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Clinical Summary

Mild trauma may produce hematomas of the rectus sheath. This injury results in intense abdominal pain, which can mimic an acute abdomen. The diagnosis is difficult by physical exam since most hematomas are in the posterior rectus sheath and are not palpable or visible. Palpation of the abdominal wall may reveal a tender mass that is accentuated by contraction of the rectus. Ultrasound and CT can confirm the diagnosis.

FIGURE 7.78

Abdominal Wall Hematoma. This 50-year-old man with chronic obstructive pulmonary disease developed right lower quadrant pain after an episode of coughing. A repeat examination on the second visit showed clearly visible ecchymosis. There was no coagulopathy, and amylase was normal. A CT scan revealed a 10- by 8-cm hematoma in the right rectus abdominis sheath. (Photo contributor: Stephen W. Corbett, MD.)

FIGURE 7.79

Rectus Abdominis Hematoma. Periumbilical ecchymoses after a coughing episode while on apixaban resulting in rectus abdominis hematoma. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 7.80

Rectus Abdominis Hematoma—CT. Axial slice of contrast-enhanced CT in a patient with a left rectus abdominis hematoma. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 7.81

Abdominal Wall Hematoma. A 60-year-old woman, who was a restrained passenger in a motor vehicle crash, has an expanding abdominal wall hematoma. Contrasted CT scan of the abdomen (Figure 7.82) reveals contrast extravasation into the hematoma. (Photo contributor: Lawrence B. Stack, MD.)

Major traumatic force, especially when belted in a vehicle crash, may result in a massive abdominal wall hematoma that requires intervention. Active extravasation, demonstrated by a contrast blush within the hematoma, suggests active bleeding within the hematoma.

Management and Disposition

Assuming that there is no underlying blood dyscrasia or coagulopathy, hematomas of the rectus sheath usually resolve in 1 to 2 weeks. Expanding abdominal wall hematomas with active extravasation of blood may require embolization by interventional radiology.

Pearls

  1. Fothergill sign is enhancement of a rectus sheath hematoma when the abdominal wall is tensed. The mass should not cross the midline and should be easier to palpate with abdominal muscle contractions. Intra-abdominal masses are more difficult to palpate with such contractions.

  2. Carnett sign is also assessed after the abdominal wall muscles are tensed; decreased pain suggests an intra-abdominal source, whereas increased pain suggests an abdominal wall source.

FIGURE 7.82

CT of Abdominal Wall Hematoma. Contrast-enhanced CT of the patient in Fig. 7.81 demonstrates active extravasation of contrast (arrow) into the hematoma. Embolization of the hematoma ceased the hemorrhage. (Photo contributor: Lawrence B. ...

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