A 54 year-old woman admitted to emergency department of a state hospital complaining with a 4-hour history of sudden severe right upper abdominal pain. She had been using warfarin and diltiazem for the treatment of atrial fibrillation, and she had a history of mitral valvuloplasty 3 years ago because of mitral stenosis. She also had hypertension and diabetes. She denied any history of trauma (or Sport activity) before admission. Vital signs of the patient recorded as Blood pressure was 110/70 mm Hg, pulse rate was 95 per minute, and temperature was 37.2?C. Physical examination relieved tenderness at upper right quadrant of the abdomen. Hepatobiliary ultrasonography (USG) and laboratory tests studies were planned. Laboratory tests were as follows: hemoglobin (Hb) 9.51 g/dL, hematocrit (Hct) 27.8%, white blood cell (WBC) 12 300/mm³, platelet (Plt) 120.000/mm³, prothrombine time (PT) 59.52 seconds, activated partial tromboplastin time 41.8 seconds, interna- tional normalized ratio (INR) 4.96, and Alanine aminotrans- ferase (ALT) 40 U/L, aspartate aminotransferase

36 U/L, Alkaline phosphatase (ALP) 220 U/L, and Gammaglutamyl transpeptidase (GGT) 29 U/L. All other biochemical markers were normal. There was no pathologic finding at hepatobiliary USG and plain abdominal radiog- raphy (Fig. 1). At the second hour of follow-up, re- examination of the patient revealed an elongated tender mass in the right abdomen and a little bluish discoloration at the same area. Hemoglobin and Hct levels had dropped to

6.41 g/100 mL and 19.1%, respectively, whereas WBC raised up to 15 300 mm³. Plt count was 130.000/mm³. Due to deterioration of patients condition (pulse 120/min, BP 90/40 mm Hg), Abdominal computed tomography (CT) was performed, and it showed the mass correlated with anatomic position of the rectus sheath which had the consistency of fluid-blood with an estimated volume of 1300 mL (Fig. 2). At the third hour of follow-up, the mass had enlarged down to the umbilicus, and bruising had developed in the right upper quadrant and around the umbilicus.

The patient was hospitalized and received 4 U of red blood cell pack and 4 U of fresh frozen plasma. After red blood cell transfusion, the patient became hemodynamically stabilized (BP 100/60 mm Hg; pulse, 92/min; Hb, 10.53 g/100 ml; Hct 31.1%; INR, 1.62), so the department of surgery decided to observe medically. In subsequent examinations of the patient, no enlargement of mass has been noticed. At the fourth day of follow-up, WBC count

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Fig. 1 Abdominal scanogram (CT).

was 9400 cell/mm³; Hb, 9.57 g/100 ml; Hct, 27.4%; Plt, 123.000/mm³; PT, 20.7 seconds; and INR, 1.71. The patient was discharged after 1 week of follow-up. Control abdominal USGs of hematoma were performed weekly for

1 month and monthly for 6 months. After 6 months, hematoma was resorbed with no sequelae (Fig. 3).

rectus sheath hematoma incidence is highest in the fifth decade and occurs commonly in women. Although most are

Fig. 2 Computed tomographic scan illustrating rectus sheath hematoma at umbilicus level.

self-limiting, it can lead to significant morbidity and has an overall mortality reported as 4%; for those on anticoagulation therapy, the mortality has been reported as high as 25% [1,7]. Our patient was a 54-year-old woman receiving warfarin treatment after mitral valvuloplasty.

Both USG and CT have been used to differentiate rectus sheath hematoma from other intra-Abdominal pathologies with a fair degree of success [3]. Although both USG and CT reduce unnecessary laparotomy, CT is more sensitive and specific [1]. In our case, there was no pathologic finding at USG. Due to rapidly progression of abdominal wall enlargement and deterioration of patient’s condition, abdom- inal CT was performed for the second imaging. Ultrasonog- raphy may miss the diagnosis as in our case, and abdominal CT could detect these pathologies especially in early stages. Exploratory laparotomy was performed in a significant number of patients with rectus sheath hematoma because of the difficulty in distinguishing hematoma from other intra- abdominal disorders [3]. On admission, our patient’s presentation was mimicking cholecystitis. Rapid progression of abdominal swelling made us consider other causes of

acute abdominal pathologies.

Most Rectus sheath hematomas can be treated conserva- tively. The main purpose of treatment must include elimination of predisposing conditions and cessation of anticoagulation therapy. When necessary, Fluid replacement and reversal of anticoagulation and/or Antiplatelet therapy should be carried

out with expert advice from hematologists [1]. Surgical evacuation or guided drainage of a rectus sheath hematoma is not generally indicated even if it may cause persistent bleeding by decreasing a potential tamponade effect. However, it may become necessary if the hematoma is very large and Abdominal compartment syndrome is suspected [1]. In some cases, active bleeding can be managed either surgically by evacuating the hematoma and ligating the bleeding vessels or radiologically with catheter embolization [1].

According to the CT classification, there are 3 types of rectus sheath hematoma: type 1 hematomas are mild, and the hematoma occurs within the muscle with an increase in muscle length; type 2 hematomas are moderate-the hematoma is within the muscle but bleeding occurs into the space between transversalis fascia and the muscle; and type 3 hematomas are severe and located between transversalis fascia and the muscle, anterior to the peritoneum and urinary bladder [1].

In type I hematomas, hospitalization is not usually required, and the hematoma resorbs spontaneously within 30 days. Type 2 and 3 hematomas require hospitalization. In type 2 lesions bed rest, intravenous fluid replacement and analgesia is the appropriate treatment. In type 3 lesions additional blood product transfusions are required. These kind of hematomas resorb approximately in 3 months [8] (our case is an example for type 3 hematomas). In our case, a rapidly progressive type 3 hematoma was present, which seemed to have been resorbed after 6 months of follow-up.

Fig. 3 Computed tomographic scan illustrating rectus sheath hematoma at right upper quadrant that thought to be tearing of muscle was started.

After 1 week of hospitalization, the patient was discharged with regulation of anticoagulant therapy.

Rectus sheath hematoma may occur more frequently than previously described in a population of relatively elderly patients. The classic signs of localized tenderness or mass with a characteristic history of straining may be completely absent. The diagnosis can be made confidently by urgent CT scanning, especially in patients without mass.

Enver Atalar Hacettepe University Hospital Department of Cardiology 06100 Ankara, Turkey

doi:10.1016/j.ajem.2010.08.003

Mahir Sahin Kirsehir State Hospital Emergency Medicine 06550 Ankara, Turkey

E-mail address: drsahinmahir@yahoo.com

Selcuk Coskun Ankara Mesa Hospital 06510 Ankara, Turkey

Murat Cobanoglu Ankara Guven Hospital 06540 Ankara, Turkey

Isa Kilicaslan Gazi University Faculty of Medicine Department of Emergency Medicine

06500 Ankara, Turkey

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