- 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
- Investigations
- 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