

Some cases of rectus sheath hematomas need more than just watching and waiting. Two main treatments are angiographic embolization and surgical evacuation. The right choice depends on the hematoma’s size, how stable the patient is, and if there’s active bleeding.

Angiographic Embolization

Arterial embolization is a small procedure that stops the bleeding artery. It’s for patients who keep bleeding or are unstable despite initial care. This method works well, with success rates from 80% to 100% in studies.

The benefits of arterial embolization are:

• It’s a small procedure
• No need for general anesthesia
• Recovery is quicker than surgery
• It stops bleeding well

Surgical Evacuation and Ligation

Surgery is for big, growing hematomas that hurt a lot, press on important areas, or make the patient unstable. The surgery removes the hematoma and stops any bleeding vessels. It lets doctors see and control the bleeding directly.

When surgery is needed, it’s for:

Choosing between angiographic embolization and surgery depends on the situation and the hospital’s capabilities. Sometimes, both methods are used together for the best outcome.

Complications and Prognosis of Rectus Sheath Hematoma

Rectus sheath hematoma is usually not serious but can cause problems. It might come back, mainly if you’re on blood thinners. It’s key to watch your blood thinner doses to avoid more bleeding.

A big hematoma can lead to abdominal compartment syndrome. This is when the blood clot presses too hard on your belly, hurting your organs. It’s vital to treat this quickly to avoid big issues.

There’s also a chance of getting an infection, which is more likely with big hematomas or skin damage. Watch for fever, more pain, and redness. Antibiotics might be needed to fight off infections.

Most people with rectus sheath hematoma get better on their own in a few weeks to months. But, bigger hematomas or surgery might take longer to heal. It’s important to keep up with follow-up care to make sure you’re fully recovered and avoid future problems.