Letters to the Editor - November 15, 2001 - American Family Physician

Letters to the Editor

Rectus Sheath Hematoma as a Cause of Acute Abdominal Pain

TO THE EDITOR: Rectus sheath hematoma is an uncommon cause of acute abdominal pain. It may occur as a result of direct trauma, spontaneously, or as a result of twisting or abrupt changes in position.¹ Other precipitating factors include anticoagulation, recent surgery, medication injection, or increased intra-abdominal pressure from coughing or pregnancy.¹ Rectus sheath hematoma has been previously described in a patient receiving enoxaparin at 30 mg subcutaneously every 12 hours.¹ We report the case of a patient who developed rectus sheath hematoma during treatment with enoxaparin, 70 mg subcutaneously every 12 hours, and in whom bleeding was controlled through coil embolization of the inferior epigastric artery.

A 75-year-old woman was admitted to the hospital for pneumonia and new-onset atrial fibrillation. In addition to antibiotics, the patient was placed on enoxaparin, 70 mg subcutaneously every 12 hours. On the second day after admission, the patient complained of a sudden onset of right lower quadrant abdominal pain followed by evidence of hypovolemic shock. Laboratory studies revealed a 3 g per dL drop in the hemoglobin concentration. Physical examination revealed a palpable, firm, tender, nonmobile 5 3 6 cm right lower quadrant abdominal mass. Abdominal ultrasound confirmed an 18 3 9 3 16 cm rectus sheath cystic mass. There was a small previous injection site near the center of the hematoma. A computed tomographic scan of the abdomen performed three hours later showed a 21 3 14 3 8 cm hematoma expanding in the lower half of the right rectus sheath (see the accompanying figure).

FIGURE . Computed tomographic scan of the abdomen revealing hematoma expanding in the lower half of the right rectus sheath.

The patient was resuscitated with intravenous fluids, fresh frozen plasma, packed red blood cells, crystalloids, and protamine sulfate. Aortoiliac and pelvic arteriography with superselective catheterization showed bleeding emanating from two small collaterals from the right inferior epigastric artery. Bleeding was stopped through embolization with two tornado coils in the right inferior epigastric artery. The patient made a gradual and full clinical recovery.

Low-molecular-weight heparin (LMWH) offers several advantages when compared with unfractionated heparin (UH), including improved bioavailability, ease of administration, lack of required monitoring, and a decreased incidence of heparin-induced thrombocytopenia. In most clinical circumstances, the risk of bleeding appears to be comparable with that of UH.²

LMWH has an equal or improved efficacy to that of UH in prophylaxis against venous thromboembolism and in the treatment of patients with venous thromboembolism and unstable angina.^2,3

Results of a small prospective study in patients with atrial fibrillation showed that LMWH was an effective alternative for providing anticoagulation.⁴ Protamine sulfate was administered because of the persistent bleeding despite the fact that it incompletely reverses antifactor Xa activity produced by LMWH. LMWH has some disadvantages as opposed to unfractionated heparin. First, it is difficult to obtain a prompt and accurate assessment of the degree of anticoagulation that has been induced with LMWH. Second, the anticoagulant effect of LMWH is more difficult to reverse promptly because of its administration into the subcutaneous tissue and a longer biologic half-life.

We believe that the patient's coughing, anticoagulation, and possible needle puncture of the inferior epigastric artery contributed to the hematoma. Awareness of this rare clinical entity is important in the differential diagnosis of acute abdominal pain. The majority of patients with rectus sheath hematoma are treated conservatively. Catheter embolization offers a suitable alternative to surgical management in cases in which the hematoma continues to expand.

SALLY J. HOLMES, D.O.
STEVEN H. YALE, M.D.
JOSEPH J. MAZZA, M.D.
Marshfield Clinic
1000 North Oak Ave.
Marshfield, WI 54449

REFERENCES

Edlow JA, Juang P, Margulies S, Burstein J. Rectus sheath hematoma. Ann Emerg Med 1999;34:671-5.

Huang JN, Shimamura A. Low-molecular-weight heparin. Hematol Oncol Clin North Am 1998;12: 1251-81.

Weitz JI. Low-molecular-weight heparins. N Engl J Med 1997;337:688-98.

Harenberg J, Huhle G, Piazolo L, Giese C, Heene DL. Long-term anticoagulation of outpatients with adverse events to oral anticoagulants using low-molecular-weight heparin. Semin Thromb Hemost 1997;23:167-72.

Clarification

The article "Diagnosis and Management of Malignant Melanoma" (April 1, 2001, page 1359) requires some clarifications. The article states on page 1363 in the third line of the right-hand column that pruritus, ulceration and bleeding in a mole are common early warning symptoms of melanoma. This sentence should have been stated as follows: "Pruritus, ulceration and bleeding in a mole are warning symptoms." Although pruritus may represent an early warning sign of melanoma, ulceration and bleeding tend to occur later in the course of disease and should not be relied on in making an early diagnosis of melanoma. Any suspicious or changing mole should be considered for early biopsy.

In the section on melanoma and pregnancy, on page 1367, the opening sentence of the final paragraph states that, until recently, women with a history of melanoma were discouraged from becoming pregnant for two years. Instead, that statement should read as follows: "Until recently, women with a history of melanoma were discouraged by physicians from becoming pregnant. Currently, women with a history of melanoma are counseled to avoid pregnancy for two years after diagnosis, because that is the period during which the risk of recurrence is greatest." In the past, doctors discouraged women with a history of melanoma from ever becoming pregnant because of the possibility that estrogen would negatively affect melanoma prognosis. Currently, this restriction applies only to women who have had a melanoma with a significant probability of recurrence or metastasis.¹

Table 1 on page 1360 contains an error. The heading for the second column should not include the percent sign since the values given represent relative risk. Also, the final paragraph on page 1360 refers the reader to Figure 1, which illustrates a small congenital nevus, while the text refers to giant congenital nevi.

The attributions for some of the figures were incorrect. Figures 1 and 7 were used with permission from the Department of Dermatology, University of North Carolina at Chapel Hill. Figure 4 was used with permission of John Cook, M.D., Aiken, S.C. Figure 6 was used with permission of the Department of Dermatology, Medical College of Georgia, Augusta. Figure 8 was used with permission from Goldstein BG, Goldstein AO. Practical dermatology. 2d ed. St. Louis: Mosby, 1997:146.

REFERENCES

MacKie RM. Pregnancy and exogenous female sex hormones in melanoma patients. In: Balch CM, Houghton AN, Sober AJ, Song S, eds. Cutaneous melanoma. 3d ed. St. Louis: Quality Medical, 1998:187-93.

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The editors of AFP welcome input concerning topics of current medical interest and feedback in response to articles and other material published in AFP. Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Letters submitted for publication in AFP must not be submitted to any other publication. Letters pertaining to AFP subject matter must be received within two months of publication. Any financial associations or other possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors reserve the right to edit correspondence to meet style and space requirements.

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