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Rectus sheath hematoma

Authors
Michael Rosen, MD
Ivy N Haskins, MD
Section Editor
Russell S Berman, MD
Deputy Editor
Wenliang Chen, MD, PhD

INTRODUCTION

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 intraabdominal 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" and "Anterior cutaneous nerve entrapment syndrome".)

PATHOGENESIS

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 [1].

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 [2]. (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 a symptomatic RSHs.

                  

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Literature review current through: Nov 2016. | This topic last updated: Mon Oct 19 00:00:00 GMT+00:00 2015.
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References
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  1. Hatjipetrou A, Anyfantakis D, Kastanakis M. Rectus sheath hematoma: a review of the literature. Int J Surg 2015; 13:267.
  2. Turnage RH, Badgwell B. Abdominal Wall, Umbilicus, Peritoneum, Mesenteries, Omentum, and Retroperitoneum. In: Sabiston Textbook of Surgery, 19th ed, Townsend C, Beauchamp RD, Evers BM, et al (Eds), Elsevier Saunders, Philadelphia 2012. p.1088.
  3. Salemis NS, Gourgiotis S, Karalis G. Diagnostic evaluation and management of patients with rectus sheath hematoma. A retrospective study. Int J Surg 2010; 8:290.
  4. Wiler JL. Diagnosis: Rectus Sheath Hematoma. Emergency Medicine News 2007; 29:70.
  5. TESKE JM. Hematoma of the rectus abdominis muscle; report of a case and analysis of 100 cases from the literature. Am J Surg 1946; 71:689.
  6. Levine MN, Raskob G, Landefeld S, Kearon C. Hemorrhagic complications of anticoagulant treatment. Chest 2001; 119:108S.
  7. Kasotakis G. Retroperitoneal and rectus sheath hematomas. Surg Clin North Am 2014; 94:71.
  8. Berná JD, Garcia-Medina V, Guirao J, Garcia-Medina J. Rectus sheath hematoma: diagnostic classification by CT. Abdom Imaging 1996; 21:62.
  9. Klingler PJ, Wetscher G, Glaser K, et al. The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders. Surg Endosc 1999; 13:1129.
  10. Lohle PN, Puylaert JB, Coerkamp EG, Hermans ET. Nonpalpable rectus sheath hematoma clinically masquerading as appendicitis: US and CT diagnosis. Abdom Imaging 1995; 20:152.
  11. Rimola J, Perendreu J, Falcó J, et al. Percutaneous arterial embolization in the management of rectus sheath hematoma. AJR Am J Roentgenol 2007; 188:W497.