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Acute Abdomen in a Coughing Asthmatic: Do We Really Think of Rectus Sheath Hematoma? FREE TO VIEW

Bikash Bhattarai, MD; Meenakshi Ghosh, MBBS; Abhisekh Sinha Ray, MBBS; Saurav Pokharel, MBBS; Rakesh Vadde, MBBS; Vikram Oke, MBBS; Marie Frances Schmidt, MD; Danilo Enriquez, MD; Joseph Quist, MD; Anita Pandey, MBBS; Saveena Manhas, MD
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Interfaith Medical Center, Brooklyn, NY

Chest. 2014;146(4_MeetingAbstracts):342A. doi:10.1378/chest.1972044
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SESSION TITLE: Miscellaneous Case Report Posters III

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Rectus Sheath Hematoma (RSH) is a rare but important clinical entity that can mimic acute intra abdominal pathology and therefore should be in the differentials of acute abdomen. Although it mainly occurs in patients receiving anticoagulation therapy intractable coughing can also cause RSH. Here, we report a case of RSH that occurs secondary to intractable coughing in an asthmatic.

CASE PRESENTATION: A 53-year-old woman presented to the ED with a 2 day history of increasing LUQ abdominal pain, swelling, SOB and cough. She had a history of asthma and hypertension and denied recent use of anticoagulants or aspirin. Her ED course was complicated by one episode of hypotension that responded well to a bolus of fluids. Physical examination revealed LUQ fullness and tenderness with no rebound. On labs, CBC revealed 1 g/dl drop in HCT, platelet count 371,000, PT 12sec and aPTT 20sec . On abdominal CT a 7.2x5.2x11.4cm left upper rectus muscle hematoma was seen. The patient was subsequently admitted and recovered uneventfully on conservative management. She was discharged after 5 days

DISCUSSION: Other than coughing, risk factors for RSH include anticoagulation, trauma, hypertension and straining. RSH is more common in women and usually presents in the fifth to seventh decade. It results when the inferior epigastric arteries below the arcuate line are torn by the overlying rectus abdominus muscle. Below the arcuate line, the arteries are not protected by the posterior rectus sheath and thus are susceptible to the contracting rectus abdominus muscle. When torn, the blood from the arteries dissects the muscle and presents as a painful, distended abdomen. The reported accuracy of clinical diagnosis in RSH is 17-40% with CT scan being approximately 100% sensitive. Stable patients are managed conservatively with unstable patients requiring surgical intervention and trans-catheter embolization. Overall mortality from RSH is 4% but if patients are on previous anticoagulation therapy mortality is 25%. Patients treated with surgery have an overall mortality of 18%.

CONCLUSIONS: RSH is rare but it is an important differential to consider in acute abdominal pain because with a prompt diagnosis unnecessary laparotomies can be avoided leading to more effective and less invasive management

Reference #1: Rectus Sheath Hematoma: R.T. Skelly et al.: Ulster Medical Journal 1999: Volume 68, No 2 pg 100-102

Reference #2: Bilateral Rectus Sheath Hematomas In a Coughing Patient, L Jensen et al. American Journal of Medicine 2013 volume 126 issue 6 pg e5-e6

DISCLOSURE: The following authors have nothing to disclose: Bikash Bhattarai, Meenakshi Ghosh, Abhisekh Sinha Ray, Saurav Pokharel, Rakesh Vadde, Vikram Oke, Marie Frances Schmidt, Danilo Enriquez, Joseph Quist, Anita Pandey, Saveena Manhas

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