title: Diagnostic and management of spontaneous rectus sheath hematoma.
abstract: 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.
authors.affiliation: Emergency Department, Fundació Hospital de l'Esperit Sant, Santa Coloma de Gramenet, Spain. asa30412@hotmail.com
authors.forename: Alex
authors.initials: A
authors.lastname: Smithson
authors.forename: Jessica
authors.initials: J
authors.lastname: Ruiz
authors.forename: Rafael
authors.initials: R
authors.lastname: Perello
authors.forename: Marta
authors.initials: M
authors.lastname: Valverde
authors.forename: Javier
authors.initials: J
authors.lastname: Ramos
authors.forename: Luïsa
authors.initials: L
authors.lastname: Garzo
mesh_terms: D015746:Abdominal Pain / Q000209:etiology; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects*; D015331:Cohort Studies; D004621:Embolization, Therapeutic; D019074:Epigastric Arteries; D005260:Female; D006406:Hematoma / Q000150:complications / Q000175:diagnosis* / Q000628:therapy; D006801:Humans; D006973:Hypertension / Q000150:complications; D008297:Male; D008875:Middle Aged; D017568:Rectus Abdominis / Q000000981:diagnostic imaging; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014463:Ultrasonography
chemical_list: D000925:Anticoagulants
keywords: Abdominal pain; Embolization; Rectus sheath hematoma; Spontaneous