Rectus sheath hematoma (RSH) is an uncommon cause of acute abdominal pain, accounting for less than 2% of cases. It arises from rupture of the superior or inferior epigastric vessels or a direct tear of the rectus muscle. Risk factors include anticoagulation therapy, advanced age, comorbidities, trauma, and vigorous abdominal wall activity. Although mortality is generally low, it can increase significantly in anticoagulated patients, emphasizing the need for prompt recognition. A woman in her mid-40s presented with right-sided abdominal pain and a one-week history of cough. She denied recent trauma, gastrointestinal symptoms, or other systemic complaints. On examination, localized tenderness was observed in the right lower and middle abdominal quadrants. Laboratory investigations revealed leukocytosis and anemia, and computed tomography of the abdomen confirmed a rectus sheath hematoma. The patient was hemodynamically stable and managed conservatively with intravenous fluids, analgesics, close monitoring, and bed rest, resulting in progressive clinical improvement without surgical intervention. Most RSH cases are self-limiting and resolve within 2-3 months. Imaging, particularly CT, is essential for accurate diagnosis and assessment of hematoma size, location, and extension. Conservative management remains the first-line approach, while evidence-based perioperative strategies, such as rectus sheath blocks, may optimize pain control and reduce complications, ensuring favorable patient outcomes.

Rectus sheath hematoma, Acute abdominal pain, Anticoagulation, Conservative management, Computed tomography.

Rectus sheath hematoma (RSH) is an uncommon cause of acute abdominal pain, resulting from bleeding into the rectus sheath due to epigastric vessel rupture or muscle tear. Although recognized since antiquity, it remains frequently misdiagnosed, accounting for less than 2% of acute abdominal pain presentations. Awareness is vital, as RSH may lead to unnecessary laparotomy or even mortality, particularly in anticoagulated patients. RSH has a reported incidence of about 1.8% among patients with abdominal pain. Mortality is generally low (1-4%) but can rise to 25% in anticoagulated individuals. It is more common in women (2-3:1), often linked to lower muscle mass and pregnancy. Risk increases with age, comorbidities, and anticoagulant use. Key risk factors include abdominal trauma, surgery, anticoagulation therapy, vigorous coughing or straining, pregnancy, and systemic conditions such as hypertension or vasculitis.[1]

Typical presentation includes acute abdominal pain, a palpable mass, tenderness, and sometimes guarding. Carnett’s and Fothergill’s signs help distinguish abdominal wall pathology from intra-abdominal causes. Severe cases may lead to hypovolemia or complications such as abdominal compartment syndrome.[2]

Laboratory findings are nonspecific, but serial hematocrit monitoring aids management. Imaging is central: ultrasonography is a rapid first-line tool but has limited specificity, while CT offers nearly 100% sensitivity and specificity, defining size, location, and extent. CT-based classification (Types I–III) correlates with severity and guides management. MRI has a limited role, mainly for chronic hematomas.[3]

A woman in her mid-40s presented to the clinic with a primary complaint of abdominal pain that had persisted for the past two days, accompanied by a cough lasting approximately one week. She explicitly denied experiencing any recent trauma or injury, shortness of breath, chest pain, nausea, vomiting, or any additional symptoms. Her medical history is notable for hypertension and hypothyroidism, which are currently managed.

On physical examination, her vital signs were within normal limits, indicating hemodynamic stability. The general physical examination was largely unremarkable, except for localized tenderness and a sense of fullness in the right lower quadrant and right middle regions of the abdomen.

Laboratory investigations revealed a leukocytosis, with an elevated white blood cell count, suggestive of a possible inflammatory or infectious process, along with a reduced red blood cell count, indicating anemia. To further evaluate the underlying cause of her abdominal symptoms, a computed tomography (CT) scan of the abdomen was performed.

Initial management includes pain relief, hydration, and continued monitoring of vitals. Further investigations, such as CT abdomen, urinalysis, liver and renal function tests, and inflammatory markers, help guide diagnosis. Based on CT findings, treatment may involve antibiotics for infection, surgical consultation for appendicitis or abscess, or symptomatic care if no structural cause is found. Her hypertension and hypothyroidism should continue to be managed, and anemia should be investigated for possible nutritional deficiency or chronic blood loss. Most patients experience a full recovery without complications, as the hematoma is gradually reabsorbed over a period of two to three months.

RSH is a rare but important cause of acute abdominal pain, often misdiagnosed, especially in anticoagulated or high-risk patients. Clinical presentation includes localized pain, palpable mass, and tenderness, with imaging, particularly CT, being crucial for diagnosis and classification. Most cases are self-limiting and respond well to conservative management, including fluids, analgesia, monitoring, and bed rest, avoiding unnecessary surgery and ensuring favorable outcomes.

A prospective, randomized trial in Finland that evaluated 57 patients undergoing midline laparotomy, comparing control with three rectus sheath block (RSB) regimens: single-dose, repeated-dose, or continuous infusion. Opioid use, pain scores, satisfaction, and plasma drug concentrations were assessed. Repeated-dose RSB reduced oxycodone use within 12-48 h, improved pain scores at rest and with coughing, and yielded higher patient satisfaction versus control. Plasma oxycodone levels were similar across groups, and levobupivacaine concentrations remained within safe limits. No serious adverse events occurred. Overall, repeated-dose RSB showed opioid-sparing benefits and superior pain relief, suggesting it as a valuable strategy post-laparotomy.[4]

A randomized clinical trial of 63 women undergoing elective cesarean section compared tranexamic acid–soaked gelatin sponges (Group 1), plain sponges (Group 2), and no sponges (Group 3). Postoperative outcomes included hemoglobin (Hb), hematocrit (HCT), estimated blood loss (EBL), and drain output. Group 1 had significantly higher Hb (10.66 vs. 9.77 g/dL, P = 0.009) and HCT (31.87% vs. 28.54%, P = 0.001) than Group 2, with lower EBL versus Groups 2 and 3 (P = 0.003, P = 0.040). Drain output was also reduced compared to Group 3 (P = 0.004). Tranexamic acid–soaked sponges safely reduced postoperative blood loss and drainage.[5]

A randomized, blinded trial compared wound infiltration (WI) and ultrasound-guided rectus sheath block (USGRSB) in 40 children undergoing umbilical hernia repair. WI (n = 20) received 1 mg·kg⁻¹ 0.25% bupivacaine, while USGRSB (n = 20) received 0.5 mg·kg⁻¹ per side. Patients in the WI group had twice the risk of requiring morphine (HR 2.06, 95% CI 1.01–4.20, P = 0.05). Time to first morphine dose was longer with USGRSB (65.5 vs. 47.5 min, P = 0.049). Peak plasma bupivacaine was higher and later with USGRSB, but remained safe. USGRSB provided superior analgesia; larger doses should be avoided.[6]

RSH is a rare but significant cause of acute abdominal pain, especially in patients with risk factors like anticoagulation, trauma, surgery, pregnancy, or vigorous abdominal activity. Most cases resolve with conservative management, including fluids, analgesia, monitoring, and bed rest. CT imaging is essential for diagnosis, evaluating hematoma size, and differentiating from other abdominal conditions. Perioperative strategies such as repeated-dose rectus sheath blocks, tranexamic acid–soaked sponges, and ultrasound-guided blocks enhance pain control, reduce opioid use, and limit blood loss. Early recognition, conservative care, and targeted interventions together optimize outcomes and prevent complications.

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Corresponding Author:
Samatha Ampeti
Independent Researcher
Department of Content, medtigo India Pvt Ltd, Pune, India
Email: ampetisamatha9@gmail.com

Co-Authors:
Mansi Srivastava, Raziya Begum Sheikh, Patel Nirali Kirankumar
Independent Researcher
Department of Content, medtigo India Pvt Ltd, Pune, India

Brady Pregerson
Department of Emergency Medicine
Creator of EMresource.org and EM1minuteconsult.com, Los Angeles, California

All patient-related data were collected by Dr. Brady Pregerson. Dr. Samatha Ampeti, Mansi Srivastava, Raziya Begum Sheikh, and Patel Nirali Kirankumar contributed to the writing of the manuscript, including the original draft preparation and subsequent review and editing to refine the final version.

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This case report is based on a clinical case published in the “Cases” section of medtigo.com. The authors declare no conflicts of interest related to this publication.

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https://doi.org/10.63096/medtigo3092243

Mansi S, Samatha A, Raziya BS, Patel NK, Pregerson B. Rectus Sheath Hematoma in Adults: Diagnosis and Conservative Care. medtigo J Emerg Med. 2025;2(4):e3092243. doi:10.63096/medtigo3092243 Crossref