Abdominal wall haemorrhage

Section: Emergency Curriculum: Curriculum, page 27

Relevant anatomy

• Blood supply
  • Superior Epigastric Artery off Internal thoracic artery, enters rectus sheath
  • Inferior Epigastric Artery – off External Iliac Artery at inguinal ligament, passes up over conjoint tendon, slips over arcuate line to enter sheath
  • Segmental arteries off the aorta
    • Posterior Intercostal arteries (T7-T11) – between transversalis & IO
    • Subcostal
    • Lumbar x4
  • Iliolumbar Artery – 5th lumbar, branch off the Internal Iliac Artery
  • Deep circumflex iliac artery (off EIA) – runs to ASIS – anastomoses with branch of Iliolumbar & superior gluteal artery (both branches of IIA) – ascending branch off this vessel can be encountered during open appendectomy
  • Superficial circumflex iliac artery - branch off the Femoral Artery
  • Superficial inferior epigastric artery - branch off the Femoral Artery
• ASIS ANASTOMOSIS;
  • deep circumflex iliac (EIA)
  • superior gluteal (IIA)
  • iliac branch Iliolumbar (IIA)
  • superficial circumflex iliac (fem)

Rectus hematoma

• Bleed into the rectus muscle
• Incidence: Uncommon –1% of unusual abdo pain admissions, F>M
• Classification (CT scan)
  • Type I - small and confined within the rectus muscle; does not cross the midline or dissect fascial planes
  • Type II - also confined within the rectus muscle but can dissect along the transversalis fascial plane or cross the midline
  • type III - large, usually below the arcuate line, and often presents with evidence of haemoperitoneum and/or blood within the prevesical space of Retzius (retropubic space)
• Etiology
  • Trauma
  • Previous surgery
  • Coughing, stretching, vomiting, constipation – vigorous contraction if muscle
  • Pregnancy
  • HT
  • Intra-abdo injections
  • Iatrogenic – laparoscopy trocars
  • anticoagulation
• Clinical
  • Abdo pain, abdo mass in RLQ / LLQ
    • Pain may be sudden, or progressive
  • Abdo wall ecchymosis
  • Nausea / vomiting
  • Tachycardia
  • Abdo distension
  • Constipation
  • Carnett’s sign: ↑ed pain/tenderness over the hematoma by contraction of rectus muscle (by sitting halfway up in a supine position)
  • Fothergill’s sign: a mass, that does not cross the midline, remains palpable when the pt tenses their rectus muscle
  • Occasionally causes hypovolemic shock
• Pathology
  • Bleeding disorder / anticoagulation = frequent contributing factor
  • Bleed usually from inferior (or sup) epigastric artery, or its branches or occasionally due to a direct tear of the rectus muscle
    • Due to the position of the arteries, most hematomas are posterior to the muscle
  • Hematomas below the arcuate line bleed more (and are more likely to cross the midline) because there is no posterior sheath (& midline decussation) to tamponade the bleeding
• Investiations
  • USS: may be difficult to determine location (e.g. intra- vs. extra-peritoneal)
  • CT + CTA
• Management
  • Conservative Mx: hospitalize, bed rest (for type II /III), analgesia, reverse anticoagulation, transfuse
  • If blush on CT consider embolisation
  • If hematoma expanding or infected or causing severe pain → consider surgery
  • In high risk pts with failure of conservative Mx → consider angiography + embolization
• Prognosis / Natural Hx:
  • Usually self-limiting
  • MR: 4%; higher if pt anticoagulated
  • Acute pain usually resolves within 3 days; but mass may persist for weeks
  • Type I: hematoma usually resorbs spontaneously within 30 days
  • Type II/III haematomas reabsorb in ≈3/12