diagnosis of paralytic ileus due to bed rest was made. Fluid therapy and finger enema were done. She was defecated large amount of stool, but complained aggravating pain despite pain control medication. To differentiate other disease, a computed tomographic scan of the abdomen was obtained. The contrast abdominal pelvic computed tomo- graphic scan revealed 15-cm-sized hematoma with active bleeding in left Rectus abdominis muscle (Fig. 1). She was admitted for conservative care including pain control and recovered with fluid therapy. She was discharged on the 14th day without complication.

rectus sheath hematoma (RSH) is generally not considered a reason for abdominal pain, and its incidence as cause of abdominal pain is unknown [1]. Rectus sheath hematoma is a rarely seen but important disease causing abdominal pain [2].

Superior and inferior epigastric vessels run along the posterior border of muscle within the sheath along its entire course. Sudden disruption of a deep epigastric vessel or rupture of the rectus abdominis muscle may result in an Abdominal wall hematoma, which, depending upon its location and size, can produce symptoms and clinical

Fig. 1 Computed tomographic scan showing a rectus muscle hematoma with active bleeding. The white arrow indicates a hematoma.

0735-6757/$ - see front matter (C) 2012

837.e4 Case Report

findings compatible with a variety of acute intra-abdominal condition [3,4]. In twisting or sudden position change without a direct blow, there is no posterior sheath below the arcuate line of Douglas, so the posterior side of the rectus muscle contacts directly with transversalis fascia and peritoneum. Below the arcuate line, the abdominal pressure exerts direct influence on the inferior epigastric vessels, which have no protection from the posterior rectus sheath [1].

Firm attachment of branches of the inferior epiGastric artery while piercing the rectus abdominis muscle and movement of the body creates shearing forces at the arterial branch attachment. During contractions of the rectus abdominis muscle, the Inferior epigastric artery must glide with the muscle to avoid tearing. When the inferior epigastric artery is torn, blood dissects along the rectus sheath leading to hematoma formation [3,5].

Risk factors of RSH include trauma, obesity, straining, coughing, previous abdominal surgery, use of anticoagulant therapy, injection, and pregnancy. Older patient may have more than 1 risk factor [4]. In our case, old age and underlying disease (DM) could have contributed to vascular degeneration. Degenerated vessels are vulnerable to shear force [6].

Common presenting symptoms are abdominal pain, abdominal swelling, fall in hemoglobin level, nausea, vomiting, tachycardia, orthostatic symptoms, ecchymosis, syncope, peritoneal signs, and fever [7].

Computed tomography scanning has been shown to be 100% sensitivity in the diagnosis of RSH of less than 5 days of duration and is superior to ultrasound, which has sensitivity of 85% to 96% [8]. Ultrasound imaging remains the key investigation of choice. It is easily performed and avoids ionizing radiation. However, it is less specific and falsely suggests intra-abdominal process.

Specific treatment, surgical Hematoma evacuation, angio- graphic embolization, or conservative treatment for RSH depends on the severity of the hemorrhage. Conservative treatment of RSH with rest, analgesics, and discontinuation of anticoagulation therapy, blood, and blood products transfusion, if necessary, is feasible [8,9].

In current case, rectus abdominis muscle stretched because of overdistended bladder. After the patient was catheterized to drain Urinary retention, the rectus abdominis

muscle contracted abruptly. Vessels were injured by rapid muscle contraction caused by Foley catheterization.

We report that the Foley catheterization, which per- formed to who was immovable, can be one of the etiologic factor of RSH.

Yoon Hee Choi MD, PhD Ewha Womans University Medical Center 911-1 Mokdong Yangcheon-gu Seoul, Korea Department of Emergency Medicine

Ewha Womans University, Seoul, Korea E-mail address: [email protected]

Duk Hee Lee MD Soon Young Yun MD Jae Hee Lee MD

Department of Emergency Medicine Eulji University, Seoul, Korea

doi:10.1016/j.ajem.2011.03.020

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