Spontaneous Rectus Sheath Hematoma: An Uncommon Cause of Acute Abdominal Pain

BACKGROUND A clinical condition that is often misdiagnosed, rectus sheath hematoma (RSH) is usually seen in the context of blunt abdominal trauma and/or anticoagulation therapy, rarely occurring spontaneously. We present a case of spontaneous rectus sheath hematoma (SRSH) without obvious risk factors and review the literature regarding diagnosis modalities and management. The aim of this case presentation is to highlight this rare clinical condition and emphasize the role of the physical exam in determining the appropriate treatment approach.   CASE REPORT A 50-year-old woman presented to the emergency room with right-sided pelvic pain for one day. Her medical history was specifically notable for recent coughing due to acute bronchitis, as well as the use of NSAIDs. Physical examination revealed marked tenderness in the hypogastric and right lower quadrant, with guarding and fullness in the same area. Laboratory investigation showed mild anemia and normal coagulation tests. Computed tomography demonstrated a right rectus muscle hematoma measuring 8.5×8.5 cm and extending into the lower abdomen and the extraperitoneal space, without active contrast extravasation. Close monitoring of vital signs and hemoglobin hematocrit levels along with supportive care with fluid resuscitation and pain control were initiated and the patient remained stable throughout her hospital stay. CONCLUSIONS Prompt recognition and management of SRSH are crucial. Physical examination is a key part of this process and imaging is the mainstay of diagnosis. Management remains for the most part supportive, although surgery or vascular embolization is required for uncontrolled hematomas with hemodynamic instability.