Article

Rectus sheath haematoma: A rare presentation of non-contact strenuous exercises

Department of Surgery, Whiston Hospital, Prescot, Merseyside, UK.
British Journal of Sports Medicine (Impact Factor: 5.03). 11/2007; 41(10):688-90. DOI: 10.1136/bjsm.2007.036087
Source: PubMed

ABSTRACT

Rectus sheath haematoma (RSH) is a well-documented but uncommon clinical condition. It is usually a self-limiting condition but can present as a life-threatening emergency. RSH after non-contact vigorous exercise is unknown. Two such cases secondary to yoga and laughter therapy sessions, respectively, are reported. One of them required surgical intervention, whereas the other was successfully treated conservatively.

SHORT REPORT
Rectus sheath haematoma: a rare presentation of non-contact
strenuous exercises
Hemant Sharma, Narayan Singh Shekhawat, Sudhir Bhandari, Breda Memon, Muhammed Ashraf
Memon
...................................................................................................................................
Br J Sports Med 2007;41:688–690. doi: 10.1136/bjsm.2007.036087
Rectus sheath haematoma (RSH) is a well-documented but
uncommon clinical condition. It is usually a self-limiting condition
but can present as a life-threatening emergency. RSH after non-
contact vigorous exercise is unknown. Two such cases secondary
to yoga and laughter therapy sessions, respectively, are reported.
One of them required surgical intervention, whereas the other was
successfully treated conservatively.
R
ectus sheath haematoma (RSH) is an uncommon but well-
documented clinical entity.
12
It results from haemorrhage
into the rectus muscle due to rupture of the superior or
inferior epigastric arteries, their branches or a tear of the rectus
abdominis muscle.
13
It is a known complication of abdominal
trauma and anticoagulation.
1–7
Other rare associations include
exertion, pregnancy, insulin injection, paroxysmal coughing
and abdominal surgery.
245
RSH is often misdiagnosed and can
mimic various intra-abdominal diseases.
346
Although it is
generally self-limiting, it can cause life-threatening clinical
conditions such as hypovolaemic shock, leading to morbidity
and mortality.
137
Abdominal wall injuries are rarely reported
but more often perceived by sports medicine practitioners.
8
We
present two unique non-contact sport-related presentations of
RSH, one after yoga and the other as a consequence of laughter
therapy exercises. RSH secondary to these conditions has not
been reported in the English literature to our knowledge.
CASE REPORTS
Case 1
A 61-year-old woman presented to the accident and emergency
department with severe, lower abdominal pain and abdominal
distension. She had attended a pranayama session of a yoga
course nearly 6 hours before and had to stop in between owing
to abdominal discomfort. She had a past history of hyperten-
sion and was taking bendrofluazide and aspirin. On admission
she was hypotensive with a blood pressure of 84/46 mm Hg,
and tachycardic with a heart rate of 128 beats/min. The ECG
showed sinus tachycardia. She was actively resuscitated with
intravenous crystalloids, catheterised and given adequate
analgesia. Abdominal examination disclosed generalised peri-
tonitis and a smooth tender mass over the left iliac fossa
extending up to the midline (fig 1). Routine blood tests showed
low haemoglobin 84 g/l. Her clotting test, however, showed a
slightly raised international normalised ratio of 1.6 and
activated partial thromboplastin time of 32 seconds. She was
transfused with 2 units of whole blood and an urgent CT scan
of the abdomen was performed. This showed an RSH
1061268 cm in size over the left lower quadrant of the
abdomen (fig 2). Despite blood transfusion, her blood pressure
dropped further and therefore an emergency surgical explora-
tion was undertaken. A large RSH consisting of about 750 ml of
dark blood with clots was drained and the actively bleeding left
inferior epigastric artery was ligated. The patient recovered well
and was discharged home on the fourth postoperative day.
Case 2
A 67-year-old woman presented to the accident and emergency
department with gradually worsening pain in the left lower
quadrant over the past 3 days. She had been attending laughter
therapy sessions for the past month after reading about it in a
Figure 1 Abdominal distension in case 1.
Figure 2 CT scan of abdomen in case 1 showing a rectus sheath
haematoma.
688
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Page 1
health and sport magazine. The last session was 3 days before
developing niggling pain over the left lower quadrant. She was
otherwise healthy and was taking prophylactic aspirin pre-
scribed by her family physician. At presentation, her blood
pressure was 128/76 mm Hg and her heart rate 86 beats/min.
Abdominal examination disclosed an ill-defined tender mass in
the left iliac fossa with localised peritonism. All her routine
blood tests were normal. A CT scan of the abdomen showed an
RSH of 106665 cm size (fig 3). Because the patient was stable,
she was treated with analgesia and was discharged home.
Subsequent review in the outpatient clinic showed complete
resolution of her left lower quadrant mass.
DISCUSSION
RSH is more common in women,
1
probably owing to lean rectus
muscle mass in comparison with men. This leads to a greater
likelihood of bleeding in response to trivial abdominal wall
trauma. Anticoagulation and trauma are the two most common
predisposing factors in its development.
1–7
None of the patients
in the present report were receiving anticoagulants and their
clotting profile was normal. However, both these patients were
taking a small dose of aspirin, which might have aggravated
bleeding because of platelet dysfunction.
Severe abdominal wall injury due to strenuous exercises is
rare.
8
Pranayama is a special exercise in yoga. It is done with
continuous actions of inhaling and exhaling air, keeping the
abdomen taut and relaxed alternately
9
(fig 4). Laughter therapy
sessions involve forced laughing for abdominal exercise and
stress management. Forced laughing raises transdiaphragmatic
pressure
10
and as a result there is an increase in abdominal
pressure. Thus the plausible explanation for RSH in the present
report is vigorous abdominal contractions in Pranayama and
laughter therapy exercises.
Abdominal pain and abdominal mass not only occur in RSH
but also in numerous intra-abdominal emergencies. RSH is
therefore often misdiagnosed.
1–7
The absence of any pathogno-
monic features renders imaging modalities as the sole non-
invasive alternative for the diagnosis of this condition.
Although ultrasound, CT and magnetic resonance imaging of
the abdomen have been used for diagnosis of RSH, a CT scan is
the preferred radiological modality.
1457
Both our patients were
correctly diagnosed with a CT scan. Stable patients should be
managed conservatively, but unstable patients will require
active resuscitation and surgical control of bleeding if further
deterioration occurs.
13
CONCLUSION
Strenuous abdominal exercises may lead to RSH. Clinicians
therefore need to be aware of this complication after
Figure 3 CT scan of abdomen in case 2 showing rectus sheath
haematoma.
Figure 4 Pranayama technique of yoga.
What is already known on this topic
N
It is an uncommon cause of abdominal pain which is
often misdiagnosed
N
It occurs because of bleeding into the rectus sheath from
damage to the superior or inferior epigastric arteries or
their branches or from rectus muscle tear.
N
A number of risk factors have been identified and include
anticoagulant treatment, vigorous coughing, contact sports,
pregnancy, abdominal surgery, abdominal wall trauma,
vigorous rectus muscle contractions, and certain medical
conditions such as leukaemia and blood disorders.
N
Ultrasound scan and CT are the two best imaging
modalities for an accurate diagnosis.
N
The patient’s clinical condition determines the type of
treatment. For a haemodynamically stable patient,
treatment of the primary cause together with conservative
management is appropriate. Emergency radiologically
guided embolisation or surgery is reserved for those
patients who are haemodynamically unstable and
unresponsive to initial fluid resuscitation.
What this study adds
N
Both of our cases occurred in patients taking part in non-
contact sports activities—yoga and laughter therapy—
which has not been described previously.
N
Aspirin treatment might have predisposed our patients to
this uncommon condition.
Rectus sheath haematoma 689
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Page 2
non-contact strenuous exercises such as yoga and laughter
exercises. The clinical condition of the patient dictates the
approach to treatment: conservative or surgical.
Authors’ affiliations
.......................
Narayan Singh Shekhawat, Sudhir Bhandari, Department of Surgery,
Sawai Mansingh Medical College, Jaipur, India
Hemant Sharma, Breda Memon, Muhammed Ashraf Memon, Department
of Surgery, Whiston Hospital, Prescot, Merseyside, UK
Conflict of interest: None declared.
Informed consent was obtained for publication.
Correspondence to: Dr M A Memon, Astley House, Whitehall Road,
Darwen, Lancashire BB3 2LH, UK; mmemon@yahoo.com
Accepted 19 April 2007
Published Online First 11 May 2007
REFERENCES
1 Cherry WB, Mueller PS. Rectus sheath hematoma: review of 126 cases at a single
institution. Medicine (Baltimore) 2006;85:105–10.
2 Maharaj D, Ramdass M, Teelucksingh S, et al. Rectus sheath haematoma: a new
set of diagnostic features. Postgrad Med J 2002;78:755–66.
3 Linhares MM, Lopes Filho GJ, Bruna PC, et al. Spontaneous hematoma of the
rectus abdominis sheath: a review of 177 cases with report of 7 personal cases.
Int Surg 1999;84:251–7.
4 Buckingham R, Dwerryhouse S, Roe A. Rectus sheath haematoma mimicking
splenic enlargement. J R Soc Med 1995;88:334–5.
5 Zainea GG, Jordan F. Rectus sheath hematomas: their pathogenesis, diagnosis,
and management. Am Surg 1988;54:630–3.
6 Dineen RA, Lewis NR, Altaf N. Small bowel infarction complicating rectus sheath
haematoma in an anticoagulated patient. Med Sci Monit 2005;11:57–9.
7 James RF. Rectus sheath haematoma. Lancet 2005;365:1824.
8 Johnson R. Abdominal wall injuries: rectus abdominis strains, oblique strains,
rectus sheath hematoma. Curr Sports Med Rep 2006;5:99–103.
9 Johnson DB, Tierney MJ, Sadighi PJ. Kapalabhati pranayama: breath of fire or
cause of pneumothorax? A case report. Chest 2004;125:1951–2.
10 Filippelli M, Pellegrino R, Iandelli I, et al. Respiratory dynamics during laughter.
J Appl Physiol 2001;90:1441–6.
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690 Sharma, Shekhawat, Bhandari, et al
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