Rectus Sheath Hematoma (RSH)

Rectus Sheath Hematoma (RSH)

David Ray Velez, MD

Table of Contents

Definition
Etiology and Epidemiology
Presentation and Diagnosis
Classification
Management

Definition

Definition: Accumulation of Blood within the Rectus Sheath

Etiology and Epidemiology

The Majority are Due to Injury to a Branch of the Epigastric Vessels

The Inferior Epigastric Vessels are Particularly Susceptible to Injury Because Their Relatively Fixed Course within the Rectus Sheath Limits Mobility – Increasing Vulnerability to Shearing Forces

Most Are Spontaneous and Not from Trauma

Risk Factors

  • Anticoagulation and/or Antiplatelet Use – Present in 50-89% of Patients
  • Elderly (Smaller Muscle)
  • Female Sex
  • Pregnancy
  • Asthma/COPD – Vigorous Coughing Spells
  • Chronic Medical Conditions (HTN, Cirrhosis, CKD)
  • Abdominal Injections – Particularly Subcutaneous Heparin/Lovenox

Presentation and Diagnosis

Presentation

  • Abdominal Pain
  • Abdominal Mass/Bruising
  • Nausea and Vomiting
  • Fothergill’s Sign – Does Not Cross Midline and Does Not Change with Flexion
    • Hernias are Generally More Painful/Prominent with Rectus Flexion
  • Carnett’s Sign – Point of Maximal Tenderness Does Not Change from Supine to Sitting

Complications

  • Hemorrhagic Shock
  • Infection
  • Abdominal Compartment Syndrome

Diagnosis

  • Generally Diagnosed by CT Imaging
  • May Also Consider US or MRI in Select Scenarios

Rectus Sheath Hematoma on CT 1

Classification

Type I: Small, Confined to the Rectus, and Does Not Cross Midline

Type II: Confined to the Rectus but Crosses Midline

  • Dissects Along Transversalis Fascial Plane

Type III: Large and Not Confined

  • Usually Below the Arcuate Line – May Cause Severe Bleeding Due to Lack of Aponeurosis to Contain/Tamponade
  • Often See Hemoperitoneum and/or Blood in Prevesical Space of Retzius

Management

The Majority are Managed Conservatively with Observation and Medical Therapy

Reverse Anticoagulation if Unstable or with Active Bleeding

Indications for IR Angioembolization:

  • Hemodynamically Unstable
  • Ongoing Requirement for Blood Transfusions
  • Enlarging/Expanding
  • Active Contrast Extravasation on CT

Indications for Surgery:

  • Skin Necrosis
  • Failure of Angioembolization
  • Compressive Symptoms (Femoral Neuropathy, etc.)
  • Abdominal Compartment Syndrome – Rare

Surgical Intervention

  • Procedure: Surgical Evacuation and Vessel Ligation
  • Incision: Midline or Paramedian to Expose the Posterior Sheath
  • Avoid Entering the Peritoneum
  • Obtain Hemostasis by Electrocautery and Ligation of Any Bleeding Vessels
  • May Require Ligation of the Superior or Inferior Epigastric Vessels – Generally Well Tolerated Due to Good Collateral Flow
  • Pack with Wet-to-Dry Dressings for Compression or Close Space Over a Drain

Inferior Epigastric Artery Ligation

  • Incision: Oblique Over the Groin
    • Carried Down to the Inguinal Ligament
  • Inferior Epigastric Found Branching Off the Medial Aspect of the Distal External Oblique Artery
  • Rarely Required Only for Persistent Bleeding that Cannot Be Controlled

References

  1. Sullivan LE, Wortham DC, Litton KM. Rectus sheath hematoma with low molecular weight heparin administration: a case series. BMC Res Notes. 2014 Sep 1;7:586. (License: CC BY-2.0)