A rare case of bilateral rectus sheath hematoma due to anticoagulation: An abdominal CT scan revelation

Rectus sheath hematoma (RSH) is an uncommon yet clinically significant cause of acute abdominal pain, often overlooked due to its variable presentation and resemblance to other intra-abdominal pathologies. Predisposing factors include anticoagulation therapy, trauma, pregnancy, and strenuous activity, with anticoagulation-associated RSH carrying particularly high morbidity and mortality. We report a case of bilateral RSH in a 68-year-old female with multiple comorbidities, including atrial fibrillation, who was admitted for community-acquired pneumonia. During hospitalization, she developed atrial flutter with rapid ventricular response, necessitating a transition from her home apixaban to therapeutic-dose low molecular weight heparin (LMWH) in anticipation of potential cardioversion or invasive procedures. Later, she experienced sudden-onset severe abdominal pain and distension, accompanied by a marked hemoglobin drop (from 10.2 g/dL to 7.4 g/dL). An emergent abdominal CT scan confirmed bilateral RSH without active extravasation. Given hemodynamic stability, she was managed conservatively with packed red blood cell transfusions, serial hemoglobin monitoring, analgesia, and warm compresses. Her condition improved gradually, with no further bleeding or recurrence of arrhythmia. To our knowledge, this is the second reported case of bilateral RSH linked to LMWH use.