A 27 y.o. female presents with RLQ pain. The US appears below.

 What is the differential

What is the differential

Our patient had been doing sit-ups on an incline and suffered a rectus sheath hematoma.  Her initial Her hemoglobin was 11 which dropped to 8 when she arrived in our ED. 

The rectus muscles attached to the ventral aspect of the 5,6,7 costal cartilages and extend to the superior pubic ramus.  The arcuate line is located 5 cm below the umbilicus and separates the rectus muscles into upper and lower sections.  The upper section has three or four transverse tendinous insertions attaching the muscle to the under lying fascia, creating the “six pack” seen in body builders.

During contractions of the rectus muscle, the length of the muscle changes and the superior and inferior epigastric arteries must glide with the muscle.  The arteries themselves are loosely attached and move easily but their branches are more fixed and shear stress is created during contraction of the muscle.  This is the area most likely to tear.

Rectus muscle hematomas may have a positive Carnett’s sign.  This was first described in 1926 by John Carnett.  When the muscles of the abdominal wall are tensed by asking the patient to lift the head and shoulders from the bed; pain is worsened with abdominal wall pathology.  The test will be positive with hernias, nerve entrapment syndrome, and irritation of intercostal nerve roots.

The treatment of rectus hematomas is almost always conservative.   Our patient was transfused and watched.  She was seen several months later still complaining of abdominal pain although it had improved.  This is the usual course of rectus sheath hematomas with resolution occurring over 2-3 months.  Clinical pearl: consider the rectus sheath hematoma in patients with abdominal pain.

 

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Gray DW, Dixon JM. Seabrook G, Collin J. Is abd wall tenderness a useful sign in the diagnosis of non-specific abdominal pain? Ann R Coll Surg Engl. 1988.  70(4):233-4.

Fitzgerald JEF, fitzgerald LA, Anderson FE, Acheson AG The changing nature of rectus sheath haematoma: case series and literature review.  International Journal of Surgery 2009. 7 (2) 150-54.