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Rectus Sheath Hematoma

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Rectus Sheath Hematoma

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    1. Rectus Sheath Hematoma

    11. Dx: Rectus sheath hematoma

    12. Rectus Sheath Hematomas First case reported in US by Richardson in 1857 1999 Klinger found incidence of 1.8% in 1257 pts admitted to hospital w/ abd pain who had an abdominal U/S Richardson SB: Rupture of the right rectus abdominis muscle from muscular efforts: operation and recovery, with remarks. Am J Med Sci 1857; 33: 41-5 Klingler PJ, Wetscher G, Glaser K, et al: The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders. Surg Endosc 1999 Nov; 13(11): 1129-34

    14. Arcuate line ~ 5cm below umbilicus; Below arcuate line only transversalis fascia and peritoneum

    15. Pathophysiology Rupture of one of the epigastric vessels -which run posteriorly on recti Rectus tear w/ shearing of sm vessel Causes: trauma, surgery, strenuated exercise or repeated valsalva (coughing/striaining for stool)

    16. Risk Factors Anticoagulation Surgery Trauma Coughing Pregnancy (labor/postpartum) Medical conditions Leukemia, blood dyscrasias etc

    17. Presentation non-specific Dx is in the history & high level of suspicion

    18. Imaging Ultrasound - 85% sensitivity; pregnancy CT - 100% sensitive / 100% specific in RSH < 5days old Type I - intramuscular; homogenous Type II - may be bilateral; HCT drop Type III -intra-peritoneal; layering (HCT effect)

    19. Berna JD, Zuazu I, Madrigal M, et al: Conservative treatment of large rectus sheath hematoma in patients undergoing anticoagulant therapy. Abdom Imaging 2000 May-Jun; 25(3) MRI - diff. chronic RSH from abd wall masses Angiography - may be both diagnostic / therapeutic Bleeding scan

    20. U/S

    21. Type II

    22. Type III

    23. Management Identify etiology / address Medical / Conservative mgmt Most commonly from anticoagulation: stop A/C correct coagulopathy PRBCs, FFP, Vit K

    24. Mgmt cont. IR - angio --> embolization of bleeding vessel (Levy 1980 - gelfoam) Surgical - clot evacuation; ligation of vessels; leave drain Levy JM, Gordon HW, Pitha NR, Nykamp PW: Gelfoam embolization for control of bleeding from rectus sheath hematoma. Am J Roentgenol 1980 Dec; 135(6): 1283

    25. Zainea GG, Jordan F: Rectus sheath hematomas: their pathogenesis, diagnosis, and management. Am Surg 1988 Oct; 54(10): 630 N = 8 (9 yrs) 4 clinically dx & 4 dx in OR Retrospective study Conservative therapy

    26. Berna JD, Zuazu I, Madrigal M, et al: Conservative treatment of large rectus sheath hematoma in patients undergoing anticoagulant therapy. Abdom Imaging 2000 May-Jun; 25(3) N = 12 (retrospective - 8yrs) Coumadin = 7, Heparin gtt = 3, SQH = 2 U/S dx in 9/12; while Ct in 12/12 type III hematomas - reqd PRBCs All cases managed conservatively

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