Rectus sheath haematoma

Case contributed by Dr David Preston

Presentation

A 70 year old female transferred from a private facility for investigation of abdominal pain 2 weeks post total knee replacement. On initial examination she was found to have a tense, painful abdomen with guarding. She was referred for surgical review and plain films were obtained.

Patient Data

Age: 70
Gender: Female
X-ray

Initial plain films of chest and abdomen.

Plain films showed increased bowel gas but no evidence of obstruction, constipation, mass or perforation.

CT

The surgical consultant examined the patient and was concerned about a palpable mass, ordered a ct scan.

There is a large haematoma within the left anterior abdominal wall, involving the rectus abdominis, and the internal and external oblique muscles. This measures approximately 9cm x 20.9cm x 16.7cm. This is heterogeneous in attenuation likely due to presence of fibrin and blood products. There is contrast extravasation indicating active bleeding, within the superior abdominal wall (2-32 and 4-12), and within the mid abdominal wall posteriorly (2-46 and 4-22). Stranding is seen surrounding the haematoma.

The multilobulated cystic lesion involving the head and uncinate process of the pancreas appears unchanged in size since last scan, measuring approximately 51mm x 48mm x 52mm. The rest of the pancreas defines normally.

Case Discussion

This lady had no history of bleeding disorders or any family history. She had been started on subcutaneous heparin since her knee operation for DVT prophylaxis and had recently started to self inject into her abdomen. Her haemoglobin dropped to 89 from 125 overnight and was transfused 2 units of packed \rbCs the next day. Her haemoglobin and pain levels stabilised within 3 days and she was transferred back to the private hospital following education on self administration of heparin.
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Case information

rID: 20603
Case created: 29th Nov 2012
Last edited: 9th Feb 2016
Inclusion in quiz mode: Included

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