The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders

Background: Rectus sheath hematoma (RSH) is a rare entity that can mimic an acute abdomen. Therefore, we designed a study to analyze the etiology, frequency, diagnosis using ultrasound, and treatment of RSH. Methods: A total of 1,257 patients admitted for abdominal ultrasound for acute abdominal pain or unclear acute abdominal disorders were evaluated. Results: In 23 (1.8%) patients, an RSH was diagnosed; three of them were not diagnosed preoperatively by ultrasound. Of 13 men and 10 women (mean age, 57 ± 23 years), 13 developed RSH after local trauma, three after severe coughing, two after defecation, and five spontaneously. Fifteen had nonsurgical therapy, and eight underwent surgery. The use of anticoagulants was accompanied by a larger diameter of the RSH (p < .012), and surgical therapy was more frequently required in these patients. In the surgically treated group, more intraabdominal free fluid could be detected by ultrasound (p < .0005), patients required less analgesics (p < .001), and the mean hospital stay was shorter (p < .001). Conclusions: RSH is a rare condition that is usually associated with abdominal trauma and/or anticoagulation therapy. Ultrasound is a good screening technique. Nonsurgical therapy is appropriate but leads to a greater need for analgesics. Surgery should be restricted to cases with a large hematoma or free intraabdominal rupture. Received: 29 June 1998/Accepted: 19 December 1998     

Rupture of internal iliac artery aneurysm presenting as rectus sheath hematoma: case report

This report describes a ruptured internal iliac artery aneurysm that presented as a rectus sheath hematoma (RSH). The patient developed abdominal pain and a large, tense lower abdominal wall mass without peritoneal signs. Computed tomography scan demonstrated a massive RSH contiguous with a ruptured left internal iliac artery aneurysm. Hypovolemic shock prompted immediate laparotomy, aneurysmorrhaphy of the ruptured aneurysm, and evacuation of the rectus hematoma. This uncommon presentation of internal iliac aneurysm rupture should caution against a simple diagnosis of "spontaneous" RSH in a patient with a potentially ruptured iliac aneurysm.     

Spontaneous Rectus Sheath Hematomas: When to Restart Anticoagulation?

Background

The aim of the present study was to obtain data regarding the timing of anticoagulation resumption in patients with spontaneous rectus sheath hematomas (RSH).

Patients and methods

The study is based on review of patients receiving anticoagulation medication who were diagnosed with a spontaneous RSH (traumatic and iatrogenic excluded) between 14 July 1997 and 17 March 2012.

Results

There were 156 patients (37 % male; aged 73 ± 13 years) with an average body mass index of 29 ± 7 (procedure group 28 ± 6). Anticoagulants included coumadin (64 %), intravenous heparin (21 %), aspirin (8 %), and others (7 %). An intervention was needed in 29 (19 %) of the patients (5 % operative; 16 % embolization). Sixty-two percent of patients had their anticoagulation restarted during their hospitalization, with a median re-initiation time of 4 days after RSH diagnosis (range 2–8 days). Timing of anticoagulant resumption did not differ regardless of the need for intervention (3 vs. 4 days). The complication rate was 19 % (42 % in the procedure group, none specific to the procedure), with the most common being acute renal failure (n = 8; 5 %), death (n = 8; 5 %), and thrombotic events (n = 5; 3 %). After resumption of anticoagulation, two patients suffered enlargement of their RSH, both 2 days after resumption.

Conclusions

Intervention to control hemorrhage was unnecessary in the majority of patients with RSH. In those with resumption of anticoagulation, the majority of patients were safely restarted by day 4. Even though complications secondary to anticoagulation were few, thrombotic complications outnumbered bleeding complications, suggesting that anticoagulation was withheld for too long after RSH diagnosis.     

Rectus sheath haematoma: are there prognostic risk factors of haemodynamic instability motivating an early operative treatment?

Purpose

Rectus sheath haematoma (RSH) is an uncommon condition caused by lesion of the superior or inferior epigastric arteries or their branches or by rupture of the rectus muscle. Treatment is usually supportive; however, if haemodynamic compromise develops, intravascular embolisation or surgery may be required. Furthermore, in some cases, bleeding may be so conspicuous that it can determine the patient’s death before an adequate treatment is performed. We performed a retrospective study on 78 consecutive patients with the diagnosis of RSH admitted to the General Surgery Unit of our hospital between January 2000 and December 2010 in order to identify possible prognostic risk factors that could affect the operational approach before the onset of haemodynamic instability.

Methods

Demographic characteristics, patient history, laboratory and diagnostic imaging examinations were investigated. The variables considered were: gender, age, anti-coagulation or anti-platelet therapy, trauma, international normalised ratio (INR) and bleeding time in the first 72?h of observation and concomitant diseases. The data were used for statistical analysis.

Results

Sixty patients received a conservative treatment, while 18 underwent operative treatment for haemodynamic instability (embolisation in 2 patients and surgery in 16 patients). Three of these 18 patients (17?%) died for consumption coagulopathy after surgery. None of the variables included in the univariate statistical analysis was significant (p?=?ns).

Conclusion

Ultrasonography or computed tomography are the most common methods used to establish the diagnosis of RSH, so it is no longer a diagnostic dilemma. Most patients can be treated conservatively and an operative treatment is justified only in case of haemodynamic instability. Our retrospective study could not identify any prognostic risk factor of haemodynamic instability in RSH. We believe that only a close observation of the patients with RSH and “common sense” can prevent a possible fatal outcome.     

Spontaneous Hematoma of the Rectus Abdominis Muscle: a Rare Cause of Acute Abdominal Pain in the Elderly

A rectus abdominis sheath hematoma (RSH) is uncommon. It may mimic other acute abdominal disorders. The underlying conditions are trauma, coagulation disorders, or anticoagulant therapy, complications related to operations, subcutaneous injections to the abdominal wall, although it can also develop spontaneously. Acute abdominal pain and a palpable mass after muscular strain such as coughing, sneezing, and twisting were features highly suggestive of RSH. The diagnostic means of choice is computerized tomography. The treatment is usually conservative, but surgery may be needed in cases with large or progressing hematomas or with severe symptoms. We herein report an elderly woman presenting with an acute painful abdominal mass, without any underlying conditions, which was diagnosed as spontaneous RSH. She needed an operation. We concluded that RSH should be considered in the differential diagnosis of acute abdominal pain in the elderly, even in the absence of underlying conditions.     

Spontaneous hematoma of the rectus abdominis muscle: a rare cause of acute abdominal pain in the elderly

A rectus abdominis sheath hematoma (RSH) is uncommon. It may mimic other acute abdominal disorders. The underlying conditions are trauma, coagulation disorders, or anticoagulant therapy, complications related to operations, subcutaneous injections to the abdominal wall, although it can also develop spontaneously. Acute abdominal pain and a palpable mass after muscular strain such as coughing, sneezing, and twisting were features highly suggestive of RSH. The diagnostic means of choice is computerized tomography. The treatment is usually conservative, but surgery may be needed in cases with large or progressing hematomas or with severe symptoms. We herein report an elderly woman presenting with an acute painful abdominal mass, without any underlying conditions, which was diagnosed as spontaneous RSH. She needed an operation. We concluded that RSH should be considered in the differential diagnosis of acute abdominal pain in the elderly, even in the absence of underlying conditions.     

Surgical Management of Left Upper Quadrant Sided Rectus Sheath Hematoma Occurred by Coughing in a Hemodialysis Patient

Rectus sheath hematoma (RSH) is a rarely-occurring disease that is usually associated with anticoagulation, trauma, or spontaneous events. Most spontaneous rectus sheath hematomas may be relieved with conservative management. However, some extreme situations need surgical approach. Respecting the fact that the inferior epigastric artery mainly supplies the rectus abdominis muscle, interrupting its proximal side would cease the bleeding. We present a stepped procedure of ligation of the inferior epigastric artery and evacuation of hematoma with good field of vision in case of rectus sheath hematoma in hemodialysis patient.Key words: Rectus abdominis, HematomaRectus sheath hematoma (RSH) is a rarely-occurring disease. Most spontaneous rectus sheath hematoma may be relieved with conservative management. However, some cases need interventional approach. One way is coil embolization of the epigastric artery through arteriography.¹ However, embolization is time-consuming, expensive, and sometimes not available. In such cases, it is possible to directly ligate the inferior epigastric artery just below the hematoma location at its proximal with separated skin incision and it enables the hematoma to be evacuated easily with good field of vision.² We reported on a patient on hemodialysis who presented with rectus sheath hematoma at left upper quadrant abdomen accompanied by coughing, and introduced a simplified surgical procedure.     

Acute abdomen in abdominal wall hemorrhage in anticoagulation]

10 patients with a history of systemic anticoagulation presented with an acute abdomen which proved to be due to a rectus sheath hematoma. Four patients gave a history of antecedent trauma. The prothrombin time was prolonged beyond the therapeutic range in 8 patients and therapeutic in two. The diagnosis of rectus sheath hematoma was made by non-invasive imaging (sonography [n = 8], CT-scan) in 9 patients and by operative exploration in one. 8 patients were treated non-operatively and one patient required a delayed evacuation of the infected hematoma. One patient died from myocardial infarction. We conclude that a careful history, physical examination and prothrombin time, in combination with radiologic evaluation (sonography, CT-scan) can confirm the suspected diagnosis of rectus sheath hematoma. It is important to think of this specific hemorrhagic complication induced by anticoagulation to prevent unnecessary surgery.     

Bilateral rectal sheath hematomas after low-molecular weight heparin treatment in uremia

Rectus sheath hematomas (RSHs) are uncommon. They are usually unilateral and rarely bilateral. In this paper, we report the first case of spontaneous bilateral RSHs in a uremic patient after the administration of the first dose of low-molecular weight heparin during hemodialysis. The most interesting aspect of this case is that the main symptom of RSH in our patient was urinary bladder irritation. We highlight the importance of the prompt diagnosis and management of this medical emergency.     

Controlateral cavernous syndrome,brainstem congestion and posterior fossa venous thrombosis with cerebellar hematoma related to a ruptured intracavernous carotid artery aneurysm

Intracavernous carotid artery aneurysms (ICCAs) are rarely associated with life-threatening complications. We describe a 55-year-old woman who, after the rupture of an intracavernous carotid artery aneurysm, presented with a contralateral cavernous sinus syndrome and severe posterior fossa and spinal cord symptoms. Following parent artery occlusion, thrombosis of the posterior fossa and spinal cord veins caused a progressive worsening of the neurological status to a “locked-in” state. The patient fully recovered with anticoagulation therapy. Comprehension of the pathophysiological mechanism associated with the rupture of ICCA and early diagnosis of the related symptoms are essential in order to plan a correct treatment that includes the management of the aneurysm rupture and of possible complications related to venous thrombosis.     

Spontaneous bilateral chronic subdural haematoma of the posterior fossa. Case report and review of the literature

Summary. Summary.   Introduction: Chronic subdural haematomas of the posterior fossa in adults without a history of trauma are very rare. To our knowledge, only 15 cases have so far been reported in the literature, including those with anticoagulation therapy. A case of spontaneous bilateral infratentorial chronic subdural haematoma associated with anticoagulation therapy in an alive adult is presented and the relevant literature is reviewed.   Case Report: A 70 year old female presented with progressive dizziness, vertigo and gait ataxia. She was on anticoagulation therapy for heart disease. Neuro-imaging revealed bilateral infratentorial subdural masses.  The subdural masses were suspects for chronic subdural haematomas by neuroradiological criteria. Because of the progressive symptomatology, the haematomas were emptied through burrhole trepanations. Chocolate-colored fluid, not containing clotted components, gushed out under great pressure. The source of bleeding could not be identified. The patient recovered well from surgery, but died 4 months later shortly after admission to another hospital from heart failure.   Discussion: The chronic subdural haematomas in this patient may have been due to rupture of bridging veins caused by a very mild trauma not noticed by the patient and possibly aggravated by the anticoagulation therapy. Infratentorial chronic subdural haematoma should at least be a part of the differential diagnosis in elderly patients with cerebellar and vestibular symptomatology even without a history of trauma.     

Transcatheter arterial embolization of spontaneous rectus sheath haematoma in a Chinese woman

Spontaneous extraperitoneal haemorrhage is a rare but well-described complication of anticoagulation therapy. We report a case of spontaneous rectus sheath haematoma in a 69-year-old Chinese woman who had received low-molecular-weight heparin for pulmonary embolism. She presented with sudden onset of lower abdominal pain, hypotension and a tender lower abdominal mass after 1 week of anticoagulation therapy. Computed tomography revealed a huge right rectus sheath haematoma extending into the pelvis, and angiography demonstrated active contrast extravasation from the right inferior epigastric artery. Arterial embolization with Gelfoam was performed and succeeded in stopping the bleeding. Transcatheter arterial embolization can be an effective and safe modality to localize and treat the bleeder in spontaneous extraperitoneal haematoma for high-risk patients.     

Recurrent Hematomas Within the Iliopsoas Muscle Caused by Impingement After Total Hip Arthroplasty

Impingement of the iliopsoas muscle after total hip arthroplasty is a potential cause of postoperative groin pain. In addition, hematoma within the iliopsoas sheath has been documented as a cause of groin pain in patients on long-term anticoagulation. We present the case of a patient on long-term anticoagulation presenting after total hip arthroplasty with recurrent, symptomatic iliopsoas sheath hematomas. We believe this was due to iliopsoas impingement caused by a malpositioned acetabular component. His pain was relieved after revision of the acetabular component and debridement of the inflamed psoas tendon.     

Surgical therapy of femoral artery pseudoaneurysm after angiography

Seventy patients requiring surgical treatment for femoral artery pseudoaneurysm after angiographic procedures have been presented. The 10 year study period encompassed 38,822 catheter procedures (31,951 cardiology procedures and 6,871 radiology procedures) performed through the femoral artery. Presenting complaints included pain (51 percent) and neuropathy (19 percent). Additional morbidity has been discussed. The present study differs from previous ones in that many of the patients had femoral artery pseudoaneurysm formation in the common femoral artery without a history of smoking, diabetes, or hypertension. There was no demonstrable association with anticoagulation or antiplatelet therapy. The incidence of femoral artery pseudoaneurysm did increase with the use of a catheter sheath from 0.06 to 0.3 percent (p less than 0.005). This has not been reported previously. Direct arterial repair was utilized in 63 patients, whereas arterial reconstruction was required in 7 patients (saphenous vein graft in 4 and prosthetic graft in 3). There was one wound complication but no mortality associated with the surgical repair. Acceptable reasons for repair of femoral artery pseudoaneurysms are persisting or enlarging femoral artery pseudoaneurysms, associated pain or neuropathy, and rupture of femoral artery pseudoaneurysms.     

Tendoscopy of the peroneal tendons

An anatomic cadaver study was performed. Subsequently, in a prospective study, diagnostic and therapeutic tendoscopy (tendon sheath endoscopy) was performed in nine consecutive patients with a history of persistent posterolateral ankle pain for at least 6 months. All patients had pain on palpation over the peroneal tendons, a positive peroneal tendon resistance test, and most often local swelling. In two patients, a peroneal click was found without symptoms of dislocation of the tendons over the fibula. The indications for arthroscopy were diagnostic procedure postsurgery (3), diagnostic procedure postfracture (2), snapping sensation (2), removal of exostosis (1), and partial tendon rupture (1). Inspection and surgery of both tendons and tendon sheath could be performed well by a standard two-portal technique. A new finding is the vincula that was consistently present in all our autopsy specimens, as well as in all our patients. The vincula attaches both tendons to each other and to the tendon sheath. At a mean follow-up of 19 months, three of the four patients in which adhesions were found and resected were symptom free. In one patient, a symptomatic prominent peroneal tubercle was successfully removed. One patient had a longitudinal rupture of the peroneus brevis tendon that was successfully sutured. There were no complications.Arthroscopy 1998 Jul-Aug;14(5):471-8     

Konservative Therapie der tiefen Bein-Becken-Venenthrombose

The basic aspects in treating deep vein thrombosis (DVT) are immediate anticoagulation and compression. Nowadays the therapy of DVT aims at the patients’ safety concerning pulmonary embolism and bleeding, while the removal of the clot is not intended. Important current issues are the following: (1) patients with a high clinical probability of DVT should receive anticoagulation as soon as possible and before the diagnosis has been confirmed. (2) Cessation of anticoagulation should only been performed answering the question “When may I stop anticoagulation?” and not as it was to the question “How long is anticoagulation to be performed?” All patients with DVT remain at increased risk for recurrence for life time. (3) Investigation for thrombophilia can wait until after anticoagulation has been stopped for it does not affect standard therapy. (4) Among the new oral anticoagulants, rivaroxaban is the only one currently approved for DVT therapy, although approval of other substances is likely in the future for positive study results. (5) A mobile patient with acutely diagnosed DVT does not need to be immobilized regardless of the extent of DVT. However, it is unclear when an immobile patient with acutely diagnoses DVT can be mobilized.     

Spontaneous rupture of the spleen caused by a <Emphasis Type="Italic">Bacillus</Emphasis> infection: Report of a case

We report a case of spontaneous splenic rupture (SSR) caused by a Bacillus species (sp.) infection. A 36-year-old man on warfarin therapy since an aortic valve replacement at the age of 13 was admitted to our hospital with a 3-week history of a high fever. He had been asymptomatic until 4 months previously, when he suffered a cerebral embolism despite adequate oral anticoagulation. Abdominal computed tomography revealed splenic infarctions, which resulted in splenic rupture 2 days later. After embolization of the splenic artery, splenectomy was successfully performed. Pathologic examination revealed splenic infarction, resulting from septic emboli, with associated rupture of the splenic capsule, but no abscess was found. Bacillus sp. was isolated from cultures of arterial blood preoperatively, and the excised splenic specimens, postoperatively. In addition to rupture of the suppurating intrasplenic vessels with hematoma formation, the anticoagulant therapy possibly contributed to distension of the intrasplenic hematoma.     

The isolated scapho-trapezio-trapezoid ligament injury : Diagnosis and surgical treatment in four cases

Isolated injuries of the scapho-trapezial ligament complex are not well recognized. The ligament complex comprises the stout scapho-trapezial ligament, the floor of the flexor carpi radialis (FCR) tendon sheath and the scapho-capitate ligament.Between August 1991 and May 1992, we diagnosed and treated four cases of partial chronic post-traumatic lesions of this ligament complex. There was chronic pain at the base of the thenar eminence and instability of the thumb-index-middle finger pinch. Standard X-rays were normal. The diagnosis of ligament rupture was confirmed by mid-carpal arthrography showing filling of the sheath of FCR tendon. Surgical exploration showed complete rupture of the tendon sheath of FCR in two cases, associated in the other two cases with complete rupture of the scapho-trapezial ligament. Direct repair of the ligamentous elements was performed in all cases. The tendon of FCR was sutured to the tubercle of scaphoid to protect and to reinforce the ligament repair.The patients have been followed-up for between 6 and 12 months. All four patients recovered normal pinch strength to the middle finger. One patient suffered from chronic pain at work.     

Aneurysmal rupture during embolization with Guglielmi detachable coils

OBJECTIVE: The purpose of this study is to determinate the frequency, causes, management and outcome of aneurysmal rupture occurring during embolization. We present our experience with this severe and feared complication. METHODS: We retrospectively reviewed 314 acute cerebral aneurysms that were treated with endovascular coiling. These patients were identified and the management and outcomes were recorded. The literature was reviewed. RESULTS: Six patients had an intraprocedural aneurysmal rupture. This complication occurred sporadically. Prevalence was 1.9%. Of these six, four were women and two were men. The mean age was 68 years (range: 43-74 years). Four aneurysms were located in the anterior circulation and two in the posterior circulation. Perforation occurred during microcatheterization of the aneurysm in one case and during coil deposition in five cases. In these five patients, aneurysmal rupture resulted from detachment of the first coil in three patients and detachment of the third and last coil in two patients. Hemodynamic changes were noted for one patient. The Glasgow Outcome Scale score at last follow-up examination was 1 in three patients and 3 in one patient (fair recovery). Mortality was 33% and morbidity was 16.7%. CONCLUSION: Aneurysmal perforation during embolization is a rare event (1.8 to 4.4%). When perforation is recognized, embolization can be completed immediately with further coil deposition and reversal of anticoagulation therapy.     

Destruction of renal parenchyma at percutaneous nephrolithotripsy; experimental study

The destruction of renal parenchyma caused by excess deflection of the sheath was examined to determine at what level of force the renal parenchyma was ruptured during PNL. The kidney obtained from right nephroureterectomy due to renal pelvic cancer (stage T2N0M0) of a 54-year-old female patient was punctured at the posterolateral portion with a puncture needle. The tract was dilated up to 26 Fr. in size with an Amplatz renal dilation set. The 26 Fr. sheath was left in the tract and fixed to the metal bar attached to Gig Boring Machine (Hydroptic-6) which could sense the change of pressure added to the renal parenchyma in the parallel movement of the metal bar. The critical angle in regard to the deflection of the renal parenchyma in order not to cause the rupture of renal parenchyma on PNL was calculated from both the resultant force and the shape of the wound of renal parenchyma at rupture. The safety angle against horizontal plane of the tract ranged from 18 to 37 degree.