Hospital: Hospital Universitario de Badajoz.
Nº: C2019-728
Aut@r o Autores: C. Gil Perea, P. Fernández Tejado, S. Fernández Gomez, M. Relaño, G. Rueda Monago, R. Martínez Sanchez.
Presentación
A 70 year old man presented to the Emergency Department with complaints of abdominal pain, nausea and an abdominal mass in the left upper quadrant. He had a history of congestive hearth failure , cronic atrial fibrillation and chronic obstructive lung disease. The patient had been taking Acenocumarol.Physical examination revealed a large mass in the left upper quadrant of the abdomen extending to the lower abdomen.Mean arterial pressure was 970/70 mmHg, pulse rate was 70/min, hemoglobin level 7.4 g/dL, hematocrit 23 %, platelet 202000/UL, prothrombin time (PT) 61 sec and international normalized ratio (INR) 1.43. The other biochemical tests were normal.Computerized tomography (CT) showed a hematoma on the left side ( red arrow) of abdominal wall with lateral muscles extension ( green arrow) , normal abdominal wall on the rigth ( blue arrow) and active contrast arterial extravasation (purple arrow) .After analgesic treatment , intravenous fluid replacement, 3 units of erythrocyte transfusion 2 units of fresh frozen plasma and vitamin K, complete blood celll revealed a decrease in the hemoglobin leves. The patient was referred to our interventional radiology section and we realized a selective catheterization of the left inferior epigastric artery and subsequently embolize with glue (picture C and D) . He was discharged from the hospital on the 7th day of admission.
Discusión
Rectus sheath haematoma (RSH) is a rare but a dangerous complication in anticoagulated patients. Acute abdominal pain and no pulsatil and firm abdominal mass are typical clinical manifestations. The anticoagulant is the principal risk factors. Radiographic diagnostic could be realized by two main imaging modalities : ultrasound and CT . Commonly used CT as the first diagnostic tool in no painful abdominal mass in patients with risk factors because it is more sensitive and specific than US. It shows haematoma confined to the abdominal wall or with intraabdominal extension. Additionally contrast extravasation on arterial phase of CT-Angio is the commonest sign . Conservative mangement is the therapy for rectus steath hematoma if the lesion is self-limited. On the other hand, embolization of the inferior epigastric artery is an effective minimally invasive treatment useful in patients with unsuccessful conservative treatment. (Fig C and D).
Conclusión
RSH is a rare but a dangerous complication in anticoagulated patients. Keep in mind than US is not as sensitive as CT. Accurate diagnosis with directed history, physical examination and CT or CT Angio followed by endovascular embolisation help to decrease unnecessary laparotomy.
Bibliografía
- Galyfos G, Karantzikos G, Palogos K, et al. Spontaneous Rectus Sheath Hematoma in the Elderly: An Unusual Case and Update on Proper Management. Case Rep Emerg Med. 2014,2014:675–678Sullivan LEJ, - Mendoza Moreno F, Díez Alonso M, Villeta Plaza