Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Rectus sheath hematoma

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


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 [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 symptomatic RSHs.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: May 03, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  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.
  12. Saber AA, Meslemani AM, Davis R, Pimentel R. Safety zones for anterior abdominal wall entry during laparoscopy: a CT scan mapping of epigastric vessels. Ann Surg 2004; 239:182.