Rectus sheath hematoma
- Michael Rosen, MD
Michael Rosen, MD
- Section Editor — Hernia Surgery
- Professor of Surgery
- Cleveland Clinic Foundation
- Ivy N Haskins, MD
Ivy N Haskins, MD
- Resident Physician/Research Fellow
- Cleveland Clinic Foundation
Rectus sheath hematoma (RSH) is a rare clinical entity that results from accumulation of blood within the rectus sheath. RSH may mimic a number of acute intra-abdominal pathologies, warranting heightened suspicion and prompting diagnostic evaluation and management. This topic will review the pathophysiology, diagnostic evaluation, and management of RSH. The evaluation of patients with abdominal pain from other conditions is discussed elsewhere. (See "Evaluation of the adult with abdominal pain in the emergency department".)
Rectus sheath hematomas (RSHs) arise from disruption of a branch of the inferior epigastric artery at its insertion into the rectus abdominis muscle combined with an inability to tamponade the bleeding .
The rectus abdominis muscle receives its blood supply from the superior and inferior epigastric arteries (figure 1). The inferior epigastric artery (IEA) perforates the rectus abdominis muscle at the arcuate line, where the IEA is relatively fixed within the muscle, making its branches vulnerable to shearing forces . (See "Anatomy of the abdominal wall", section on 'Inferior epigastric arteries'.)
The arcuate line, which is a horizontal line occurring one-third of the distance from the umbilicus to the pubic symphysis, demarcates the lower limit of the posterior rectus sheath (figure 2). Without a supporting posterior rectus sheath, the lower half of the rectus abdominis muscle is susceptible to changes associated with movements, which explains why a majority of RSHs occur in the lower abdomen [3,4]. (See "Anatomy of the abdominal wall", section on 'Rectus sheath'.)
Once a branch of the inferior epigastric artery is disrupted, bleeding ensues, and the inability to quickly tamponade the bleeding results in symptomatic RSHs.
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- RISK FACTORS
- Asthma or COPD
- Women or older patients
- Chronic medical conditions
- CLINICAL PRESENTATION
- DIAGNOSIS AND EVALUATION
- Type I RSH
- Type II RSH
- Type III RSH
- Type I RSH
- Type II and III RSH
- - Hemodynamically stable
- - Hemodynamically unstable
- Surgical intervention
- SUMMARY AND RECOMMENDATIONS