Rectus Sheath Hematoma: A Rare Surgical Emergency

Area of Science:

• Vascular Surgery
• Abdominal Surgery
• Radiology

Background:

• Rectus sheath hematoma (RSH) is a rare condition involving blood accumulation within the rectus abdominis muscle sheath, often stemming from epigastric artery hemorrhage.
• Anticoagulant use is a significant risk factor, with increasing incidence correlating with broader anticoagulant prescription.
• RSH can lead to abdominal compartment syndrome (ACS), a critical complication necessitating prompt intervention to prevent severe morbidity and mortality.

Observation:

• A 79-year-old male on anticoagulants developed a right-sided RSH, which rapidly progressed to ACS.
• Clinical presentation included abdominal swelling, pain, nausea, vomiting, and urinary difficulties, followed by hemodynamic instability and significant hemoglobin drop.
• Imaging revealed a large RSH extending into the preperitoneal space.

Findings:

• The patient experienced acute decompensation with hypotension and respiratory distress during management, indicating hematoma expansion and increased intra-abdominal pressure.
• Interventional radiology (IR) successfully embolized the bleeding inferior epigastric artery after initial attempts to correct coagulopathy.
• Surgical decompression, packing, and subsequent exploration were critical in managing the ACS and RSH.

Implications:

• This case underscores the potential for RSH to rapidly evolve into life-threatening ACS, particularly in patients on anticoagulation.
• Aggressive management, including coagulopathy reversal, embolization, and surgical decompression, is crucial for favorable outcomes.
• Awareness of RSH as a complication of anticoagulation is vital for timely diagnosis and intervention.