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Case of the Month 05/10

This 87 year old female with PMHx of HTN and atrial fibrillation on warfarin presented to the ED complaining of coughing x 1 week and lower abdominal pain x 2-3 days.

Question 1: What's wrong with these pictures?

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Answer 1:

There is a hematoma in the right rectus sheath. This is an uncommon cause of abdominal pain which usually presents as fairly severe abdominal pain and a palpable mass. It is usually caused by external trauma, iatrogenic trauma (with surgery) or excessive pressure due to repeated valsalva maneuvers (in this case with coughing.) There is an increased risk in patients on anticoagulation - including those receiving low molecular weight heparin which may be accidentally injected directly into the rectus muscle.

Question 2: Which types of imaging which may used to make this diagnosis?

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Answer 2:

Ultrasound and/or CT are the initial studies of choice. In suspected rectus sheath hematomas older than 5 days, MRI may be needed to differentiate hematoma from abdominal mass.

Question 3: What are the possible treatment options in patients with these diagnoses?

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Answer 3:

Most of these patients can be treated conservatively with analgesics, serial hematocrits, and transfusion and/or reversal of anticoagulation as needed. In cases which are more severe, angiography with embolization of the bleeding vessel or operative vessel ligation may be required.

This patient was observed for three days in the hospital and discharged in stable condition. Her warfarin was held for an initial INR of 3.38 and her hemoglobin level dropped from 14.5 to 11.8 during her admission. A repeat CT showed a more organized hematoma of slightly smaller size (see below).