The patient presented with acute pain in the lower abdominal quadrant with low haematocrit and haemoglobin. She had been admitted 7 days previously and discharged with a diagnosis of left leg thrombophlebitis treated with anticoagulation therapy - low molecular weight heparin.
The patient presented with acute pain in the lower abdominal quadrant with low haematocrit (20%) and haemoglobin (6.9g/dl). She had been admitted 7 days previously and discharged with a diagnosis of left leg thrombophlebitis treated with anticoagulation therapy - low molecular weight heparin (LMWH). There was a history of hypertension and rheumatoid arthritis and an episode of angina pectoris 1 month prior to admission. The patient reported that the onset of the pain followed exertion.
The patient underwent ultrasound and computed tomography examination. CT examination, performed with slice thikness of 5mm, table speed of 7.5mm and Pitch 1.5,after iv administration of 140ml of contrast medium at a rate of 3ml/sec, showed an enlarging smooth-shaped mass in the layers of the abdominal wall, enlarging and obliterating the normal morphology of the right rectus abdominis muscle, limited to one side of the abdomen by the linea alba. The CT scan also disclosed other pelvic masses with the same characteristics, displacing the bladder to the left, dissecting superiorly along fascial planes and extending into the retroperitoneal space adjacent to the psoas muscle. Clinical history and laboratory findings were critical for reaching the diagnosis of haematomas. Because of the general condition of the patient, especially the low haematocrit level, a surgical laparotomy was carried out to assess the evacuation of the large masses and to stop the bleeding. The surgical evaluation disclosed that the abdominal wall haematoma was supplied by the inferior epigastric artery, while the pelvic ones were supplied by the deep circumflex iliac artery.
The increasing use of LMWH in the pharmacological management of multiple conditions will increase the rate of spontaneous acute abdominal haematoma, which is sometimes a life-threatening condition (1,2).
These hematomas originate from tears in muscle fibers and sometime the correct diagnosis may be suggested by pain, blood loss and ecchymosis. Radiological evaluation, in association with clinical history, clinical examination and laboratory findings, plays a basic role in the differential diagnosis and pre-operative localization of such haematomas (3), in wich solid tumors such as desmoid neoplasms or metastatic disease must also be taken. In the pelvic localization below the arcuate line, extending into the prevescical space displacing the bladder, we have to also consider the differential diagnosis with urinomas, abscesses or lymphoceles. In our case, even if the CT evaluation was only performed after contrast medium administration, clinical history and laboratory findings were critical for reaching the diagnosis of haematomas
Acute rectus sheath and pelvic haematoma
Based on the provided abdominal and pelvic CT images, irregular, relatively well-defined, strip-like or mass-like high-density areas can be observed in the lower abdomen and pelvic cavity. The density is higher than the surrounding soft tissues, suggesting the presence of hematoma components. Some lesions appear to extend into the retropubic or pre-vesical space, with unclear boundaries between these lesions and surrounding muscle groups, indicating possible separation of muscle fibers or fascial layers. No obvious signs of fracture are noted. Considering the clinical information (pain, decreased hemoglobin and hematocrit, previous use of low-molecular-weight heparin), these imaging findings strongly suggest hematoma formation.
Taking into account the patient’s advanced age, history of anticoagulation with low-molecular-weight heparin for previously diagnosed left lower extremity thrombosis, current clinical symptoms (acute lower abdominal pain, significant declines in hemoglobin and hematocrit), and CT findings indicating signs of bleeding in the pelvis/abdominal wall, the most likely diagnosis is:
“Anticoagulation-related Spontaneous Hematoma of the Abdominal Wall (or Pelvis).”
If doubt remains, further angiographic studies or repeated imaging follow-ups can be performed as clinically necessary to rule out other rare entities.
During the acute phase, the patient should avoid vigorous activities to prevent expansion of the hematoma. After the condition stabilizes, gradually proceed with individualized rehabilitation training.
Throughout the rehabilitation process, regular blood tests and coagulation profiles should be performed to ensure safety. If significant pain worsens, bleeding, or other discomfort occurs, suspend the respective exercise and seek medical evaluation.
Disclaimer: The above report is a reference analysis based on the provided imaging data and clinical information. It does not represent a final medical opinion. For an accurate diagnosis and treatment plan, please consult a qualified physician or seek in-person medical advice.
Acute rectus sheath and pelvic haematoma
