Diagnostic and management of spontaneous rectus sheath hematoma.

Background: Spontaneous rectus sheath hematoma is an uncommon and often misdiagnosed cause of abdominal pain. The aim of this study is to describe our experience in their management.

Methods: Retrospective analysis of the characteristics and outcomes of the spontaneous rectus sheath hematomas diagnosed over the last 12years was conducted.

Results: 24 patients were included (66% women; mean age: 74years; range: 54-87). All cases presented predisposing factors mainly anticoagulant therapy in 21 (87.5%) patients, hypertension in 19 (79.1%) and abdominal surgery in 12 (50%) cases. Eighteen (75%) referred triggering factors like coughing being the most common one, present in 17 (70.8%) patients. The main clinical findings were abdominal pain in 21 (87.5%) cases and the existence of an abdominal mass in 20 (83.3%). The diagnosis was confirmed by abdominal ultrasonography and/or computerized tomography in 23 (95.8%) patients. Nineteen cases (79.1%) responded to conservative management while 5 (20.8%) required interventional treatment, which consisted in an arteriography with selective embolization of the epigastric arteries in all cases. Four (80%) of the patients needing interventional treatment were receiving low molecular weight heparin. Nine (37.5%) patients developed hypovolemic shock and 1 (4%) died.

Conclusions: Spontaneous rectus sheath hematomas should be considered in the differential diagnosis of abdominal pain, particularly in elderly women under anticoagulant therapy with onset of symptoms after a bout of cough. Most cases respond to conservative management, although those related to low molecular weight heparin might require interventional treatment; arteriography with selective embolization of the epigastric arteries is the first therapeutic option.