Rectus sheath hematoma: Clinical sciences

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Introduction0:00–0:38

Rectus sheath hematoma refers to an accumulation of blood within the sheath of the rectus abdominis muscle. It typically occurs as a result of an injury to the epigastric artery or one of its branches, either due to abdominal trauma, or forceful contractions of the abdominal wall.
There are three types of rectus sheath hematoma. Type I is located within the rectus abdominis.
Type II is when the blood builds up between the muscle and the fascia, while Type III extends into the peritoneum.Alright, the first thing you should do if you suspect a rectus sheath hematoma is an ABCDE assessment to determine if your patient is unstable or stable.

Unstable branch0:38–1:05

If the patient is unstable, you need to stabilize their airway, breathing, and circulation. This means that you may need to intubate the patient, establish IV access, and administer fluids before continuing with your assessment.
If the patient doesn’t respond to these measures, consult the surgical team right away. On the flip side, if the patient is stable, your next step is to obtain a focused history and physical examination, and order labs such as CBC followed by serial hemoglobin and hematocrit levels every 4 to 6 hours, and coagulation studies, including PT, INR, and PTT.

History, physical, and labs1:05–3:38

Now, patients with a rectus sheath hematoma usually report acute abdominal pain, which is often sharp, persistent, and non-radiating.
History might also reveal some important risk factors like anticoagulation or antiplatelet therapy; recent abdominal surgery; pregnancy; biological female sex ; or chronic conditions such as renal disease, cirrhosis, arteriosclerosis, and hypertension.
Additionally, patients with a history of asthma and COPD may also be at an increased risk due to repeated and forceful contractions of the rectus abdominis muscle during coughing spells.
On the other hand, the physical exam usually reveals abdominal wall ecchymosis as well as tender, palpable, and non-pulsating abdominal mass in the area of the hematoma, which doesn’t cross the midline due to the linea alba confining it.
During the exam, you should assess your patient for two clinical signs called Carnett sign and Fothergill sign. Carnett sign is used to determine if the pain originates from the abdominal wall muscles, or intra-abdominally, from the abdominal viscera.
Carnett sign is a two-step test. First, have the patient relax and palpate the abdomen to localize the pain.
Then, have the patient tense their abdominal muscles and palpate the same point again. If the pain worsens, it is from the abdominal wall, and Carnett sign is positive.
However, if the pain remains the same, then you should think of intra-abdominal causes. When it comes to the Fothergill sign, it is used to determine if the mass is extra-abdominal, or intra-abdominal.
Fothergill sign is positive if the abdominal mass remains fixed when the patient contracts the abdominal wall muscles. On the flip side, if the mass “disappears”, it’s probably located within the abdomen and you should think of alternative diagnoses.
Finally, labs might show a decrease in hemoglobin, and elevated coagulation studies like PT, INR, or PTT.Okay, if the history, physical exam, and labs suggest rectus sheath hematoma, order a CT of the abdomen and pelvis.

CT scan3:38–4:51

If you are worried about an active bleed, order the CT scan with IV contrast. Here is some high-yield information to keep in mind!
When deciding on the appropriate imaging modality for your patient, you should pay attention to two groups: pediatric and pregnant individuals.
In these cases, you should do an ultrasound because it eliminates the possibility of radiation exposure.If imaging reveals no signs of a hematoma, then this is most likely not the appropriate diagnosis, and you should consider other possibilities.
However, if imaging does reveal a rectus sheath hematoma, it will most likely present as an organized fluid collection posterior to or within the rectus abdominis muscle in the anterior abdominal wall.
Once IV contrast is added, you can assess for contrast extravasation or blush which is a sign of an ongoing active bleed.
Alright, now that the imaging has confirmed the diagnosis, your next step is to assess its size and location. If the hematoma is located within the rectus abdominis muscle and doesn’t cross the midline or dissect the transversalis fascial plane, your patient has a rectus sheath hematoma Type I.

Main Branch 1: Type I Rectus sheath hematoma4:51–5:54

These patients are usually treated in the outpatient setting, but might be admitted for observation if they have any risk factors for severe disease.
The treatment is conservative, meaning patients should get bed rest and apply ice and compression to the affected area. You might also prescribe pain medications as needed.
If your patient is on anticoagulation therapy, you may need to adjust it, or even reverse the therapy, in order to allow the bleeding to stop, and perform serial exams like hemoglobin and coagulation studies to make sure it’s not worsening.
Now, let’s take a look at Type II and III hematomas. If the CT reveals a hematoma in the rectus abdominis muscle that crosses the midline and dissects the transversalis fascial plane, then your patient has a Type II rectus sheath hematoma.

Main Branch 2 and 3: Type II and III Rectus sheath hematomas5:54–7:19

But, if the CT reveals a hematoma located below the arcuate line, where there’s no posterior rectus sheath, the hematoma can more easily extend into the peritoneum and perivesical space as a Type III rectus sheath hematoma.
Since Type II and III hematomas are larger, you should treat these individuals in the inpatient setting. Just like with Type I hematomas, you should first attempt conservative management and reverse anticoagulation therapy, if they’re on it.
You should also start IV fluids and monitor hemoglobin levels. If the hemoglobin levels continue to drop, or the patient develops hypotension despite ongoing hydration, you might need to transfuse blood products.
Remember to keep monitoring the patient during treatment. If your patient doesn’t respond to treatment, becomes unstable, or the CT shows any signs of contrast extravasation, then they require angioembolization.
Now, if angioembolization fails, or the patient develops hemorrhagic shock or compressive symptoms like femoral neuropathy or hydronephrosis, you should call the surgical team for emergent consultation and control of the bleeding.
Alright, as a quick recap… Patients with rectus sheath hematoma can present as stable or unstable. Unstable patients should be stabilized before doing any assessments.

Review7:19–8:38

If they don’t respond to management, you should consult surgery immediately. On the other hand, stable patients should undergo a CT scan of the abdomen and pelvis with IV contrast to diagnose rectus sheath hematoma and determine the type.
Type I rectus sheath hematomas are usually treated in the outpatient setting, but might be admitted for observation if they have any risk factors for severe disease.
The treatment is conservative, which includes bed rest, icing the hematoma, applying compression, administering pain medications, and reversing anticoagulation if needed.
On the other hand, Types II and III are treated in the inpatient setting. Initial treatment involves conservative treatment and IV hydration.
If the patient’s hemoglobin level drops despite IV hydration, you should transfuse blood products. If the patient doesn’t respond to conservative treatment, becomes unstable, or CT shows signs of contrast extravasation or blush, they require angioembolization.
Finally, if this doesn’t work, or the patient develops signs of hemorrhagic shock or compression,
Rectus sheath hematoma: Video, Causes, Symptoms | Osmosis