A 54-year-old obese female was admitted to the emergency department as she had an acute abdominal pain localized to the right lower quadrant, nausea and fever.She had a palpable mass in the same location and pretibial edema.
A 54-year-old obese female was admitted to the emergency department as she had an acute abdominal pain localized to the right lower quadrant, nausea and fever. She had a mass in the same location and pretibial edema. She had a coronary bypass operation an year ago and she was taking oral anticoagulants since then. The laboratory tests were as follows: WBC=6000, Hb=27 mg/dl, Hct=31, PLT= 14 seconds. The patient was suspected to have acute appendicitis based on surgery findings. Then sonography and CT were performed. CT reports showed a iso-hyperdense muscle enlargement (Fig. 1). On doing contrast enhanced CT examinations, we detected a fusiform nonenhanced isodense lesion in the rectus abdominis muscle (Fig. 2a, 2b). The muscle on enlargement reached its maximum dimensions at the pelvic brim (Fig. 1). There was a small amount of fluid in the perihepatic region and hepatorenal fossa. The patient was evaluated as having a rectus sheath hematoma (RSH), and an unneccessary laparotomy was prevented.
RSH must be suspected in women of advanced age who undergo treatment with anticoagulants and who present the clinical triad of acute abdominal pain, infraumbilical mass, and anemic syndrome, especially at the 6th and 7th decades. Arterial hypertension, strained coughing, tetanus and pregnancy are believed to be the other predisposing factors. The development of abdominal pain in the patient receiving anticoagulants, or attending a hemodialysis program especially with a documented drop in hematocrit levels almost certainly indicates a major hemorrhage. If loss of blood from the GI tract is not documented, some form of internal bleeding must be considered. The diagnosis of a hematoma of the rectus abdominis, although sometimes misleading, should be included as a differential diagnosis in all the patients who present with an acute abdominal pain and blood loss. The rectus abdominis muscle lies between the aponeuroses of the transverse and oblique abdominal muscles. This arrangement is seen from the costal arch to a level approximately between the umbilicus and the pubic symphisis, where the rear layer of the rectus sheath ends with a curved edge, called the semicircular line of Douglas. Beneath this line, the aponeuroses of the three muscles pass in front of the rectus which is separated from the peritoneum only by the fascia trasversalis, a thin connective layer between the rectus and the preperitoneal fat. In this lower aspect of the muscle, the perforating branches of the inferior epigastric artery running in the preperitoneal fat may rupture causing a large hematoma that spreads widely in this loose space. The diagnosis is sometimes misleading, and the clinical appearance can mimic acute appendicitis or a ventral hernia. CT can help to make the diagnosis by showing the typical hyperdensity of fresh blood and by defining the exact location of the palpable mass as to whether it is intraperitoneal or not. Sonography shows a mass of mixed echogenicity with no internal vascularity. But the exact location as to whether the lesion is suprafacial or not can be confirmed with CT. The typical pattern of the pseudocysts with the hematocrit effect is quite specific but less sensitive and can be better defined by B-mode US. Sonographically, these hematomas may be confused with abdominal wall tumors. On performing CT scans, a hyperdense mass posterior to the rectus abdominis muscle with an ipsilateral anterolateral muscular enlargement is considered as a characteristic of acute RSH, although chronic RSH may be isodense or hypodense relative to the surrounding muscle. MRI is a very useful tool in the diagnosis of RSH, and it demonstrates as hıgh signal intensity areas on both T1- and T2-weighted images, especially when the CT findings are not specific for RSH. The RSH showed up as heterogeneous signal intensities with areas of high signal intensity on T1-weighted images. Fluid–fluid levels and a concentric ring sign were also noted. In patients who are sonographically examined for suspected appendicitis, the abdominal wall should be studied as well, to exclude the presence of a nonpalpable RSH. In cases in which a hematoma is found, an unnecessary laparatomy can be prevented. Serial scans demonstrating a decrease in size and/or attenuation of the mass confirm the diagnosis of a hemorrhage. In our opinion, a negative CT examination is a reliable indicator which proves that such a bleeding complication has not occurred.
Rectus sheath hematoma.
Based on the provided multiple transverse CT images:
These imaging findings correlate with the palpable mass in the right lower abdomen, acute abdominal pain, and a possible coagulopathy, suggesting the possibility of an abdominal wall hemorrhage (in particular, a rectus sheath hematoma).
Based on the patient’s clinical presentation (acute right lower abdominal pain, palpable mass, obesity, possible coagulopathy) and imaging findings, the potential diagnoses include:
Taking into account the patient's clinical features (acute right lower abdominal pain, palpable mass, obesity, potential coagulopathy, and associated anemia or decreased hemoglobin), together with these imaging findings, the most likely diagnosis is:
Rectus Sheath Hematoma (RSH).
For further confirmation, follow-up imaging (such as CT or MRI) or monitoring of hemoglobin and coagulation profiles could be considered to determine the progression and stability of the hemorrhage. If the mass gradually decreases in size and hemoglobin levels remain stable or improve, this would further support the diagnosis of a hematoma.
After the acute phase has subsided and the hematoma is confirmed to be stable, a gradual rehabilitation program should be initiated to prevent muscle deconditioning from prolonged bed rest while avoiding excessive stress on the abdominal wall that could trigger rebleeding. The following approach follows the FITT-VP principle:
Throughout the rehabilitation process, closely monitor abdominal pain, changes in the abdominal wall mass, and blood pressure/heart rate. If any abnormality occurs (e.g., worsening pain, a significant drop in hemoglobin), seek medical attention promptly.
This report is a reference analysis based on the patient's basic medical history and imaging findings and does not replace an in-person clinical diagnosis or professional medical advice. If there are any concerns or worsening symptoms, please seek further evaluation and treatment at a certified medical institution without delay.
Rectus sheath hematoma.
