Abdominal Hematoma – StatPearls – NCBI Bookshelf

Continuing Education Activity

A hematoma is a blood collection in an extravascular space and is named according to the location of the blood collection. Rectus sheath hematomas result from bleeding inside the vascular rectus muscle layer of the abdominal wall. This activity reviews the evaluation and management of rectus sheath hematomas and emphasizes the role of the interprofessional care team in recognizing and managing this condition.

Objectives:

• Identify the location of the majority of rectus sheath hematomas.

• Outline the pathophysiology of rectus sheath hematomas.

• Describe some symptoms and signs that may be present in a patient with a rectus sheath hematoma.

• Delineate the role of interprofessional team members in recognizing and managing rectus sheath hematomas to improve patient outcomes.

Access free multiple choice questions on this topic.

Introduction

A hematoma is a blood collection in an extravascular space. It results from bleeding from a vascular structure. Depending on the location of the blood collection, hematomas are named accordingly, e.g., intracranial hematoma[1], hemothorax[2], pelvic hematoma[3], and abdominal hematoma. Hematomas can collect in extravascular areas near bleeding vessels with space to accommodate this blood collection. An abdominal hematoma can be intrabdominal or an abdominal wall hematoma. Abdominal wall hematoma usually results from bleeding inside the muscle layers of the abdominal wall, most commonly the vascular rectus muscle. A known category of this hematoma is rectus sheath hematoma. This activity will be focused on rectus sheath hematoma or rectus hematoma. 

Rectus sheath hematoma is bleeding in the rectus sheath. It is a confined space where the blood collects, commonly in the form of localized hematoma. Inferior or superior epigastric arteries and veins or their branches and tributaries form the basis of the bleeding source. A rectus hematoma can occur spontaneously in certain categories of people. But, it usually follows an injury to the inferior or superior epigastric vessels or their perforating branches. While this condition does resolve on its own, sometimes the hematoma can be extensive and lead to hypovolemic shock [4][5][6].

Etiology

Rectus sheath hematomas result from bleeding of the epigastric vessels or their perforator branches in the rectus abdominis muscle sheath[3]. Although rarely life-threatening, they can be severe and lead to hemodynamic instability. However, in most cases, rectus hematoma is self-limiting and usually spontaneously resolves.

Like in other types of bleeding, the cause can be due to the bleeding tendency, anticoagulation, or injury to the vessels. Vascular injury may occur due to external abdominal trauma, trauma during surgery (iatrogenic), or intense contraction of the rectus muscles during activities associated with Valsalva maneuver, as in severe retching, vomiting, or straining [7][8]. In most cases, the hematoma is localized. But in people with excessive loose connective tissue, the hematoma can spread to above the umbilicus, the contralateral side, or become intraabdominal. Risk factors include the use of anticoagulant medications, advanced age, female gender, and intense physical activity. With the increased use of anticoagulation, the rates of rectus sheath hematoma appear to be on the rise.

Epidemiology

Rectus sheath hematomas are uncommon [9][10]. The exact incidence of rectus sheath hematoma is not known as the condition is often misdiagnosed or undiagnosed. Some studies report an incidence of 1.5% to 2% in hospitalized patients.

Overall, rectus sheath hematoma is more common in females than males. A higher female incidence has been linked to decreased muscle mass. While pregnancy is a risk factor in women, trauma and exercise seem to be the most common causes in men. Rectus sheath hematomas are more common on the right side, and the majority are located in the lower quadrant of the abdomen below the arcuate line. 

Pathophysiology

Rectus sheath hematoma is caused by rupture of an epigastric artery or one of its perforating branches. The vessel injury may be due to blunt or penetrating trauma, surgery, or strong contractions of the rectus muscle. Since the epigastric arteries run deep along the posterior rectus sheath, making a diagnosis during a physical exam is difficult, especially in patients who have obesity. The hematoma is usually posterior to the rectus muscle fibers, subcutaneous fat, and skin. Palpating a tender firm bulge is the most common physic exam finding. The fluctuation sign of a fluid collection is not usually possible to detect due to the deep location of the hematoma. The lower quadrants of the abdomen are usually involved because of the long epigastric branches and the lack of a tamponade effect from the loose connective tissues of the rectus sheath.

History and Physical

The typical presentation of a rectus sheath hematoma is abdominal pain and its associated symptoms like nausea and vomiting. The pain is often sudden in onset, sharp, and does not radiate. In extremely rare cases, the hematoma may be large and present with hypovolemia, tachycardia, and tachypnea. Physical exam usually reveals a palpable localized mass that is non-pulsatile. The Fothergill sign is a mass in the abdominal wall that does not cross the midline and does not change with flexion of the rectus muscles. This suggests a rectus sheath hematoma and is useful to determine if the abdominal mass is within the abdominal wall or intraabdominal cavity. It is not a highly sensitive sign and is often inconclusive in individuals who are obese.

The clinician should obtain a thorough medical history to determine the presence of any risk factors like surgery, coughing, constipation, asthma, bronchitis, anticoagulation therapy, and use of oral anticoagulants and corticosteroids.

Evaluation

Ultrasound is the first test of choice to confirm a rectus sheath hematoma diagnosis after basic blood work, and coagulation profile are obtained. The hematoma appears as hypoechoic space in the posterior rectus sheath. Further information like the size and exact location of the hematoma can be obtained from the ultrasound study. If the ultrasound study is inconclusive, a CT scan is the next test. It can show more details about the location, size, and extension of the hematoma. When intravenous contrast is administered with the CT scan, active bleeding can be detected by the presence of the contrast in the form of blush in the hematoma if the bleeding is active.

Unless a contrast is visualized in the hematoma, the differential diagnosis of a fluid collection in the rectus sheath should not be ignored. If the diagnosis of hematoma is still in doubt after imaging, needle aspiration can be performed to differentiate a hematoma from an abscess. However, with needle aspiration, there is a risk of puncture the bladder, bowel, or a hernia.[11]

Evaluation of the hematoma should be part of the comprehensive evaluation of the patient’s condition. General assessment addressing the related factors and conditions causing the hematoma or as a complication of the hematoma is necessary for a proper evaluation[12]. Simultaneous treatment of the underlying condition and the possible or pending complications is mandatory for successful management. 

Treatment / Management

Treatment of rectus hematomas depends on the severity of symptoms, size, the stability of the hematoma, and the underlying pathology. The goal of the treatment is to relieve or minimize symptoms, prevent complications, and address the underlying condition. Proper patient’s condition assessment, volume replacement, and correction of any coagulation abnormalities are important initial measures that should be performed before considering more aggressive steps.

If the hematoma is enlarging and or causing significant blood loss, intervention should be taken to stop the bleeding. Interventional radiology localizing and embolizing the bleeding vessel is the appropriate first modality of treatment to use. In most cases, this is successful and sufficient to stop the bleeding, especially with the confined space and the pressure created that counteracts the flow of bleeding.

In a few cases of ongoing bleeding that is not amenable to radiologic intervention or if the service is not available, surgical control of the bleeding and evacuation of the hematoma is necessary. Controlling the bleeding is achieved by ligating the bleeding vessel (epigastric vessel) surgically.

In most cases, bleeding stops after enough pressure build-up inside the rectus sheath. The size of the developed hematoma varies according to the size and pressure of the bleeding vessel, expandability of the rectus space, and the presence and severity of coagulation abnormalities. Once the bleeding stops and the hematoma size stabilizes, treatment is usually directed on the relief of the symptoms. There is no urgency in evacuating the hematoma. In fact, maintaining the pressure inside the hematoma at the initial phase is important to prevent rebleeding. Large hematomas can be drained percutaneously after stabilization and recovery from the acute phase. Small hematomas can be left to be reabsorbed spontaneously to avoid unnecessary intervention.  

Patients with rectus sheath hematoma can be treated as outpatients as long as the hemodynamic status is stable and there is no change in the hematocrit. Patients on anticoagulation therapy should be admitted to ensure that the hematoma is not expanding.[7][13]

Differential Diagnosis

Conditions presenting with a mass:

Conditions presenting pain or acute abdomen:

• Peptic ulcer disease

• Bowel perforation

• Tubo-ovarian abscess

• Appendicitis

• Cholecystitis

• Urinary tract infection

• Pancreatitis.

A comprehensive history, physical exam, and a low index of suspicion will usually identify the pathology, confirm the diagnosis and assist in the management planning.

Prognosis

Most cases of rectus hematomas are self-limited, non-life-threatening, and can be identified and treated successfully with minimal interventions. Even though fatalities have been reported, most of the fatalities have come to light during an autopsy. Rectus sheath hematoma mortality is higher in elderly individuals who are on oral anticoagulants. Pregnant women are at a higher risk for mortality. Anecdotal old reports reveal a mortality rate of 15% in the mother and nearly 50% in the fetus. However, it is important to know that these data were collected before the wide use of ultrasound and CT scans. Today, these imaging modalities can rapidly diagnose the condition.

Complications

The main consequence of undiagnosed or untreated rectus hematomas is pain. In addition to pain, severe bleeding is serious and can be life-threatening. Therefore severe bleeding should be promptly identified and aggressively treated. Another potential complication is abscess formation. As in any blood collection that is not drained, there is always a chance of superseding infection and the development of an abscess. Draining of abscess becomes mandatory when it develops.

Postoperative and Rehabilitation Care

Follow up and reassessment, including physical activities adjustment to prevent recurrent and further tissue damage. Patients should be advised to avoid indulging in heavy exercises. The decision to restart oral anticoagulation requires clinical judgment and balance between the indication of anticoagulation treatment and possible rebleeding in the rectus sheath.

Consultations

Rectus hematoma is a surgical condition. Once a patient has been diagnosed with a rectus sheath hematoma, surgical consultation should be made. Interventional radiology and hematology specialties may be needed depending on the severity and or the underlying condition.

Pearls and Other Issues

• Rectus sheath hematoma is an uncommon disorder.

• It can be confused with other abdominal wall pathologies like tumors or hernias.

• Ultrasound or CT scan can assist in confirming the diagnosis.

• Many patients are on oral anticoagulation therapy. They should be held if possible.

• The condition is usually treated conservatively with pain control and supportive treatment.

• In a few cases, arterial embolization or surgical intervention are required to stop the bleeding.

Enhancing Healthcare Team Outcomes

Abdominal wall hematoma can occur from a variety of causes. The patient often presents with abdominal pain, which can be mistaken for a number of abdominal pathologies; hence an interprofessional approach to management is necessary. Nurses should be aware of and familiar with abdominal hematomas as they can occur from repeated heparin or insulin injections; they can consult with the pharmacy team to ensure proper dosing and no drug interactions that contribute to the condition. The diagnosis can be difficult to confirm clinically. Imaging studies are usually necessary. Most abdominal hematomas resolve spontaneously over 4 to 6 weeks. Nowadays, mortality rates from abdominal wall hematomas are negligible because of the availability of imaging studies. Patients who recover usually have no residual sequelae. These outcomes are made possible, as described above, by interprofessional teamwork and collaboration/communication, contributing to positive patient outcomes. [Level 5]

References

1.

Elder T, Tuma F. Bilateral vertebral artery transection following blunt trauma. Int J Surg Case Rep. 2018;51:29-32. [PMC free article: PMC6104585] [PubMed: 30138866]

2.

Ogobuiro I, Wehrle CJ, Tuma F. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 10, 2020. Anatomy, Thorax, Heart Coronary Arteries. [PubMed: 30521211]

3.

Kalra A, Wehrle CJ, Tuma F. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 10, 2020. Anatomy, Abdomen and Pelvis, Peritoneum. [PubMed: 30521209]

4.

Takahashi M, Hotta K, Tamai K, Niwa Y, Egawa A, Takeuchi M. [Abdominal Oblique Muscle Hematoma after Ultrasound-guided Transverse Abdominis Plane Block]. Masui. 2016 Dec;65(12):1276-1278. [PubMed: 30379470]

5.

Queiroz RM, Filho FB. Spontaneous hematoma of the rectus sheath following percutaneous transluminal coronary angioplasty and stent placement. Pan Afr Med J. 2018;30:88. [PMC free article: PMC6191267] [PubMed: 30344872]

6.

Joo C, Min JW, Noh G, Seo J. A case report of unexpected sudden cardiac death due to aortic rupture following laparoscopic appendectomy. Medicine (Baltimore). 2018 Oct;97(42):e12823. [PMC free article: PMC6211873] [PubMed: 30334980]

7.

Ueno T, Nakamura T, Hikichi H, Arai A, Suzuki C, Tomiyama M. Rectus Sheath Hematoma Following Intravenous Thrombolysis With Recombinant Tissue Plasminogen Activator for Cerebral Infarction: A Case Report. J Stroke Cerebrovasc Dis. 2018 Dec;27(12):e237-e238. [PubMed: 30122629]

8.

Mohammady M, Janani L, Akbari Sari A. Slow versus fast subcutaneous heparin injections for prevention of bruising and site pain intensity. Cochrane Database Syst Rev. 2017 Nov 01;11:CD008077. [PMC free article: PMC6486131] [PubMed: 29090459]

9.

Povar M, Lasala M, Ruiz A, Povar BJ. [Rectus sheath haematoma: experience in our centre]. An Sist Sanit Navar. 2017 Dec 29;40(3):361-369. [PubMed: 28937152]

10.

Wu JD, Huang WH, Qiu SQ, He LF, Guo CP, Zhang YQ, Zhang F, Zhang GJ. Breast reconstruction with single-pedicle TRAM flap in breast cancer patients with low midline abdominal scar. Sci Rep. 2016 Jul 13;6:29580. [PMC free article: PMC4942775] [PubMed: 27406872]

11.

Jareño-Collado R, Sánchez-Sánchez MM, Fraile-Gamo MP, García-Crespo N, Barba-Aragón S, Bermejo-García H, Sánchez-Izquierdo R, Sánchez-Muñoz EI, López-López A, Arias-Rivera S. Ecchymosis and/or haematoma formation after prophylactic administration of subcutaneous enoxaparin in the abdomen or arm of the critically ill patient. Enferm Intensiva (Engl Ed). 2018 Jan – Mar;29(1):4-13. [PubMed: 29326015]

12.

Shaydakov ME, Tuma F. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): May 4, 2021. Operative Risk. [PubMed: 30335273]

13.

Pierro A, Cilla S, Modugno P, Centritto EM, De Filippo CM, Sallustio G. Spontaneous rectus sheath hematoma: The utility of CT angiography. Radiol Case Rep. 2018 Apr;13(2):328-332. [PMC free article: PMC6000050] [PubMed: 29904466]

14.

Hope WW, Tuma F. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jun 26, 2021. Incisional Hernia. [PubMed: 28613766]

15.

Shaydakov ME, Pastorino A, Tuma F. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): May 4, 2021. Enterovesical Fistula. [PubMed: 30422531]

Abdominal Hematoma – StatPearls – NCBI Bookshelf

Continuing Education Activity

A hematoma is a blood collection in an extravascular space and is named according to the location of the blood collection. Rectus sheath hematomas result from bleeding inside the vascular rectus muscle layer of the abdominal wall. This activity reviews the evaluation and management of rectus sheath hematomas and emphasizes the role of the interprofessional care team in recognizing and managing this condition.

Objectives:

• Identify the location of the majority of rectus sheath hematomas.

• Outline the pathophysiology of rectus sheath hematomas.

• Describe some symptoms and signs that may be present in a patient with a rectus sheath hematoma.

• Delineate the role of interprofessional team members in recognizing and managing rectus sheath hematomas to improve patient outcomes.

Access free multiple choice questions on this topic.

Introduction

A hematoma is a blood collection in an extravascular space. It results from bleeding from a vascular structure. Depending on the location of the blood collection, hematomas are named accordingly, e.g., intracranial hematoma[1], hemothorax[2], pelvic hematoma[3], and abdominal hematoma. Hematomas can collect in extravascular areas near bleeding vessels with space to accommodate this blood collection. An abdominal hematoma can be intrabdominal or an abdominal wall hematoma. Abdominal wall hematoma usually results from bleeding inside the muscle layers of the abdominal wall, most commonly the vascular rectus muscle. A known category of this hematoma is rectus sheath hematoma. This activity will be focused on rectus sheath hematoma or rectus hematoma. 

Rectus sheath hematoma is bleeding in the rectus sheath. It is a confined space where the blood collects, commonly in the form of localized hematoma. Inferior or superior epigastric arteries and veins or their branches and tributaries form the basis of the bleeding source. A rectus hematoma can occur spontaneously in certain categories of people. But, it usually follows an injury to the inferior or superior epigastric vessels or their perforating branches. While this condition does resolve on its own, sometimes the hematoma can be extensive and lead to hypovolemic shock [4][5][6].

Etiology

Rectus sheath hematomas result from bleeding of the epigastric vessels or their perforator branches in the rectus abdominis muscle sheath[3]. Although rarely life-threatening, they can be severe and lead to hemodynamic instability. However, in most cases, rectus hematoma is self-limiting and usually spontaneously resolves.

Like in other types of bleeding, the cause can be due to the bleeding tendency, anticoagulation, or injury to the vessels. Vascular injury may occur due to external abdominal trauma, trauma during surgery (iatrogenic), or intense contraction of the rectus muscles during activities associated with Valsalva maneuver, as in severe retching, vomiting, or straining [7][8]. In most cases, the hematoma is localized. But in people with excessive loose connective tissue, the hematoma can spread to above the umbilicus, the contralateral side, or become intraabdominal. Risk factors include the use of anticoagulant medications, advanced age, female gender, and intense physical activity. With the increased use of anticoagulation, the rates of rectus sheath hematoma appear to be on the rise.

Epidemiology

Rectus sheath hematomas are uncommon [9][10]. The exact incidence of rectus sheath hematoma is not known as the condition is often misdiagnosed or undiagnosed. Some studies report an incidence of 1.5% to 2% in hospitalized patients.

Overall, rectus sheath hematoma is more common in females than males. A higher female incidence has been linked to decreased muscle mass. While pregnancy is a risk factor in women, trauma and exercise seem to be the most common causes in men. Rectus sheath hematomas are more common on the right side, and the majority are located in the lower quadrant of the abdomen below the arcuate line. 

Pathophysiology

Rectus sheath hematoma is caused by rupture of an epigastric artery or one of its perforating branches. The vessel injury may be due to blunt or penetrating trauma, surgery, or strong contractions of the rectus muscle. Since the epigastric arteries run deep along the posterior rectus sheath, making a diagnosis during a physical exam is difficult, especially in patients who have obesity. The hematoma is usually posterior to the rectus muscle fibers, subcutaneous fat, and skin. Palpating a tender firm bulge is the most common physic exam finding. The fluctuation sign of a fluid collection is not usually possible to detect due to the deep location of the hematoma. The lower quadrants of the abdomen are usually involved because of the long epigastric branches and the lack of a tamponade effect from the loose connective tissues of the rectus sheath.

History and Physical

The typical presentation of a rectus sheath hematoma is abdominal pain and its associated symptoms like nausea and vomiting. The pain is often sudden in onset, sharp, and does not radiate. In extremely rare cases, the hematoma may be large and present with hypovolemia, tachycardia, and tachypnea. Physical exam usually reveals a palpable localized mass that is non-pulsatile. The Fothergill sign is a mass in the abdominal wall that does not cross the midline and does not change with flexion of the rectus muscles. This suggests a rectus sheath hematoma and is useful to determine if the abdominal mass is within the abdominal wall or intraabdominal cavity. It is not a highly sensitive sign and is often inconclusive in individuals who are obese.

The clinician should obtain a thorough medical history to determine the presence of any risk factors like surgery, coughing, constipation, asthma, bronchitis, anticoagulation therapy, and use of oral anticoagulants and corticosteroids.

Evaluation

Ultrasound is the first test of choice to confirm a rectus sheath hematoma diagnosis after basic blood work, and coagulation profile are obtained. The hematoma appears as hypoechoic space in the posterior rectus sheath. Further information like the size and exact location of the hematoma can be obtained from the ultrasound study. If the ultrasound study is inconclusive, a CT scan is the next test. It can show more details about the location, size, and extension of the hematoma. When intravenous contrast is administered with the CT scan, active bleeding can be detected by the presence of the contrast in the form of blush in the hematoma if the bleeding is active.

Unless a contrast is visualized in the hematoma, the differential diagnosis of a fluid collection in the rectus sheath should not be ignored. If the diagnosis of hematoma is still in doubt after imaging, needle aspiration can be performed to differentiate a hematoma from an abscess. However, with needle aspiration, there is a risk of puncture the bladder, bowel, or a hernia.[11]

Evaluation of the hematoma should be part of the comprehensive evaluation of the patient’s condition. General assessment addressing the related factors and conditions causing the hematoma or as a complication of the hematoma is necessary for a proper evaluation[12]. Simultaneous treatment of the underlying condition and the possible or pending complications is mandatory for successful management. 

Treatment / Management

Treatment of rectus hematomas depends on the severity of symptoms, size, the stability of the hematoma, and the underlying pathology. The goal of the treatment is to relieve or minimize symptoms, prevent complications, and address the underlying condition. Proper patient’s condition assessment, volume replacement, and correction of any coagulation abnormalities are important initial measures that should be performed before considering more aggressive steps.

If the hematoma is enlarging and or causing significant blood loss, intervention should be taken to stop the bleeding. Interventional radiology localizing and embolizing the bleeding vessel is the appropriate first modality of treatment to use. In most cases, this is successful and sufficient to stop the bleeding, especially with the confined space and the pressure created that counteracts the flow of bleeding.

In a few cases of ongoing bleeding that is not amenable to radiologic intervention or if the service is not available, surgical control of the bleeding and evacuation of the hematoma is necessary. Controlling the bleeding is achieved by ligating the bleeding vessel (epigastric vessel) surgically.

In most cases, bleeding stops after enough pressure build-up inside the rectus sheath. The size of the developed hematoma varies according to the size and pressure of the bleeding vessel, expandability of the rectus space, and the presence and severity of coagulation abnormalities. Once the bleeding stops and the hematoma size stabilizes, treatment is usually directed on the relief of the symptoms. There is no urgency in evacuating the hematoma. In fact, maintaining the pressure inside the hematoma at the initial phase is important to prevent rebleeding. Large hematomas can be drained percutaneously after stabilization and recovery from the acute phase. Small hematomas can be left to be reabsorbed spontaneously to avoid unnecessary intervention.  

Patients with rectus sheath hematoma can be treated as outpatients as long as the hemodynamic status is stable and there is no change in the hematocrit. Patients on anticoagulation therapy should be admitted to ensure that the hematoma is not expanding.[7][13]

Differential Diagnosis

Conditions presenting with a mass:

Conditions presenting pain or acute abdomen:

• Peptic ulcer disease

• Bowel perforation

• Tubo-ovarian abscess

• Appendicitis

• Cholecystitis

• Urinary tract infection

• Pancreatitis.

A comprehensive history, physical exam, and a low index of suspicion will usually identify the pathology, confirm the diagnosis and assist in the management planning.

Prognosis

Most cases of rectus hematomas are self-limited, non-life-threatening, and can be identified and treated successfully with minimal interventions. Even though fatalities have been reported, most of the fatalities have come to light during an autopsy. Rectus sheath hematoma mortality is higher in elderly individuals who are on oral anticoagulants. Pregnant women are at a higher risk for mortality. Anecdotal old reports reveal a mortality rate of 15% in the mother and nearly 50% in the fetus. However, it is important to know that these data were collected before the wide use of ultrasound and CT scans. Today, these imaging modalities can rapidly diagnose the condition.

Complications

The main consequence of undiagnosed or untreated rectus hematomas is pain. In addition to pain, severe bleeding is serious and can be life-threatening. Therefore severe bleeding should be promptly identified and aggressively treated. Another potential complication is abscess formation. As in any blood collection that is not drained, there is always a chance of superseding infection and the development of an abscess. Draining of abscess becomes mandatory when it develops.

Postoperative and Rehabilitation Care

Follow up and reassessment, including physical activities adjustment to prevent recurrent and further tissue damage. Patients should be advised to avoid indulging in heavy exercises. The decision to restart oral anticoagulation requires clinical judgment and balance between the indication of anticoagulation treatment and possible rebleeding in the rectus sheath.

Consultations

Rectus hematoma is a surgical condition. Once a patient has been diagnosed with a rectus sheath hematoma, surgical consultation should be made. Interventional radiology and hematology specialties may be needed depending on the severity and or the underlying condition.

Pearls and Other Issues

• Rectus sheath hematoma is an uncommon disorder.

• It can be confused with other abdominal wall pathologies like tumors or hernias.

• Ultrasound or CT scan can assist in confirming the diagnosis.

• Many patients are on oral anticoagulation therapy. They should be held if possible.

• The condition is usually treated conservatively with pain control and supportive treatment.

• In a few cases, arterial embolization or surgical intervention are required to stop the bleeding.

Enhancing Healthcare Team Outcomes

Abdominal wall hematoma can occur from a variety of causes. The patient often presents with abdominal pain, which can be mistaken for a number of abdominal pathologies; hence an interprofessional approach to management is necessary. Nurses should be aware of and familiar with abdominal hematomas as they can occur from repeated heparin or insulin injections; they can consult with the pharmacy team to ensure proper dosing and no drug interactions that contribute to the condition. The diagnosis can be difficult to confirm clinically. Imaging studies are usually necessary. Most abdominal hematomas resolve spontaneously over 4 to 6 weeks. Nowadays, mortality rates from abdominal wall hematomas are negligible because of the availability of imaging studies. Patients who recover usually have no residual sequelae. These outcomes are made possible, as described above, by interprofessional teamwork and collaboration/communication, contributing to positive patient outcomes. [Level 5]

References

1.

Elder T, Tuma F. Bilateral vertebral artery transection following blunt trauma. Int J Surg Case Rep. 2018;51:29-32. [PMC free article: PMC6104585] [PubMed: 30138866]

2.

Ogobuiro I, Wehrle CJ, Tuma F. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 10, 2020. Anatomy, Thorax, Heart Coronary Arteries. [PubMed: 30521211]

3.

Kalra A, Wehrle CJ, Tuma F. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 10, 2020. Anatomy, Abdomen and Pelvis, Peritoneum. [PubMed: 30521209]

4.

Takahashi M, Hotta K, Tamai K, Niwa Y, Egawa A, Takeuchi M. [Abdominal Oblique Muscle Hematoma after Ultrasound-guided Transverse Abdominis Plane Block]. Masui. 2016 Dec;65(12):1276-1278. [PubMed: 30379470]

5.

Queiroz RM, Filho FB. Spontaneous hematoma of the rectus sheath following percutaneous transluminal coronary angioplasty and stent placement. Pan Afr Med J. 2018;30:88. [PMC free article: PMC6191267] [PubMed: 30344872]

6.

Joo C, Min JW, Noh G, Seo J. A case report of unexpected sudden cardiac death due to aortic rupture following laparoscopic appendectomy. Medicine (Baltimore). 2018 Oct;97(42):e12823. [PMC free article: PMC6211873] [PubMed: 30334980]

7.

Ueno T, Nakamura T, Hikichi H, Arai A, Suzuki C, Tomiyama M. Rectus Sheath Hematoma Following Intravenous Thrombolysis With Recombinant Tissue Plasminogen Activator for Cerebral Infarction: A Case Report. J Stroke Cerebrovasc Dis. 2018 Dec;27(12):e237-e238. [PubMed: 30122629]

8.

Mohammady M, Janani L, Akbari Sari A. Slow versus fast subcutaneous heparin injections for prevention of bruising and site pain intensity. Cochrane Database Syst Rev. 2017 Nov 01;11:CD008077. [PMC free article: PMC6486131] [PubMed: 29090459]

9.

Povar M, Lasala M, Ruiz A, Povar BJ. [Rectus sheath haematoma: experience in our centre]. An Sist Sanit Navar. 2017 Dec 29;40(3):361-369. [PubMed: 28937152]

10.

Wu JD, Huang WH, Qiu SQ, He LF, Guo CP, Zhang YQ, Zhang F, Zhang GJ. Breast reconstruction with single-pedicle TRAM flap in breast cancer patients with low midline abdominal scar. Sci Rep. 2016 Jul 13;6:29580. [PMC free article: PMC4942775] [PubMed: 27406872]

11.

Jareño-Collado R, Sánchez-Sánchez MM, Fraile-Gamo MP, García-Crespo N, Barba-Aragón S, Bermejo-García H, Sánchez-Izquierdo R, Sánchez-Muñoz EI, López-López A, Arias-Rivera S. Ecchymosis and/or haematoma formation after prophylactic administration of subcutaneous enoxaparin in the abdomen or arm of the critically ill patient. Enferm Intensiva (Engl Ed). 2018 Jan – Mar;29(1):4-13. [PubMed: 29326015]

12.

Shaydakov ME, Tuma F. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): May 4, 2021. Operative Risk. [PubMed: 30335273]

13.

Pierro A, Cilla S, Modugno P, Centritto EM, De Filippo CM, Sallustio G. Spontaneous rectus sheath hematoma: The utility of CT angiography. Radiol Case Rep. 2018 Apr;13(2):328-332. [PMC free article: PMC6000050] [PubMed: 29904466]

14.

Hope WW, Tuma F. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jun 26, 2021. Incisional Hernia. [PubMed: 28613766]

15.

Shaydakov ME, Pastorino A, Tuma F. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): May 4, 2021. Enterovesical Fistula. [PubMed: 30422531]

Abdominal Hematoma – StatPearls – NCBI Bookshelf

Continuing Education Activity

A hematoma is a blood collection in an extravascular space and is named according to the location of the blood collection. Rectus sheath hematomas result from bleeding inside the vascular rectus muscle layer of the abdominal wall. This activity reviews the evaluation and management of rectus sheath hematomas and emphasizes the role of the interprofessional care team in recognizing and managing this condition.

Objectives:

• Identify the location of the majority of rectus sheath hematomas.

• Outline the pathophysiology of rectus sheath hematomas.

• Describe some symptoms and signs that may be present in a patient with a rectus sheath hematoma.

• Delineate the role of interprofessional team members in recognizing and managing rectus sheath hematomas to improve patient outcomes.

Access free multiple choice questions on this topic.

Introduction

A hematoma is a blood collection in an extravascular space. It results from bleeding from a vascular structure. Depending on the location of the blood collection, hematomas are named accordingly, e.g., intracranial hematoma[1], hemothorax[2], pelvic hematoma[3], and abdominal hematoma. Hematomas can collect in extravascular areas near bleeding vessels with space to accommodate this blood collection. An abdominal hematoma can be intrabdominal or an abdominal wall hematoma. Abdominal wall hematoma usually results from bleeding inside the muscle layers of the abdominal wall, most commonly the vascular rectus muscle. A known category of this hematoma is rectus sheath hematoma. This activity will be focused on rectus sheath hematoma or rectus hematoma. 

Rectus sheath hematoma is bleeding in the rectus sheath. It is a confined space where the blood collects, commonly in the form of localized hematoma. Inferior or superior epigastric arteries and veins or their branches and tributaries form the basis of the bleeding source. A rectus hematoma can occur spontaneously in certain categories of people. But, it usually follows an injury to the inferior or superior epigastric vessels or their perforating branches. While this condition does resolve on its own, sometimes the hematoma can be extensive and lead to hypovolemic shock [4][5][6].

Etiology

Rectus sheath hematomas result from bleeding of the epigastric vessels or their perforator branches in the rectus abdominis muscle sheath[3]. Although rarely life-threatening, they can be severe and lead to hemodynamic instability. However, in most cases, rectus hematoma is self-limiting and usually spontaneously resolves.

Like in other types of bleeding, the cause can be due to the bleeding tendency, anticoagulation, or injury to the vessels. Vascular injury may occur due to external abdominal trauma, trauma during surgery (iatrogenic), or intense contraction of the rectus muscles during activities associated with Valsalva maneuver, as in severe retching, vomiting, or straining [7][8]. In most cases, the hematoma is localized. But in people with excessive loose connective tissue, the hematoma can spread to above the umbilicus, the contralateral side, or become intraabdominal. Risk factors include the use of anticoagulant medications, advanced age, female gender, and intense physical activity. With the increased use of anticoagulation, the rates of rectus sheath hematoma appear to be on the rise.

Epidemiology

Rectus sheath hematomas are uncommon [9][10]. The exact incidence of rectus sheath hematoma is not known as the condition is often misdiagnosed or undiagnosed. Some studies report an incidence of 1.5% to 2% in hospitalized patients.

Overall, rectus sheath hematoma is more common in females than males. A higher female incidence has been linked to decreased muscle mass. While pregnancy is a risk factor in women, trauma and exercise seem to be the most common causes in men. Rectus sheath hematomas are more common on the right side, and the majority are located in the lower quadrant of the abdomen below the arcuate line. 

Pathophysiology

Rectus sheath hematoma is caused by rupture of an epigastric artery or one of its perforating branches. The vessel injury may be due to blunt or penetrating trauma, surgery, or strong contractions of the rectus muscle. Since the epigastric arteries run deep along the posterior rectus sheath, making a diagnosis during a physical exam is difficult, especially in patients who have obesity. The hematoma is usually posterior to the rectus muscle fibers, subcutaneous fat, and skin. Palpating a tender firm bulge is the most common physic exam finding. The fluctuation sign of a fluid collection is not usually possible to detect due to the deep location of the hematoma. The lower quadrants of the abdomen are usually involved because of the long epigastric branches and the lack of a tamponade effect from the loose connective tissues of the rectus sheath.

History and Physical

The typical presentation of a rectus sheath hematoma is abdominal pain and its associated symptoms like nausea and vomiting. The pain is often sudden in onset, sharp, and does not radiate. In extremely rare cases, the hematoma may be large and present with hypovolemia, tachycardia, and tachypnea. Physical exam usually reveals a palpable localized mass that is non-pulsatile. The Fothergill sign is a mass in the abdominal wall that does not cross the midline and does not change with flexion of the rectus muscles. This suggests a rectus sheath hematoma and is useful to determine if the abdominal mass is within the abdominal wall or intraabdominal cavity. It is not a highly sensitive sign and is often inconclusive in individuals who are obese.

The clinician should obtain a thorough medical history to determine the presence of any risk factors like surgery, coughing, constipation, asthma, bronchitis, anticoagulation therapy, and use of oral anticoagulants and corticosteroids.

Evaluation

Ultrasound is the first test of choice to confirm a rectus sheath hematoma diagnosis after basic blood work, and coagulation profile are obtained. The hematoma appears as hypoechoic space in the posterior rectus sheath. Further information like the size and exact location of the hematoma can be obtained from the ultrasound study. If the ultrasound study is inconclusive, a CT scan is the next test. It can show more details about the location, size, and extension of the hematoma. When intravenous contrast is administered with the CT scan, active bleeding can be detected by the presence of the contrast in the form of blush in the hematoma if the bleeding is active.

Unless a contrast is visualized in the hematoma, the differential diagnosis of a fluid collection in the rectus sheath should not be ignored. If the diagnosis of hematoma is still in doubt after imaging, needle aspiration can be performed to differentiate a hematoma from an abscess. However, with needle aspiration, there is a risk of puncture the bladder, bowel, or a hernia.[11]

Evaluation of the hematoma should be part of the comprehensive evaluation of the patient’s condition. General assessment addressing the related factors and conditions causing the hematoma or as a complication of the hematoma is necessary for a proper evaluation[12]. Simultaneous treatment of the underlying condition and the possible or pending complications is mandatory for successful management. 

Treatment / Management

Treatment of rectus hematomas depends on the severity of symptoms, size, the stability of the hematoma, and the underlying pathology. The goal of the treatment is to relieve or minimize symptoms, prevent complications, and address the underlying condition. Proper patient’s condition assessment, volume replacement, and correction of any coagulation abnormalities are important initial measures that should be performed before considering more aggressive steps.

If the hematoma is enlarging and or causing significant blood loss, intervention should be taken to stop the bleeding. Interventional radiology localizing and embolizing the bleeding vessel is the appropriate first modality of treatment to use. In most cases, this is successful and sufficient to stop the bleeding, especially with the confined space and the pressure created that counteracts the flow of bleeding.

In a few cases of ongoing bleeding that is not amenable to radiologic intervention or if the service is not available, surgical control of the bleeding and evacuation of the hematoma is necessary. Controlling the bleeding is achieved by ligating the bleeding vessel (epigastric vessel) surgically.

In most cases, bleeding stops after enough pressure build-up inside the rectus sheath. The size of the developed hematoma varies according to the size and pressure of the bleeding vessel, expandability of the rectus space, and the presence and severity of coagulation abnormalities. Once the bleeding stops and the hematoma size stabilizes, treatment is usually directed on the relief of the symptoms. There is no urgency in evacuating the hematoma. In fact, maintaining the pressure inside the hematoma at the initial phase is important to prevent rebleeding. Large hematomas can be drained percutaneously after stabilization and recovery from the acute phase. Small hematomas can be left to be reabsorbed spontaneously to avoid unnecessary intervention.  

Patients with rectus sheath hematoma can be treated as outpatients as long as the hemodynamic status is stable and there is no change in the hematocrit. Patients on anticoagulation therapy should be admitted to ensure that the hematoma is not expanding.[7][13]

Differential Diagnosis

Conditions presenting with a mass:

Conditions presenting pain or acute abdomen:

• Peptic ulcer disease

• Bowel perforation

• Tubo-ovarian abscess

• Appendicitis

• Cholecystitis

• Urinary tract infection

• Pancreatitis.

A comprehensive history, physical exam, and a low index of suspicion will usually identify the pathology, confirm the diagnosis and assist in the management planning.

Prognosis

Most cases of rectus hematomas are self-limited, non-life-threatening, and can be identified and treated successfully with minimal interventions. Even though fatalities have been reported, most of the fatalities have come to light during an autopsy. Rectus sheath hematoma mortality is higher in elderly individuals who are on oral anticoagulants. Pregnant women are at a higher risk for mortality. Anecdotal old reports reveal a mortality rate of 15% in the mother and nearly 50% in the fetus. However, it is important to know that these data were collected before the wide use of ultrasound and CT scans. Today, these imaging modalities can rapidly diagnose the condition.

Complications

The main consequence of undiagnosed or untreated rectus hematomas is pain. In addition to pain, severe bleeding is serious and can be life-threatening. Therefore severe bleeding should be promptly identified and aggressively treated. Another potential complication is abscess formation. As in any blood collection that is not drained, there is always a chance of superseding infection and the development of an abscess. Draining of abscess becomes mandatory when it develops.

Postoperative and Rehabilitation Care

Follow up and reassessment, including physical activities adjustment to prevent recurrent and further tissue damage. Patients should be advised to avoid indulging in heavy exercises. The decision to restart oral anticoagulation requires clinical judgment and balance between the indication of anticoagulation treatment and possible rebleeding in the rectus sheath.

Consultations

Rectus hematoma is a surgical condition. Once a patient has been diagnosed with a rectus sheath hematoma, surgical consultation should be made. Interventional radiology and hematology specialties may be needed depending on the severity and or the underlying condition.

Pearls and Other Issues

• Rectus sheath hematoma is an uncommon disorder.

• It can be confused with other abdominal wall pathologies like tumors or hernias.

• Ultrasound or CT scan can assist in confirming the diagnosis.

• Many patients are on oral anticoagulation therapy. They should be held if possible.

• The condition is usually treated conservatively with pain control and supportive treatment.

• In a few cases, arterial embolization or surgical intervention are required to stop the bleeding.

Enhancing Healthcare Team Outcomes

Abdominal wall hematoma can occur from a variety of causes. The patient often presents with abdominal pain, which can be mistaken for a number of abdominal pathologies; hence an interprofessional approach to management is necessary. Nurses should be aware of and familiar with abdominal hematomas as they can occur from repeated heparin or insulin injections; they can consult with the pharmacy team to ensure proper dosing and no drug interactions that contribute to the condition. The diagnosis can be difficult to confirm clinically. Imaging studies are usually necessary. Most abdominal hematomas resolve spontaneously over 4 to 6 weeks. Nowadays, mortality rates from abdominal wall hematomas are negligible because of the availability of imaging studies. Patients who recover usually have no residual sequelae. These outcomes are made possible, as described above, by interprofessional teamwork and collaboration/communication, contributing to positive patient outcomes. [Level 5]

References

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Ogobuiro I, Wehrle CJ, Tuma F. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 10, 2020. Anatomy, Thorax, Heart Coronary Arteries. [PubMed: 30521211]

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Kalra A, Wehrle CJ, Tuma F. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 10, 2020. Anatomy, Abdomen and Pelvis, Peritoneum. [PubMed: 30521209]

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Takahashi M, Hotta K, Tamai K, Niwa Y, Egawa A, Takeuchi M. [Abdominal Oblique Muscle Hematoma after Ultrasound-guided Transverse Abdominis Plane Block]. Masui. 2016 Dec;65(12):1276-1278. [PubMed: 30379470]

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Queiroz RM, Filho FB. Spontaneous hematoma of the rectus sheath following percutaneous transluminal coronary angioplasty and stent placement. Pan Afr Med J. 2018;30:88. [PMC free article: PMC6191267] [PubMed: 30344872]

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Mohammady M, Janani L, Akbari Sari A. Slow versus fast subcutaneous heparin injections for prevention of bruising and site pain intensity. Cochrane Database Syst Rev. 2017 Nov 01;11:CD008077. [PMC free article: PMC6486131] [PubMed: 29090459]

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Wu JD, Huang WH, Qiu SQ, He LF, Guo CP, Zhang YQ, Zhang F, Zhang GJ. Breast reconstruction with single-pedicle TRAM flap in breast cancer patients with low midline abdominal scar. Sci Rep. 2016 Jul 13;6:29580. [PMC free article: PMC4942775] [PubMed: 27406872]

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Jareño-Collado R, Sánchez-Sánchez MM, Fraile-Gamo MP, García-Crespo N, Barba-Aragón S, Bermejo-García H, Sánchez-Izquierdo R, Sánchez-Muñoz EI, López-López A, Arias-Rivera S. Ecchymosis and/or haematoma formation after prophylactic administration of subcutaneous enoxaparin in the abdomen or arm of the critically ill patient. Enferm Intensiva (Engl Ed). 2018 Jan – Mar;29(1):4-13. [PubMed: 29326015]

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An oblique muscle hematoma as a rare cause of severe abdominal pain: a case report

BMC Res Notes. 2013; 6: 18.

,¹,²,¹ and ¹

Masanori Shimodaira

¹Department of General Medicine, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

Tomohiro Kitano

²Junior resident, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

Minoru Kibata

¹Department of General Medicine, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

Kumiko Shirahata

¹Department of General Medicine, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

¹Department of General Medicine, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

²Junior resident, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

Corresponding author.

Received 2012 Sep 18; Accepted 2013 Jan 15.

Copyright ©2013 Shimodaira et al.; licensee BioMed Central Ltd.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.This article has been cited by other articles in PMC.

Abstract

Background

Abdominal wall hematomas are an uncommon cause of acute abdominal pain and are often misdiagnosed. They are more common in elderly individuals, particularly in those under anticoagulant therapy. Most abdominal wall hematomas occur in the rectus sheath, and hematomas within the oblique muscle are very rare and are poorly described in the literature. Here we report the case of an oblique muscle hematoma in a middle-aged patient who was not under anticoagulant therapy.

Case presentation

A 42-year-old Japanese man presented with a painful, enlarging, lateral abdominal wall mass, which appeared after playing baseball. Abdominal computed tomography and ultrasonography showed a large soft tissue mass located in the patient’s left internal oblique muscle. A diagnosis of a lateral oblique muscle hematoma was made and the patient was treated conservatively.

Conclusion

Physicians should consider an oblique muscle hematoma during the initial differential diagnosis of pain in the lateral abdominal wall even in the absence of anticoagulant therapy or trauma.

Keywords: Abdominal pain, Abdominal muscle, Oblique muscle, Hematoma

Background

Abdominal wall hematomas are an uncommon cause of acute abdominal pain and are often misdiagnosed. They result from rupture of the epigastric vessels or the deep circumflex iliac artery (rarely), or from tears of the fibers of the rectus abdominis or lateral oblique muscles
[1,2]. They may occur because of trauma, physical exercise, recent surgery, or injection procedures. They may also occur because of increased intraabdominal pressure from coughing, sneezing, vomiting, or straining during urination, defecation, and labor
[1,3-6]. Other predisposing factors include increased age, arterial hypertension, atherosclerosis, and systemic anticoagulant therapy. Most abdominal wall hematomas occur in the rectus sheath, and a hematoma within the oblique muscle is very rare. Here we report a case of an oblique muscle hematoma in a middle-aged patient.

Case presentation

A 42-year-old man presented with a painful, enlarging, lateral abdominal wall mass, which appeared after playing baseball. He gave no history of direct abdominal trauma such as collision with another player. He had a history of hyperuricemia; however, he had not undergone any therapy for the same. There was no family history of bleeding diathesis or hematological diseases. On physical examination, his vital signs were as follows: temperature 36.8°C, blood pressure 108/69 mm Hg, pulse rate 58 beats/min, and respiratory rate 12 breaths/min. A firm mass was palpable over the left lateral abdominal wall and it was tender. The skin color of the area was normal. Blood biochemistry on laboratory examination was within normal ranges and the platelet count was 174 ×10³ cells/μl, prothrombin time was 11.8 s, international normalized ratio was 0.99, and activated partial thromboplastin time was 32.6 s.

Ultrasonography (US) showed a heteroechoic, well-defined mass in the patient’s left lateral abdominal wall (Figure
). An emergency noncontrast computed tomography (CT) of the abdomen showed a hyperdense mass in the left internal oblique muscle measuring 10.5 × 6.5 × 5.5 cm. Contrast-enhanced CT did not show extravasation of the contrast material within the mass (Figure
). The diagnosis of an oblique muscle hematoma was made. The patient was conservatively treated with analgesics. Four days after the first visit, the patient revisited our department for follow-up. His abdominal pain improved, but an ecchymosis was observed on the patient’s left lateral abdominal skin (Figure
).

Abdominal ultrasonography (US). An abdominal US showed a heteroechoic mass (white arrow) in the patient’s left lateral abdominal wall.

Contrast-enhanced CT. Contrast-enhanced CT did not show extravasation of the contrast material within the mass (white arrow).

Ecchymosis on the left lateral abdomen. Ecchymosis presented 4 days later on the patient’s left lateral abdomen.

Discussion

Abdominal wall hematomas are one of the causes of acute abdominal pain. A rectus sheath hematoma caused by the rupture of the epigastric artery is a rare, but well-described, manifestation of abdominal hematoma. On the other hand, an oblique muscle hematoma caused by a rupture of the deep circumflex iliac artery is very rare
[1]. The most common presenting signs and symptoms of these hematomas are acute abdominal pain and firm, palpable abdominal wall masses. Because of their rarity, abdominal wall hematomas can be mistaken for several common acute abdominal conditions such as appendicitis, sigmoid diverticulitis, perforated ulcers, ovarian cyst torsion, tumors, or incarcerated inguinal hernias
[7]. Misdiagnosis may lead to unnecessary negative laparotomies with increased morbidity and mortality
[3]. Therefore, these diseases should be considered as differential diagnoses.

Many risk factors have been reported for abdominal wall hematomas. These include aging, anticoagulant therapy, platelet disorders, trauma, recent surgery, injection procedures, and physical exercise as well as increased intraabdominal pressure from coughing, sneezing, vomiting, or straining during urination, defecation, or labor
[6]. In the review of 126 cases of rectus sheath hematoma, it is reported that most patients (69%) were on some forms of anticoagulation therapy and the mean age was 67.9 years
[5]. Our patient was not taking any medications affecting blood coagulation and laboratory data regarding coagulation function were within normal limits. Therefore, his internal oblique muscle was considered to be injured by a sudden or repetitive trunk movement, either rotation or flexion/extension, while playing baseball
[8].

An abdominal wall mass with ecchymosis is the most important diagnostic finding for suspicion of a hematoma. However, abdominal wall ecchymosis is a late sign and the average time between its presentation and its onset takes about 4 days, as reported in the literature
[9]. Furthermore, ecchymosis is a rare presentation for an abdominal wall hematoma. A study by Cherry et al. showed that only 17% abdominal wall hematoma patients present with an abdominal wall ecchymosis
[5]. In our patient, ecchymosis was detected 4 days after the appearance of the abdominal wall hematoma. To the best of our knowledge, this is the first report of an oblique muscle hematoma that was accompanied by ecchymosis.

The diagnosis of an oblique muscle hematoma is made by combining medical history, laboratory examination findings, and US and/or radiological findings. US and CT scans can provide useful information for differential diagnosis to avoid unnecessary surgery
[6]. US can be useful as a first-line investigation because it is widely available and portable
[10]. In addition to US, contrast-enhanced CT can detect and evaluate active bleeding from the rupture site
[4]. In the present case, contrast-enhanced CT findings did not show active bleeding. Therefore, we could not confirm which artery was ruptured by CT findings. Even in a patient without contrast extravasation at the bleeding site as observed on CT, selective digital subtraction angiography could be a useful imaging technique to identify an active bleeding point
[11].

Although there is no grading for an oblique muscle hematoma because of its rarity, the following grading system has been established for a rectus sheath hematoma on the basis of CT findings. Grade I is an intramuscular hematoma with an observable increase in muscle size. Grade II is also an intramuscular hematoma but with blood between the muscle and transversalis fascia. Grade III hematoma may or may not affect the muscle and blood is seen between the transversalis fascia and muscle in the peritoneum and prevesical space that results in a drop in hemoglobin
[12]. Grade I hematoma may resolve rapidly within approximately 30 days, whereas Grade II hematomas require 2–4 months and Grade III hematomas require more than 3 months to resolve
[12]. Hence, a classification based on CT findings could help a physician in predicting a patient’s outcome.

Conservative treatment including bed rest and analgesics are appropriate in most patients with abdominal wall hematomas. Although most are self-limiting because the bleeding usually stops without intervention, some patients show significant morbidity and the overall mortality rate is reported to be 4%. Surgical intervention or transcatheter arterial embolization is recommended when conservative management fails
[1,4]. In our case, conservative treatment was administered because CT findings did not suggest active bleeding.

Conclusion

An oblique muscle hematoma is a very rare condition. In the clinical setting, abdominal US and contrast-enhanced CT are useful for a diagnosis. A correct diagnosis is important to avoid increasing morbidity or unnecessary surgical intervention. Treatment is mainly conservative and includes pain management. Physicians should consider an oblique muscle hematoma in the initial differential diagnosis of abdominal pain even in the absence of history of anticoagulant therapy or obvious trauma.

Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

MS wrote the manuscript. TK contributed to the diagnosis and revised the manuscript. MK and KS reviewed the literature. All authors contributed intellectual content, have read and approved the final manuscript.

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An oblique muscle hematoma as a rare cause of severe abdominal pain: a case report

BMC Res Notes. 2013; 6: 18.

,¹,²,¹ and ¹

Masanori Shimodaira

¹Department of General Medicine, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

Tomohiro Kitano

²Junior resident, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

Minoru Kibata

¹Department of General Medicine, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

Kumiko Shirahata

¹Department of General Medicine, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

¹Department of General Medicine, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

²Junior resident, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

Corresponding author.

Received 2012 Sep 18; Accepted 2013 Jan 15.

Copyright ©2013 Shimodaira et al.; licensee BioMed Central Ltd.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.This article has been cited by other articles in PMC.

Abstract

Background

Abdominal wall hematomas are an uncommon cause of acute abdominal pain and are often misdiagnosed. They are more common in elderly individuals, particularly in those under anticoagulant therapy. Most abdominal wall hematomas occur in the rectus sheath, and hematomas within the oblique muscle are very rare and are poorly described in the literature. Here we report the case of an oblique muscle hematoma in a middle-aged patient who was not under anticoagulant therapy.

Case presentation

A 42-year-old Japanese man presented with a painful, enlarging, lateral abdominal wall mass, which appeared after playing baseball. Abdominal computed tomography and ultrasonography showed a large soft tissue mass located in the patient’s left internal oblique muscle. A diagnosis of a lateral oblique muscle hematoma was made and the patient was treated conservatively.

Conclusion

Physicians should consider an oblique muscle hematoma during the initial differential diagnosis of pain in the lateral abdominal wall even in the absence of anticoagulant therapy or trauma.

Keywords: Abdominal pain, Abdominal muscle, Oblique muscle, Hematoma

Background

Abdominal wall hematomas are an uncommon cause of acute abdominal pain and are often misdiagnosed. They result from rupture of the epigastric vessels or the deep circumflex iliac artery (rarely), or from tears of the fibers of the rectus abdominis or lateral oblique muscles
[1,2]. They may occur because of trauma, physical exercise, recent surgery, or injection procedures. They may also occur because of increased intraabdominal pressure from coughing, sneezing, vomiting, or straining during urination, defecation, and labor
[1,3-6]. Other predisposing factors include increased age, arterial hypertension, atherosclerosis, and systemic anticoagulant therapy. Most abdominal wall hematomas occur in the rectus sheath, and a hematoma within the oblique muscle is very rare. Here we report a case of an oblique muscle hematoma in a middle-aged patient.

Case presentation

A 42-year-old man presented with a painful, enlarging, lateral abdominal wall mass, which appeared after playing baseball. He gave no history of direct abdominal trauma such as collision with another player. He had a history of hyperuricemia; however, he had not undergone any therapy for the same. There was no family history of bleeding diathesis or hematological diseases. On physical examination, his vital signs were as follows: temperature 36.8°C, blood pressure 108/69 mm Hg, pulse rate 58 beats/min, and respiratory rate 12 breaths/min. A firm mass was palpable over the left lateral abdominal wall and it was tender. The skin color of the area was normal. Blood biochemistry on laboratory examination was within normal ranges and the platelet count was 174 ×10³ cells/μl, prothrombin time was 11.8 s, international normalized ratio was 0.99, and activated partial thromboplastin time was 32.6 s.

Ultrasonography (US) showed a heteroechoic, well-defined mass in the patient’s left lateral abdominal wall (Figure
). An emergency noncontrast computed tomography (CT) of the abdomen showed a hyperdense mass in the left internal oblique muscle measuring 10.5 × 6.5 × 5.5 cm. Contrast-enhanced CT did not show extravasation of the contrast material within the mass (Figure
). The diagnosis of an oblique muscle hematoma was made. The patient was conservatively treated with analgesics. Four days after the first visit, the patient revisited our department for follow-up. His abdominal pain improved, but an ecchymosis was observed on the patient’s left lateral abdominal skin (Figure
).

Abdominal ultrasonography (US). An abdominal US showed a heteroechoic mass (white arrow) in the patient’s left lateral abdominal wall.

Contrast-enhanced CT. Contrast-enhanced CT did not show extravasation of the contrast material within the mass (white arrow).

Ecchymosis on the left lateral abdomen. Ecchymosis presented 4 days later on the patient’s left lateral abdomen.

Discussion

Abdominal wall hematomas are one of the causes of acute abdominal pain. A rectus sheath hematoma caused by the rupture of the epigastric artery is a rare, but well-described, manifestation of abdominal hematoma. On the other hand, an oblique muscle hematoma caused by a rupture of the deep circumflex iliac artery is very rare
[1]. The most common presenting signs and symptoms of these hematomas are acute abdominal pain and firm, palpable abdominal wall masses. Because of their rarity, abdominal wall hematomas can be mistaken for several common acute abdominal conditions such as appendicitis, sigmoid diverticulitis, perforated ulcers, ovarian cyst torsion, tumors, or incarcerated inguinal hernias
[7]. Misdiagnosis may lead to unnecessary negative laparotomies with increased morbidity and mortality
[3]. Therefore, these diseases should be considered as differential diagnoses.

Many risk factors have been reported for abdominal wall hematomas. These include aging, anticoagulant therapy, platelet disorders, trauma, recent surgery, injection procedures, and physical exercise as well as increased intraabdominal pressure from coughing, sneezing, vomiting, or straining during urination, defecation, or labor
[6]. In the review of 126 cases of rectus sheath hematoma, it is reported that most patients (69%) were on some forms of anticoagulation therapy and the mean age was 67.9 years
[5]. Our patient was not taking any medications affecting blood coagulation and laboratory data regarding coagulation function were within normal limits. Therefore, his internal oblique muscle was considered to be injured by a sudden or repetitive trunk movement, either rotation or flexion/extension, while playing baseball
[8].

An abdominal wall mass with ecchymosis is the most important diagnostic finding for suspicion of a hematoma. However, abdominal wall ecchymosis is a late sign and the average time between its presentation and its onset takes about 4 days, as reported in the literature
[9]. Furthermore, ecchymosis is a rare presentation for an abdominal wall hematoma. A study by Cherry et al. showed that only 17% abdominal wall hematoma patients present with an abdominal wall ecchymosis
[5]. In our patient, ecchymosis was detected 4 days after the appearance of the abdominal wall hematoma. To the best of our knowledge, this is the first report of an oblique muscle hematoma that was accompanied by ecchymosis.

The diagnosis of an oblique muscle hematoma is made by combining medical history, laboratory examination findings, and US and/or radiological findings. US and CT scans can provide useful information for differential diagnosis to avoid unnecessary surgery
[6]. US can be useful as a first-line investigation because it is widely available and portable
[10]. In addition to US, contrast-enhanced CT can detect and evaluate active bleeding from the rupture site
[4]. In the present case, contrast-enhanced CT findings did not show active bleeding. Therefore, we could not confirm which artery was ruptured by CT findings. Even in a patient without contrast extravasation at the bleeding site as observed on CT, selective digital subtraction angiography could be a useful imaging technique to identify an active bleeding point
[11].

Although there is no grading for an oblique muscle hematoma because of its rarity, the following grading system has been established for a rectus sheath hematoma on the basis of CT findings. Grade I is an intramuscular hematoma with an observable increase in muscle size. Grade II is also an intramuscular hematoma but with blood between the muscle and transversalis fascia. Grade III hematoma may or may not affect the muscle and blood is seen between the transversalis fascia and muscle in the peritoneum and prevesical space that results in a drop in hemoglobin
[12]. Grade I hematoma may resolve rapidly within approximately 30 days, whereas Grade II hematomas require 2–4 months and Grade III hematomas require more than 3 months to resolve
[12]. Hence, a classification based on CT findings could help a physician in predicting a patient’s outcome.

Conservative treatment including bed rest and analgesics are appropriate in most patients with abdominal wall hematomas. Although most are self-limiting because the bleeding usually stops without intervention, some patients show significant morbidity and the overall mortality rate is reported to be 4%. Surgical intervention or transcatheter arterial embolization is recommended when conservative management fails
[1,4]. In our case, conservative treatment was administered because CT findings did not suggest active bleeding.

Conclusion

An oblique muscle hematoma is a very rare condition. In the clinical setting, abdominal US and contrast-enhanced CT are useful for a diagnosis. A correct diagnosis is important to avoid increasing morbidity or unnecessary surgical intervention. Treatment is mainly conservative and includes pain management. Physicians should consider an oblique muscle hematoma in the initial differential diagnosis of abdominal pain even in the absence of history of anticoagulant therapy or obvious trauma.

Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

MS wrote the manuscript. TK contributed to the diagnosis and revised the manuscript. MK and KS reviewed the literature. All authors contributed intellectual content, have read and approved the final manuscript.

References

• Shimizu T, Hanasawa K, Yoshioka T, Mori T, Kajinami T, Yokoyama K, Sho K, Tani T. Spontaneous hematoma of the lateral abdominal wall caused by a rupture of a deep circumflex iliac artery: report of two cases. Surg Today. 2003;33:475–478. doi: 10.1007/s10595-002-2512-1. [PubMed] [CrossRef] [Google Scholar]
• Tai CM, Liu KL, Chen CC, Lin JT, Wang HP. Lateral abdominal wall hematoma due to tear of internal abdominal oblique muscle in a patient under warfarin therapy. Am J Emerg Med. 2005;23:911–912. doi: 10.1016/j.ajem.2005.04.013. [PubMed] [CrossRef] [Google Scholar]
• Linhares MM, Lopes Filho GJ, Bruna PC, Ricca AB, Sato NY, Sacalabrini M. Spontaneous hematoma of the rectus abdominis sheath: a review of 177 cases with report of 7 personal cases. Int Surg. 1999;84:251–257. [PubMed] [Google Scholar]
• Nakayama T, Ishibashi T, Eguchi D, Yamada K, Tsurumaru D, Sakamoto K, Hidaka H, Masuda H. Spontaneous internal oblique hematoma successfully treated by transcatheter arterial embolization. Radiat Med. 2008;26:446–449. doi: 10.1007/s11604-008-0254-7. [PubMed] [CrossRef] [Google Scholar]
• Cherry WB, Mueller PS. Rectus sheath hematoma: review of 126 cases at a single institution. Medicine (Baltimore) 2006;85:105–110. doi: 10.1097/01.md.0000216818.13067.5a. [PubMed] [CrossRef] [Google Scholar]
• Moreno Gallego A, Aguayo JL, Flores B, Soria T, Hernandez Q, Ortiz S, Gonzalez-Costea R, Parrilla P. Ultrasonography and computed tomography reduce unnecessary surgery in abdominal rectus sheath haematoma. Br J Surg. 1997;84:1295–1297. doi: 10.1002/bjs.1800840928. [PubMed] [CrossRef] [Google Scholar]
• Luhmann A, Williams EV. Rectus sheath hematoma: a series of unfortunate events. World J Surg. 2006;30:2050–2055. doi: 10.1007/s00268-005-0702-9. [PubMed] [CrossRef] [Google Scholar]
• Johnson R. Abdominal wall injuries: rectus abdominis strains, oblique strains, rectus sheath hematoma. Curr Sports Med Rep. 2006;5:99–103. [PubMed] [Google Scholar]
• Zainea GG, Jordan F. Rectus sheath hematomas: their pathogenesis, diagnosis, and management. Am Surg. 1988;54:630–633. [PubMed] [Google Scholar]
• Klingler PJ, Wetscher G, Glaser K, Tschmelitsch J, Schmid T, Hinder RA. The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders. Surg Endosc. 1999;13:1129–1134. doi: 10.1007/s004649901188. [PubMed] [CrossRef] [Google Scholar]
• Rimola J, Perendreu J, Falco J, Fortuno JR, Massuet A, Branera J. Percutaneous arterial embolization in the management of rectus sheath hematoma. AJR Am J Roentgenol. 2007;188:W497–502. doi: 10.2214/AJR.06.0861. [PubMed] [CrossRef] [Google Scholar]
• Berna JD, Garcia-Medina V, Guirao J, Garcia-Medina J. Rectus sheath hematoma: diagnostic classification by CT. Abdom Imaging. 1996;21:62–64. doi: 10.1007/s002619900011. [PubMed] [CrossRef] [Google Scholar]

An oblique muscle hematoma as a rare cause of severe abdominal pain: a case report

BMC Res Notes. 2013; 6: 18.

,¹,²,¹ and ¹

Masanori Shimodaira

¹Department of General Medicine, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

Tomohiro Kitano

²Junior resident, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

Minoru Kibata

¹Department of General Medicine, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

Kumiko Shirahata

¹Department of General Medicine, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

¹Department of General Medicine, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

²Junior resident, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

Corresponding author.

Received 2012 Sep 18; Accepted 2013 Jan 15.

Copyright ©2013 Shimodaira et al.; licensee BioMed Central Ltd.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.This article has been cited by other articles in PMC.

Abstract

Background

Abdominal wall hematomas are an uncommon cause of acute abdominal pain and are often misdiagnosed. They are more common in elderly individuals, particularly in those under anticoagulant therapy. Most abdominal wall hematomas occur in the rectus sheath, and hematomas within the oblique muscle are very rare and are poorly described in the literature. Here we report the case of an oblique muscle hematoma in a middle-aged patient who was not under anticoagulant therapy.

Case presentation

A 42-year-old Japanese man presented with a painful, enlarging, lateral abdominal wall mass, which appeared after playing baseball. Abdominal computed tomography and ultrasonography showed a large soft tissue mass located in the patient’s left internal oblique muscle. A diagnosis of a lateral oblique muscle hematoma was made and the patient was treated conservatively.

Conclusion

Physicians should consider an oblique muscle hematoma during the initial differential diagnosis of pain in the lateral abdominal wall even in the absence of anticoagulant therapy or trauma.

Keywords: Abdominal pain, Abdominal muscle, Oblique muscle, Hematoma

Background

Abdominal wall hematomas are an uncommon cause of acute abdominal pain and are often misdiagnosed. They result from rupture of the epigastric vessels or the deep circumflex iliac artery (rarely), or from tears of the fibers of the rectus abdominis or lateral oblique muscles
[1,2]. They may occur because of trauma, physical exercise, recent surgery, or injection procedures. They may also occur because of increased intraabdominal pressure from coughing, sneezing, vomiting, or straining during urination, defecation, and labor
[1,3-6]. Other predisposing factors include increased age, arterial hypertension, atherosclerosis, and systemic anticoagulant therapy. Most abdominal wall hematomas occur in the rectus sheath, and a hematoma within the oblique muscle is very rare. Here we report a case of an oblique muscle hematoma in a middle-aged patient.

Case presentation

A 42-year-old man presented with a painful, enlarging, lateral abdominal wall mass, which appeared after playing baseball. He gave no history of direct abdominal trauma such as collision with another player. He had a history of hyperuricemia; however, he had not undergone any therapy for the same. There was no family history of bleeding diathesis or hematological diseases. On physical examination, his vital signs were as follows: temperature 36.8°C, blood pressure 108/69 mm Hg, pulse rate 58 beats/min, and respiratory rate 12 breaths/min. A firm mass was palpable over the left lateral abdominal wall and it was tender. The skin color of the area was normal. Blood biochemistry on laboratory examination was within normal ranges and the platelet count was 174 ×10³ cells/μl, prothrombin time was 11.8 s, international normalized ratio was 0.99, and activated partial thromboplastin time was 32.6 s.

Ultrasonography (US) showed a heteroechoic, well-defined mass in the patient’s left lateral abdominal wall (Figure
). An emergency noncontrast computed tomography (CT) of the abdomen showed a hyperdense mass in the left internal oblique muscle measuring 10.5 × 6.5 × 5.5 cm. Contrast-enhanced CT did not show extravasation of the contrast material within the mass (Figure
). The diagnosis of an oblique muscle hematoma was made. The patient was conservatively treated with analgesics. Four days after the first visit, the patient revisited our department for follow-up. His abdominal pain improved, but an ecchymosis was observed on the patient’s left lateral abdominal skin (Figure
).

Abdominal ultrasonography (US). An abdominal US showed a heteroechoic mass (white arrow) in the patient’s left lateral abdominal wall.

Contrast-enhanced CT. Contrast-enhanced CT did not show extravasation of the contrast material within the mass (white arrow).

Ecchymosis on the left lateral abdomen. Ecchymosis presented 4 days later on the patient’s left lateral abdomen.

Discussion

Abdominal wall hematomas are one of the causes of acute abdominal pain. A rectus sheath hematoma caused by the rupture of the epigastric artery is a rare, but well-described, manifestation of abdominal hematoma. On the other hand, an oblique muscle hematoma caused by a rupture of the deep circumflex iliac artery is very rare
[1]. The most common presenting signs and symptoms of these hematomas are acute abdominal pain and firm, palpable abdominal wall masses. Because of their rarity, abdominal wall hematomas can be mistaken for several common acute abdominal conditions such as appendicitis, sigmoid diverticulitis, perforated ulcers, ovarian cyst torsion, tumors, or incarcerated inguinal hernias
[7]. Misdiagnosis may lead to unnecessary negative laparotomies with increased morbidity and mortality
[3]. Therefore, these diseases should be considered as differential diagnoses.

Many risk factors have been reported for abdominal wall hematomas. These include aging, anticoagulant therapy, platelet disorders, trauma, recent surgery, injection procedures, and physical exercise as well as increased intraabdominal pressure from coughing, sneezing, vomiting, or straining during urination, defecation, or labor
[6]. In the review of 126 cases of rectus sheath hematoma, it is reported that most patients (69%) were on some forms of anticoagulation therapy and the mean age was 67.9 years
[5]. Our patient was not taking any medications affecting blood coagulation and laboratory data regarding coagulation function were within normal limits. Therefore, his internal oblique muscle was considered to be injured by a sudden or repetitive trunk movement, either rotation or flexion/extension, while playing baseball
[8].

An abdominal wall mass with ecchymosis is the most important diagnostic finding for suspicion of a hematoma. However, abdominal wall ecchymosis is a late sign and the average time between its presentation and its onset takes about 4 days, as reported in the literature
[9]. Furthermore, ecchymosis is a rare presentation for an abdominal wall hematoma. A study by Cherry et al. showed that only 17% abdominal wall hematoma patients present with an abdominal wall ecchymosis
[5]. In our patient, ecchymosis was detected 4 days after the appearance of the abdominal wall hematoma. To the best of our knowledge, this is the first report of an oblique muscle hematoma that was accompanied by ecchymosis.

The diagnosis of an oblique muscle hematoma is made by combining medical history, laboratory examination findings, and US and/or radiological findings. US and CT scans can provide useful information for differential diagnosis to avoid unnecessary surgery
[6]. US can be useful as a first-line investigation because it is widely available and portable
[10]. In addition to US, contrast-enhanced CT can detect and evaluate active bleeding from the rupture site
[4]. In the present case, contrast-enhanced CT findings did not show active bleeding. Therefore, we could not confirm which artery was ruptured by CT findings. Even in a patient without contrast extravasation at the bleeding site as observed on CT, selective digital subtraction angiography could be a useful imaging technique to identify an active bleeding point
[11].

Although there is no grading for an oblique muscle hematoma because of its rarity, the following grading system has been established for a rectus sheath hematoma on the basis of CT findings. Grade I is an intramuscular hematoma with an observable increase in muscle size. Grade II is also an intramuscular hematoma but with blood between the muscle and transversalis fascia. Grade III hematoma may or may not affect the muscle and blood is seen between the transversalis fascia and muscle in the peritoneum and prevesical space that results in a drop in hemoglobin
[12]. Grade I hematoma may resolve rapidly within approximately 30 days, whereas Grade II hematomas require 2–4 months and Grade III hematomas require more than 3 months to resolve
[12]. Hence, a classification based on CT findings could help a physician in predicting a patient’s outcome.

Conservative treatment including bed rest and analgesics are appropriate in most patients with abdominal wall hematomas. Although most are self-limiting because the bleeding usually stops without intervention, some patients show significant morbidity and the overall mortality rate is reported to be 4%. Surgical intervention or transcatheter arterial embolization is recommended when conservative management fails
[1,4]. In our case, conservative treatment was administered because CT findings did not suggest active bleeding.

Conclusion

An oblique muscle hematoma is a very rare condition. In the clinical setting, abdominal US and contrast-enhanced CT are useful for a diagnosis. A correct diagnosis is important to avoid increasing morbidity or unnecessary surgical intervention. Treatment is mainly conservative and includes pain management. Physicians should consider an oblique muscle hematoma in the initial differential diagnosis of abdominal pain even in the absence of history of anticoagulant therapy or obvious trauma.

Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

MS wrote the manuscript. TK contributed to the diagnosis and revised the manuscript. MK and KS reviewed the literature. All authors contributed intellectual content, have read and approved the final manuscript.

References

• Shimizu T, Hanasawa K, Yoshioka T, Mori T, Kajinami T, Yokoyama K, Sho K, Tani T. Spontaneous hematoma of the lateral abdominal wall caused by a rupture of a deep circumflex iliac artery: report of two cases. Surg Today. 2003;33:475–478. doi: 10.1007/s10595-002-2512-1. [PubMed] [CrossRef] [Google Scholar]
• Tai CM, Liu KL, Chen CC, Lin JT, Wang HP. Lateral abdominal wall hematoma due to tear of internal abdominal oblique muscle in a patient under warfarin therapy. Am J Emerg Med. 2005;23:911–912. doi: 10.1016/j.ajem.2005.04.013. [PubMed] [CrossRef] [Google Scholar]
• Linhares MM, Lopes Filho GJ, Bruna PC, Ricca AB, Sato NY, Sacalabrini M. Spontaneous hematoma of the rectus abdominis sheath: a review of 177 cases with report of 7 personal cases. Int Surg. 1999;84:251–257. [PubMed] [Google Scholar]
• Nakayama T, Ishibashi T, Eguchi D, Yamada K, Tsurumaru D, Sakamoto K, Hidaka H, Masuda H. Spontaneous internal oblique hematoma successfully treated by transcatheter arterial embolization. Radiat Med. 2008;26:446–449. doi: 10.1007/s11604-008-0254-7. [PubMed] [CrossRef] [Google Scholar]
• Cherry WB, Mueller PS. Rectus sheath hematoma: review of 126 cases at a single institution. Medicine (Baltimore) 2006;85:105–110. doi: 10.1097/01.md.0000216818.13067.5a. [PubMed] [CrossRef] [Google Scholar]
• Moreno Gallego A, Aguayo JL, Flores B, Soria T, Hernandez Q, Ortiz S, Gonzalez-Costea R, Parrilla P. Ultrasonography and computed tomography reduce unnecessary surgery in abdominal rectus sheath haematoma. Br J Surg. 1997;84:1295–1297. doi: 10.1002/bjs.1800840928. [PubMed] [CrossRef] [Google Scholar]
• Luhmann A, Williams EV. Rectus sheath hematoma: a series of unfortunate events. World J Surg. 2006;30:2050–2055. doi: 10.1007/s00268-005-0702-9. [PubMed] [CrossRef] [Google Scholar]
• Johnson R. Abdominal wall injuries: rectus abdominis strains, oblique strains, rectus sheath hematoma. Curr Sports Med Rep. 2006;5:99–103. [PubMed] [Google Scholar]
• Zainea GG, Jordan F. Rectus sheath hematomas: their pathogenesis, diagnosis, and management. Am Surg. 1988;54:630–633. [PubMed] [Google Scholar]
• Klingler PJ, Wetscher G, Glaser K, Tschmelitsch J, Schmid T, Hinder RA. The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders. Surg Endosc. 1999;13:1129–1134. doi: 10.1007/s004649901188. [PubMed] [CrossRef] [Google Scholar]
• Rimola J, Perendreu J, Falco J, Fortuno JR, Massuet A, Branera J. Percutaneous arterial embolization in the management of rectus sheath hematoma. AJR Am J Roentgenol. 2007;188:W497–502. doi: 10.2214/AJR.06.0861. [PubMed] [CrossRef] [Google Scholar]
• Berna JD, Garcia-Medina V, Guirao J, Garcia-Medina J. Rectus sheath hematoma: diagnostic classification by CT. Abdom Imaging. 1996;21:62–64. doi: 10.1007/s002619900011. [PubMed] [CrossRef] [Google Scholar]

An oblique muscle hematoma as a rare cause of severe abdominal pain: a case report

BMC Res Notes. 2013; 6: 18.

,¹,²,¹ and ¹

Masanori Shimodaira

¹Department of General Medicine, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

Tomohiro Kitano

²Junior resident, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

Minoru Kibata

¹Department of General Medicine, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

Kumiko Shirahata

¹Department of General Medicine, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

¹Department of General Medicine, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

²Junior resident, Iida Municipal Hospital, 438 Yawata-machi, Iida, Nagano-ken, 395-8502, Japan

Corresponding author.

Received 2012 Sep 18; Accepted 2013 Jan 15.

Copyright ©2013 Shimodaira et al.; licensee BioMed Central Ltd.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.This article has been cited by other articles in PMC.

Abstract

Background

Abdominal wall hematomas are an uncommon cause of acute abdominal pain and are often misdiagnosed. They are more common in elderly individuals, particularly in those under anticoagulant therapy. Most abdominal wall hematomas occur in the rectus sheath, and hematomas within the oblique muscle are very rare and are poorly described in the literature. Here we report the case of an oblique muscle hematoma in a middle-aged patient who was not under anticoagulant therapy.

Case presentation

A 42-year-old Japanese man presented with a painful, enlarging, lateral abdominal wall mass, which appeared after playing baseball. Abdominal computed tomography and ultrasonography showed a large soft tissue mass located in the patient’s left internal oblique muscle. A diagnosis of a lateral oblique muscle hematoma was made and the patient was treated conservatively.

Conclusion

Physicians should consider an oblique muscle hematoma during the initial differential diagnosis of pain in the lateral abdominal wall even in the absence of anticoagulant therapy or trauma.

Keywords: Abdominal pain, Abdominal muscle, Oblique muscle, Hematoma

Background

Abdominal wall hematomas are an uncommon cause of acute abdominal pain and are often misdiagnosed. They result from rupture of the epigastric vessels or the deep circumflex iliac artery (rarely), or from tears of the fibers of the rectus abdominis or lateral oblique muscles
[1,2]. They may occur because of trauma, physical exercise, recent surgery, or injection procedures. They may also occur because of increased intraabdominal pressure from coughing, sneezing, vomiting, or straining during urination, defecation, and labor
[1,3-6]. Other predisposing factors include increased age, arterial hypertension, atherosclerosis, and systemic anticoagulant therapy. Most abdominal wall hematomas occur in the rectus sheath, and a hematoma within the oblique muscle is very rare. Here we report a case of an oblique muscle hematoma in a middle-aged patient.

Case presentation

A 42-year-old man presented with a painful, enlarging, lateral abdominal wall mass, which appeared after playing baseball. He gave no history of direct abdominal trauma such as collision with another player. He had a history of hyperuricemia; however, he had not undergone any therapy for the same. There was no family history of bleeding diathesis or hematological diseases. On physical examination, his vital signs were as follows: temperature 36.8°C, blood pressure 108/69 mm Hg, pulse rate 58 beats/min, and respiratory rate 12 breaths/min. A firm mass was palpable over the left lateral abdominal wall and it was tender. The skin color of the area was normal. Blood biochemistry on laboratory examination was within normal ranges and the platelet count was 174 ×10³ cells/μl, prothrombin time was 11.8 s, international normalized ratio was 0.99, and activated partial thromboplastin time was 32.6 s.

Ultrasonography (US) showed a heteroechoic, well-defined mass in the patient’s left lateral abdominal wall (Figure
). An emergency noncontrast computed tomography (CT) of the abdomen showed a hyperdense mass in the left internal oblique muscle measuring 10.5 × 6.5 × 5.5 cm. Contrast-enhanced CT did not show extravasation of the contrast material within the mass (Figure
). The diagnosis of an oblique muscle hematoma was made. The patient was conservatively treated with analgesics. Four days after the first visit, the patient revisited our department for follow-up. His abdominal pain improved, but an ecchymosis was observed on the patient’s left lateral abdominal skin (Figure
).

Abdominal ultrasonography (US). An abdominal US showed a heteroechoic mass (white arrow) in the patient’s left lateral abdominal wall.

Contrast-enhanced CT. Contrast-enhanced CT did not show extravasation of the contrast material within the mass (white arrow).

Ecchymosis on the left lateral abdomen. Ecchymosis presented 4 days later on the patient’s left lateral abdomen.

Discussion

Abdominal wall hematomas are one of the causes of acute abdominal pain. A rectus sheath hematoma caused by the rupture of the epigastric artery is a rare, but well-described, manifestation of abdominal hematoma. On the other hand, an oblique muscle hematoma caused by a rupture of the deep circumflex iliac artery is very rare
[1]. The most common presenting signs and symptoms of these hematomas are acute abdominal pain and firm, palpable abdominal wall masses. Because of their rarity, abdominal wall hematomas can be mistaken for several common acute abdominal conditions such as appendicitis, sigmoid diverticulitis, perforated ulcers, ovarian cyst torsion, tumors, or incarcerated inguinal hernias
[7]. Misdiagnosis may lead to unnecessary negative laparotomies with increased morbidity and mortality
[3]. Therefore, these diseases should be considered as differential diagnoses.

Many risk factors have been reported for abdominal wall hematomas. These include aging, anticoagulant therapy, platelet disorders, trauma, recent surgery, injection procedures, and physical exercise as well as increased intraabdominal pressure from coughing, sneezing, vomiting, or straining during urination, defecation, or labor
[6]. In the review of 126 cases of rectus sheath hematoma, it is reported that most patients (69%) were on some forms of anticoagulation therapy and the mean age was 67.9 years
[5]. Our patient was not taking any medications affecting blood coagulation and laboratory data regarding coagulation function were within normal limits. Therefore, his internal oblique muscle was considered to be injured by a sudden or repetitive trunk movement, either rotation or flexion/extension, while playing baseball
[8].

An abdominal wall mass with ecchymosis is the most important diagnostic finding for suspicion of a hematoma. However, abdominal wall ecchymosis is a late sign and the average time between its presentation and its onset takes about 4 days, as reported in the literature
[9]. Furthermore, ecchymosis is a rare presentation for an abdominal wall hematoma. A study by Cherry et al. showed that only 17% abdominal wall hematoma patients present with an abdominal wall ecchymosis
[5]. In our patient, ecchymosis was detected 4 days after the appearance of the abdominal wall hematoma. To the best of our knowledge, this is the first report of an oblique muscle hematoma that was accompanied by ecchymosis.

The diagnosis of an oblique muscle hematoma is made by combining medical history, laboratory examination findings, and US and/or radiological findings. US and CT scans can provide useful information for differential diagnosis to avoid unnecessary surgery
[6]. US can be useful as a first-line investigation because it is widely available and portable
[10]. In addition to US, contrast-enhanced CT can detect and evaluate active bleeding from the rupture site
[4]. In the present case, contrast-enhanced CT findings did not show active bleeding. Therefore, we could not confirm which artery was ruptured by CT findings. Even in a patient without contrast extravasation at the bleeding site as observed on CT, selective digital subtraction angiography could be a useful imaging technique to identify an active bleeding point
[11].

Although there is no grading for an oblique muscle hematoma because of its rarity, the following grading system has been established for a rectus sheath hematoma on the basis of CT findings. Grade I is an intramuscular hematoma with an observable increase in muscle size. Grade II is also an intramuscular hematoma but with blood between the muscle and transversalis fascia. Grade III hematoma may or may not affect the muscle and blood is seen between the transversalis fascia and muscle in the peritoneum and prevesical space that results in a drop in hemoglobin
[12]. Grade I hematoma may resolve rapidly within approximately 30 days, whereas Grade II hematomas require 2–4 months and Grade III hematomas require more than 3 months to resolve
[12]. Hence, a classification based on CT findings could help a physician in predicting a patient’s outcome.

Conservative treatment including bed rest and analgesics are appropriate in most patients with abdominal wall hematomas. Although most are self-limiting because the bleeding usually stops without intervention, some patients show significant morbidity and the overall mortality rate is reported to be 4%. Surgical intervention or transcatheter arterial embolization is recommended when conservative management fails
[1,4]. In our case, conservative treatment was administered because CT findings did not suggest active bleeding.

Conclusion

An oblique muscle hematoma is a very rare condition. In the clinical setting, abdominal US and contrast-enhanced CT are useful for a diagnosis. A correct diagnosis is important to avoid increasing morbidity or unnecessary surgical intervention. Treatment is mainly conservative and includes pain management. Physicians should consider an oblique muscle hematoma in the initial differential diagnosis of abdominal pain even in the absence of history of anticoagulant therapy or obvious trauma.

Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

MS wrote the manuscript. TK contributed to the diagnosis and revised the manuscript. MK and KS reviewed the literature. All authors contributed intellectual content, have read and approved the final manuscript.

References

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• Linhares MM, Lopes Filho GJ, Bruna PC, Ricca AB, Sato NY, Sacalabrini M. Spontaneous hematoma of the rectus abdominis sheath: a review of 177 cases with report of 7 personal cases. Int Surg. 1999;84:251–257. [PubMed] [Google Scholar]
• Nakayama T, Ishibashi T, Eguchi D, Yamada K, Tsurumaru D, Sakamoto K, Hidaka H, Masuda H. Spontaneous internal oblique hematoma successfully treated by transcatheter arterial embolization. Radiat Med. 2008;26:446–449. doi: 10.1007/s11604-008-0254-7. [PubMed] [CrossRef] [Google Scholar]
• Cherry WB, Mueller PS. Rectus sheath hematoma: review of 126 cases at a single institution. Medicine (Baltimore) 2006;85:105–110. doi: 10.1097/01.md.0000216818.13067.5a. [PubMed] [CrossRef] [Google Scholar]
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• Luhmann A, Williams EV. Rectus sheath hematoma: a series of unfortunate events. World J Surg. 2006;30:2050–2055. doi: 10.1007/s00268-005-0702-9. [PubMed] [CrossRef] [Google Scholar]
• Johnson R. Abdominal wall injuries: rectus abdominis strains, oblique strains, rectus sheath hematoma. Curr Sports Med Rep. 2006;5:99–103. [PubMed] [Google Scholar]
• Zainea GG, Jordan F. Rectus sheath hematomas: their pathogenesis, diagnosis, and management. Am Surg. 1988;54:630–633. [PubMed] [Google Scholar]
• Klingler PJ, Wetscher G, Glaser K, Tschmelitsch J, Schmid T, Hinder RA. The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders. Surg Endosc. 1999;13:1129–1134. doi: 10.1007/s004649901188. [PubMed] [CrossRef] [Google Scholar]
• Rimola J, Perendreu J, Falco J, Fortuno JR, Massuet A, Branera J. Percutaneous arterial embolization in the management of rectus sheath hematoma. AJR Am J Roentgenol. 2007;188:W497–502. doi: 10.2214/AJR.06.0861. [PubMed] [CrossRef] [Google Scholar]
• Berna JD, Garcia-Medina V, Guirao J, Garcia-Medina J. Rectus sheath hematoma: diagnostic classification by CT. Abdom Imaging. 1996;21:62–64. doi: 10.1007/s002619900011. [PubMed] [CrossRef] [Google Scholar]

90,000 Diagnosis and treatment of hematomas in children

A hematoma is a collection of blood vessels in the tissues under the skin. It can be regular or irregular, red, blue or deep purple. Hematomas can be small (about the size of a pencil eraser) and quite extensive (about the size of a large coin). Some hematomas are called “strawberry” because they are shaped like various berries. Almost 10% of children under the age of one year have such hematomas.

Causes and symptoms of hematomas

There are three types of hematomas: simple, with a bright red tint, tricky, penetrating deeper under the skin and having a purple or blue tint, and mixed, which are characterized by the signs of the first two types.

Some hematomas are already present on the body of a newborn, some appear during the first months of his life. Initially, all three types of hematomas may have the same color: white, blue-gray, or pink. After a few weeks, strawberry hematomas turn red, while deep tricky ones turn blue. The blood vessels of the hematoma grow faster than ordinary ones, therefore, in the first years of a child’s life, the impression is created that the hematoma is increasing in size.

The hematoma stops increasing in size usually by the first year of a child’s life, sometimes by the second.The first sign that the growth of a strawberry hematoma has stopped is the appearance of a white “edging” around the red spot. Then white spots will begin to appear on it. This indicates that it begins to dissolve. Over the next years, the hematoma will begin to acquire a pink-gray color. After that, it will start to fade. 50% of hematomas become invisible by 5 years, 75% – by 7 years, and by 9 years about 90% of hematomas disappear. Sometimes the only traces of a former hematoma are a pink tinge of the skin and slight swelling if the hematoma protrudes above the skin.Usually, there are no traces of hematomas.

Diagnostics

Since hematomas consist of blood vessels through which blood moves, the organs located under them can also increase in size along with the hematomas. If a child develops a deep or mixed hematoma, an ultrasound examination is performed to make sure that the child’s internal organs are not affected. In the presence of a large hematoma, a general blood test will be taken.

Hematoma treatment

If hematomas bleed heavily, it becomes necessary to use drugs or remove them.This also applies to hematomas that rapidly increase in size (especially those located on the face of the child).

There are two methods of treatment: medical and surgical. In the first case, steroids are prescribed, which stop the growth of the vessels that make up the hematoma. Steroids are taken over several weeks or even months. They can have side effects on the child’s body: he may change his appetite, mood, a slight decrease in the growth rate, the appearance of swelling (especially on the face), stomatitis and the inability to vaccinate while taking medications.All side effects go away with stopping the medication.

Surgical intervention is another type of hematoma treatment. It is produced using a laser or scalpel. The laser can destroy the growing vessels that make up the hematoma. This leads to the cessation of its growth. When using a scalpel, the entire hematoma can be excised.

The application of a particular treatment method depends directly on the size, shape, location and type of hematoma. In order to choose the most appropriate treatment method, you need to consult a dermatologist or surgeon.

The doctor explained which bruises are worth paying attention to

https://ria.ru/20210514/zdorove-1732232884.html

The doctor explained which bruises are worth paying attention to

The doctor explained which bruises are worth paying attention to – RIA Novosti, 14.05.2021

The doctor explained which bruises should be paid attention to

When any bruises appear on the body, you should see a doctor, an ultrasound diagnostic doctor, a surgeon-phlebologist of the Center… RIA Novosti, 14.05.2021

2021-05-14T02: 11

2021-05-14T02: 11

2021-05-14T10: 48

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MOSCOW, May 14 – RIA Novosti. When any bruises appear on the body, it is worth seeing a doctor, Amiran Demurov, a doctor of ultrasound diagnostics, a surgeon-phlebologist of the “Center of Phlebology” clinic, told Sputnik radio in an interview.According to him, you need to clearly understand what exactly the blue spots are, and here several options are possible. Firstly, due to some kind of household injury or bruise, blood can leave the vessel and get under the skin – this is how ordinary bruises are formed. As a rule, they go away on their own, but much depends on the volume of the hematoma, Amiran Demurov said. Amiran Demurov added that taking blood thinning drugs increases the risk of bruising. According to him, even minor bruises, which usually do not leave marks, can cause large bruises during anticoagulant therapy.“This is due to the fact that the bleeding time increases, as we thin the blood, change its coagulation system. said Amiran Demurov. Manifestations of varicose veins also outwardly resemble ordinary bruises, although the nature of their appearance is completely different, noted the phlebologist surgeon. According to him, such “bad” bruises, consisting of small vascular formations, which are also called vascular spiders or asterisks, indicate a disorder of the blood coagulation system.”In this case, you need a phlebologist’s consultation, an ultrasound examination to understand the situation – this is a superficial, cosmetic option or the tip of more serious diseases, which, if left untreated, are dangerous with complications, including thrombosis. Varicose veins must be treated.” , – said Amiran Demurov in an interview with Sputnik radio.

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MOSCOW, May 14 – RIA Novosti. When any bruises appear on the body, it is worth seeing a doctor, Amiran Demurov, a doctor of ultrasound diagnostics, a surgeon-phlebologist of the “Center of Phlebology” clinic, told Sputnik radio in an interview.

According to him, you need to clearly understand what exactly the blue spots are, and here several options are possible.

Firstly, due to some kind of household injury or bruise, blood can leave the vessel and get under the skin – this is how ordinary bruises are formed. As a rule, they go away on their own, but much depends on the volume of the hematoma, Amiran Demurov said.

“If this is a small superficial bruise, it will either go away on its own in 10-15 days, or it will pass faster while taking local heparin-containing drugs.If it is a large bruise, a large hematoma with a large blood volume, it may be necessary to consult a surgeon to observe that it dissolves and does not fester, “he explained.

Amiran Demurov added that taking blood-thinning drugs increases the risk of hematomas. According to him, even minor bruises, which usually do not leave traces, can cause large bruises during anticoagulant therapy.

“This is due to the fact that the bleeding time increases, as we thin the blood, change its coagulation system …Bruises are not an indication for stopping blood-thinning drugs, they are prolonged bleeding, but only the doctor decides when the drug should be discontinued, “Amiran Demurov said.

Manifestations of varicose veins also outwardly resemble ordinary bruises, although the nature of their appearance is completely different, said the phlebologist surgeon.According to him, such “bad” bruises, consisting of small vascular formations, which are also called vascular spiders or asterisks, indicate a disorder of the coagulation system blood.

“In this case, you need a phlebologist’s consultation, an ultrasound examination to understand the situation – this is a superficial, cosmetic option or the tip of more serious diseases, which, if left untreated, are dangerous complications, including thrombus formation. Varicose veins must be treated. “, – said Amiran Demurov in an interview with Sputnik radio.

Induction and bruises on the abdomen – Question to the surgeon

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Installation of drains in adults after surgery for chronic subdural hematoma

What is chronic subdural hematoma (CSH)?

Chronic subdural hematoma (CSH) is an accumulation of blood between the brain and the membranes surrounding it. CSH is a common type of (intracranial) hematoma that occurs most often in older people.Up to 75% of CSH are due to head trauma, and the trauma can be minor, without loss of consciousness, vomiting, seizures, or any other post-traumatic symptoms. The symptoms of CSH depend on the size of the hematoma and the areas of the brain that it puts pressure on. It may be accompanied by confusion or coma; memory problems; difficulty speaking, swallowing, or walking; drowsiness; headaches; convulsions; and weakness or numbness in the limbs and face.

How is CSH treated?

The most effective way to treat CSH is a surgical operation, in which the hematoma is evacuated through the burr hole. In this procedure, one or two holes (5 to 30 mm) are drilled in the skull above the hematoma. The accumulated blood clots are removed through the formed holes. Sometimes, at the end of the operation, surgeons insert soft silicone drainage through the burr hole to continue draining the cavity that has been filled with blood (subdural drainage).These drains evacuate fluid accumulating in the external collecting vessels and are left in place for 24 to 48 hours after surgery before being removed. Alternatively, at the end of the operation, the wounds are closed surgically without installing external drains.

Why can drains be useful?

Recurrence (that is, the formation of another CSH in the same place) is a major problem in patients with CSH, and patients may need an additional, repeated surgical procedure to remove it.Drainage can reduce the likelihood of relapse, but is not routinely used. The authors of this Cochrane Review wanted to find out if external drainage after trepanation surgery for CSH actually reduces the likelihood of recurrence.

Research characteristics and main results

The reviewers extensively searched the medical literature up to November 2014 for randomized controlled trials (RCTs) that met the inclusion criteria that provide the most robust evidence.They found nine RCTs, including 968 patients, comparing the use of external drains in some patients versus the refusal of drains in others, after operations with opening a burr hole in patients with CHF. The studies were carried out in India, Turkey, Iran, Germany, Great Britain and Japan. All participants were adults, mostly over 60 years old. All studies performed similar operations. Six studies were conducted over six months, the rest over three, one month, and three weeks (one for each).

The authors of the studies were able to statistically combine the results of trials that showed that the use of drains reduced the risk of CSH recurrence after creating trepanation holes by about 50% compared to the group of patients who did not receive drains (control group). However, there was no clear difference between drainage and non-drainage in patient groups in terms of the number of postoperative complications (such as: infectious complications, convulsions or spontaneous bleeding), deaths or functional results (for example, restoration of functions impaired by CSH).

Quality of evidence

The results of this review are subject to change in the future as additional studies become available. In the studies conducted, there are either too few participants or interventions to show reliable results, even when statistically processed. Some studies do not describe the randomization process in detail, so they are not considered reliable enough.

Future research will also help establish:

– the effect of the installation of external drains on the occurrence of postoperative complications, mortality and functional results;

– it is better to install one or two drains when performing a surgical intervention;

is the best way to position drainage tubes in the brain;

– the duration of the drainage leaving.

Latent hematoma of soft tissues of the abdomen

Injury to the soft tissues of the abdomen often leads to the formation of hidden (not visible visually) hematomas. With the help of ultrasound, a reliable search for signs of such a pathology is ensured, the degree of damage is determined:

* subcutaneous tissue

* lymph nodes

* muscles

* connective tissue

* joints and bones

Research technique

The study of the place where the hematoma of soft tissues is suspected does not differ from the study of other areas of the skin: it must be freed from clothes, covered with a special gel, and the corresponding organic structures must be visualized.A hematoma is an enclosed structure (cavity) that is saturated with blood. The content is homogeneous, at the moment of turning the body the liquid level changes. Ultrasound is mandatory in cases where the soft tissues of the abdomen hurt, and it is not possible to establish the cause of this condition; and also after significant bruises, other mechanical injuries.

What to pay special attention to

In the process of examining the anterior abdominal wall, it is very important not to make a mistake, not to mistake malignant for intermuscular post-traumatic hematoma

neoplasm.In cases where the fact of bleeding is clear, its nature is not in doubt – additional diagnostics are not required, you should immediately proceed to therapeutic procedures.

On the echogram, the hematoma manifests itself primarily as the formation of slightly increased (in comparison with the norm) echogenicity, which has indistinct boundaries, inside there may be a site that reflects little ultrasound. It is quite possible to encounter a hematoma, the contours of which are very well traced (for the most part, internal “cells” are also visible in such formations).

Variants of echo images of hematoma

It is noted that over 10% of soft tissue hematomas give an echo pattern very close to the echo pattern of an abscess: a formation, the contours of which are uneven and indistinct, predominantly of an “irregular” configuration. The echogenicity of such structures is reduced; single zones with a zero level of reflection are found, which may adjoin (although this is not necessary) with areas of high echogenicity. In the presence of simultaneously corresponding clinical symptoms, there is a classic abscess.Its emergence from a hematoma is evidenced by the fact that an anechoic area is found with a pronounced increase in signal reflection immediately after the formation.

The difference between phlegmon in differential diagnosis is that it cannot be differentiated with the surrounding tissues, as well as the presence of narrow “tunnels” located between muscle fibers in the echo picture; in addition, many scattered superechoic formations are found.

Benefits of research

Note that even after several weeks after injury, the inside of the hematoma may contain mainly liquid blood and clots, which gives a characteristic echo pattern.In such situations, according to experts, only ultrasound is able to determine what is actually happening. Even puncture is not that versatile. On the other hand, with the help of an echogram, it can be found that the pathological condition is not too serious, and it is possible to continue conservative treatment without resorting to unnecessary surgery.

A hematoma of the soft tissues of the abdomen may be accompanied by muscle rupture – and only radiation diagnostics reliably determines whether it is present in this particular case or not.Thus, we can confidently conclude that ultrasound allows for accurate recognition of hematoma and determination of associated problems, as well as differential diagnosis.

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90,000 Russian experts have identified an atypical symptom of coronavirus :: Society :: RBC

According to doctors, inflammation of the peritoneum in COVID-19 occurs due to the body’s systemic response to a viral infection, “accompanied by massive production of cytokines, hyperactivation of immune cells and the formation of circulating immune complexes, which can lead to pathological changes in microvessels and aseptic inflammation of some serous shells “.

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On May 1, the head physician of the infectious diseases center in Kommunarka, Denis Protsenko, spoke about another symptom that was observed in patients with COVID-19 – skin rashes.“The rashes are quite varied. First of all, rashes on the skin of the hands and abdomen, ”said Protsenko. He pointed out that such symptoms were found in the majority of patients admitted to the hospital.

Prior to that, Chief Pulmonologist of the Ministry of Health of Russia and Head of the Department of Pulmonology, Moscow State Medical University. Sechenov, Sergei Avdeev called the main symptom of a severe form of the disease COVID-19 shortness of breath. According to him, shortness of breath indicates the transition of the disease into a severe stage, when it appears, it is necessary to seek medical help and prepare for hospitalization.

The main symptoms of coronavirus infection, as indicated on the website of the Infection Control Operations Headquarters, are high body temperature, cough (dry or with little phlegm), shortness of breath, muscle pain and fatigue. Among the more rare manifestations, experts named headache, chest congestion, hemoptysis, diarrhea, nausea and vomiting.

How the number of recovered and deaths from coronavirus in Russia is changing

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