Introduction

     Rectus sheath hematoma (RSH) is usually the result of rupture of the epigastric vessels or their branches(1,2,3). It may occur as a result of direct trauma but it may develop spontaneously, particularly following bouts of coughing or convulsive seizures(1,2,4,5). Anticoagulation is a predisposing factor (2,4,6).

   It may simulate the acute surgical abdomen but is usually self limiting and conservative treatment is sufficient in the majority of cases(2,5,7,8). Coil embolization of the inferior epigastric artery in the case of an expanding hematoma was recently described(6). Surgical intervention may become required when the symptoms are severe, in case of a spreading hematoma with haemodynamic instability or for an infected hematoma, although the latter may be drained percutaneously(3).

Rectus sheath hematoma is rarely described in renal transplanted patients. The following is a case report of ruptured RSH with haemoperitoneum in a renal transplanted woman in which the patient's presentation, diagnostic work up and management steps will be described highlighting the useful role of laparoscopy. We believe that the laparoscopic approach in this case expedited the recovery of this patient and it may be the first one to be reported in the literature

Case Report

     Report A 33 year old woman presented to our emergency room complaining of abdominal pain of 2 days duration. This was accompanied by development of abdominal swelling and skin discoloration. It was not clear whether she had fallen on the ground and injured her abdomen or she had just simply fainted. She had suffered repeated attacks of convulsions throughout the night before her presentation and there was a history of coughing for five days.

This patient was a cadaveric renal transplant recipient for six years and was known to suffer from systemic lupus erythematosus syndrome with thrombotic cerebral episodes and secondary epilepsy. She was hypertensive and underwent right-sided nephrectomy for severe hydronephrosis six weeks prior to this presentation.

 She was on Cyclosporin A, Immuran, Diovan, Atenolol, Aldactam, Deltiazem, Prednisolone and Losec. She was also taking Warfarin 3 mg once a day and was maintained at an International Normalized Ratio (INR) of 2-2.5, but apparently she had missed her last follow-up appointment.

On examination she was found pale and hypotensive (75/45) and she was resuscitated promptly. Fits during her presentation in the emergency room were controlled with diazepam and later with phenobarbitone. An abdominal examination revealed midline ecchymosis and most of the tenderness, guarding and swelling elicited was affecting the left lower abdomen. The swelling remained palpable and became more tender as the patient tried to tense the rectus muscles.

Investigations revealed the following: Hemoglobin 6 g/dl, Hematocrit (HCT) 17.5%, INR 7.9, APTT 74 seconds, BUN 17.1 mmol/l, Creatinine 301 mmol/l and Albumin 25 g/l. A couple of months earlier, during a follow up visit, the hemoglobin and HCT had been found stable at 10.5 g/dl and 30% respectively. Ultrasound of the abdomen revealed a hematoma, possibly infected, in relation to the left rectus abdominis muscle and intraperitoneal fluid notably around the liver . A computed tomographic (CT) scan of the abdomen revealed approximately a 10 x 6 cm mass in the left lower abdominal wall pressing posteriorly upon the viscera and urinary bladder (Fig 1).

The "hematocrit effect"in the hematoma was clearly shown (Fig 2). There was also large ascites reported around the liver. The CT scan of the brain revealed areas suspicious of ischaemia. 

The patient was maintained on intravenous fluids, given fresh frozen plasma and blood, and was started on Meropenum for upper respiratory tract infection. The patient remained stable and her INR improved to the range of 1.5 to 2.5 and the pain and tenderness decreased. On the 4th day following her admission, however, the patient was still suffering a fever with temperature spikes of more than 380C and pain attacks that required pethidine for relief. Having optimized the urea and creatinine and improved the hemoglobin to 11.6 and the INR to 1.5 the patient was taken to theatre for laparoscopy.

 A laparoscopy revealed free intraperitoneal blood and a hematoma, involving the lower aspect of the left rectus sheath, which had ruptured posteriorly into the peritoneal cavity. The rupture site was clearly seen following the dissection of adherent omentum off it and there was no active bleeding. About 150 cc of blood was suctioned from the abdomen and two sump drains were inserted. One drain was placed in the pelvis and the other one was inserted into the hematoma through the rupture site.
 On the first postoperative day the patient showed a noticeable improvement and became afebrile. The drainage initially was more than 400 ml/day and then started clearing up over the following days. The patient was well enough from a surgical and medical view point to go home following a hospital stay of two weeks. The patient was last seen in the clinic about 4 months later and was doing fine with no clinical residual abnormality.   

Discussion

     Most of the RSH cases involve the lower abdominal quadrants and this may have an anatomical explanation. The aponeuroses of the transverse and oblique muscles form the rectus sheath. The posterior layer of the rectus sheath ends about 5 cm below the level of the umbilicus with a curved edge called the arcuate or semicircular line of Douglas. Below this line the rectus muscle is separated from the peritoneum by a thin connective tissue layer, fascia transversalis, and preperitoneal fat. The inferior epigastric artery ascends loosely between the rectus muscle and the posterior rectus sheath. The combination of the loose attachment of the inferior epigastric artery and the fixity of its perforating branches to the rectus muscle belly renders the artery prone to shearing stresses at branching sites during strong muscular contractions and its rupture can cause an expanding hematoma in the preperitoneal fat loose space which may press on the intraabdominal viscera or rupture into the peritoneal cavity as happenened in our case. Predisposing factors were present in this case. The fact that the patient had previous surgery scars possibly redirecting the shearing forces of muscle contraction and placing more stress on the epigastric vessel does not seem to add much of a risk. RSH developing in renal transplanted patients is rarely reported in the literature and I think the risk of this too remains, so far, largely speculative (9).

   Our patient presented with acute abdomen but risk factors in the history and findings in the clinical examination raised the possibility of RSH. Fits, coughing spells and anticoagulant therapy as well as hypertension are known contributory factors (1,2,4,6). As these were present in this case, presentation with the pallor, hypotension and the swelling of the left lower abdomen with abdominal wall ecchymosis did indeed point at RSH as a probable diagnosis which was then confirmed by the ultrasound and CT scans.

   In one study, ultrasound and CT scan, when added to the diagnostic work up, achieved a diagnostic accuracy of 75% and 100% respectively (2). This is helpful when the differential diagnosis includes conditions like ovarian cyst torsion, ectopic pregnancy, perforated colon or abdominal neoplasm, possibilities that used to be difficult to exclude in the past and which led to unnecessary laparotomies.    

   C.T scan is the diagnostic method of choice, and it can outline the so called "hematocrit effect"(separation of cellular and liquid components of the blood) which is a useful sign (2,10). RSH classification into 3 types by CT scan was suggested by correlating the C.T findings with clinical data (3). While type 1 is mild and does not require hospitalization type 3, being described as the most severe, may present as an acute abdomen with anaemia and haemodynamic disturbance. It usually requires hospitalization and blood transfusion and its resolution may take more than three months (3).

   Our patient was admitted and classified as type 3 on C.T assessment. She required resuscitation and correction of coagulation status. Blood transfusion and anticonvulsive treatment were provided as was antibiotic therapy for upper respiratory tract infection. Bed rest and analgesia were given and conservative treatment continued for three days.

   Conservative treatment is the gold standard (2,5,7,8), but surgical intervention may be indicated when diagnosis is in doubt, symptoms are severe, hematoma is expanding, haemodynamic instability persists or when the hematoma becomes infected. The latter may be drained percutaneously under CT guidance (3).

  The patient's pain persisted requiring pethidine for relief even on the fourth day following admission. She was on steroid and immunosuppressive therapy and her fever also persisted. The ultrasound report suggested the presence of an infected hematoma. With all that in mind and with the presence of intraperitoneal blood, notably around the liver, and the possibility of having sustained a blunt abdominal trauma when she fainted, it was felt reasonable to take her to theatre for laparoscopy .

  We feel that laparoscopy was helpful in this case as it confirmed RSH, cleared the peritoneal cavity of the blood, excluded any other abnormality and provided drainage both for the peritoneal cavity and for rectus sheath blood collection from inside out as it helped to guide the drain insertion through the posterior rupture site of the RSH.

  Noticeable improvement was observed within 24 hrs. Although one would argue against placing the drain in a hematoma site, lest it proves to be a source of infection, indeed in this case it helped the drainage process and the drains were eventually removed without complications. The patient was well enough to go home following two weeks of hospital stay. Anticoagulation was restarted and was later replaced with an antiplatelets drug. During a follow up visit, about four months later, the patient's condition was excellent with resolution of most of the hematoma radiologically and nothing to detect clinically.

 Acknowledgement: The author gratefully acknowledges Maria Rodrigues for her contribution in typing the manuscript.

References

1. Adams JT, Abdominal Wall, Omentum, Mesentery, and Retroperitoneum. In: Schwartz SI, ed. Principles of Surgery. Fifth edition. McGraw-Hill; 1988:1491-1494.

2. Berna' JD, et al. Conservative treatment of large rectus sheath hemotoma in patients undergoing anticoagulant therapy. Abdom Imaging. 2000;25:230-234.

 3. Berna' JD, et al. Rectus sheath hemotoma: diagnostic classification by CT. Abdom Imaging. 1996;21:62-64.

4. Edlow JA, et al. Rectus sheath hemotoma. Ann Emerg Med. 1999; 34:671-675. 5. Titone C, Lipsius M, Krakauer JS. " Spontaneous" hemotoma of the rectus abdominis muscle: Critical review of 50 cases with emphasis on early diagnosis and treatment. Surgery. 1972;72:568-572.

6. Holmes SJ, Yale SH, Mazza JJ. Rectus sheath hematoma as a cause of acute abdominal pain. American Family Physician. 2001;64:1681-1682.

7. Gocke JE, MacCarty RL, Foulk WT. Rectus sheath hematoma: diagnosis by computed tomographic scanning. Mayo Clin Proc. 1981;56:757-761.

 8. Tsapatsaris NP. Low-dose heparin. A cause of hematoma of rectus abdominus. Arch Int Med. 1991;151:597-599.

9. Franco A, et al. Hematoma of the anterior rectus abdominis muscle as the first manifestation of lymphoproliferative disease after renal transplantation. Nefrologia. 2000;20:559-562.

10. Goodman P, Balachandran S. CT evaluation of the abdominal wall. Crit Rev Diagn Imaging. 1992;33:461-463.

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