Case Presentation:

Rectus Sheath hematoma (RSH) is an uncommon pathology that arises from rupture of the epigastric arteries which results in accumulation of blood within the rectus sheath. Patients often present as acute abdominal pain often delaying diagnosis. Here we present a unique case of cough induced rectal sheath hematoma.

Discussion:

A 38 year Caucasian female with no past medical history presented with right lower quadrant pain, sudden in onset, dull pain, 8/10 in severity, with no radiation, no relieving factors and exacerbated by coughing, and flexing her right hip. She denied any fever, chills, chest pain, shortness of breath, diarrhea or constipation. She endorsed a non–productive cough for one week and was initially diagnosed with upper respiratory tract infection and was treated with azithromycin by her primary care physician. On examination, vital signs stable, cardiovascular exam was regular rate and rhythm. Abdominal exam revealed tenderness to palpation at the right lower quadrant, tenderness and a palpable 7 × 7 cm mass with a smooth tender surface, with impalpable borders, extending to the right inguinal region, no guarding, no rebound. Labs, WBC 13.67, hemoglobin 12.9, platelets is 357. BMP and liver function tests were within normal limits with a creatinine 0.6, INR 0.9. Transvaginal ultrasound showed normal size ovaries with no uterine or ectopic pregnancy. The patient underwent CT abdomen with contrast which showed a rectus sheath hematoma, actively bleeding, involving the lower right anterior abdominal wall measuring 10.5 cm craniocaudally and 4 × 6.5 cm transversely. Interventional radiology was notified for embolization. The patient underwent right inferior epigastric artery angiogram and embolization. Upon discharge, patient was ambulating, asymptomatic and cough resolved.

Conclusions:

Rectus sheath hematoma is an unusual cause of acute abdominal pain. It can be traumatic or spontaneous. The immediate cause of the rupture may be external trauma, iatrogenic trauma from surgery, or excessively vigorous contractions of the rectus muscle. These vigorous contractions are often seen in strenuous exercise or repeated valsalva maneuvers, vomiting, straining or with severe coughing as presented in our case. RSH often present in acute onset of severe abdominal pain, exacerbated with movement. Abdominal examination usually shows a tender mass, but at times it may not be palpable as the hematoma is deep in the rectus muscle. Because of its rare incidence, it often initially misdiagnosed and has been reported to be mistaken for acute diverticulitis, acute splenic disease, strangulated ovarian mass, acute appendicitis, or strangulated hernia. Abdominal ultrasonography, computed tomography, have been used to confirm the diagnosis. Depending on the size of the hematoma, those not responding to conservative management may either need surgical evacuation, ligation of the bleeding vessels or embolization.