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The Journal of Emergency Medicine, Vol. 41, No. 1, pp. e17–e18, 2011Copyright © 2011 Elsevier Inc.

Printed in the USA. All rights reserved0736-4679/$–see front matter

Letters

to the Editor

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e ACUTE ABDOMINAL PAIN AND WARFARINTHERAPY

e To the Editor:

Rectus sheath hematoma (RSH) is an uncommon causeof acute abdomen and is known to mimic various surgi-cal conditions such as appendicitis, perforated ulcer,intestinal obstruction, or tumor (1–3). Two patients withRSH are reported.

PATIENT 1

n 84-year-old man with a history of diabetes mellitusreated with insulin and receiving warfarin therapy fortrial fibrillation presented with a 1-day history of he-optysis and right-side abdominal pain after a fit of

oughing. Abdominal examination revealed a tendermass of 8 cm, non-pulsatile, in the right lower abdomen.Carnett’s test was positive. Complete blood countshowed a normal white blood cell and platelet count, thehemoglobin level was 14 g/dL, international normalizedratio (INR) was 9, and activated partial thromboplastintime (APTT) was 46 s. Ultrasonography (US) of theabdomen showed an echogenic mass of 8 cm � 6 cm inthe right lower abdomen. Anticoagulation was stopped andtwo units of fresh frozen plasma were transfused. After 10days in the hospital with no further complications, thepatient was discharged on enoxaparin 60 mg daily. Follow-upas an outpatient revealed no further problems, and war-farin therapy was restarted 5 months later.

PATIENT 2

n 85-year-old woman receiving long-term warfarinherapy for atrial fibrillation presented with acute left-ide abdominal pain after a bout of severe coughing.bdominal examination revealed a tender and non-ulsatile mass in the left lower abdomen. Carnett’s testas positive. Complete blood count showed a normalhite blood cell and platelet count, hemoglobin level of.5 g/dL, INR of 4.81, and APTT of 56 s. US of thebdomen showed an echogenic mass of 10 cm � 8 cm in

the left lower abdomen. Anticoagulation was stopped s

e17

and two units of fresh frozen plasma and packed redblood cells were transfused. She was discharged 15 daysafter admittance on enoxaparin 60 mg daily.

An outpatient appointment 6 months later revealedcomplete resolution, and warfarin therapy was restarted.

The major complication of anticoagulant therapy isbleeding. There is a strong and proven relationship betweenthe risk of bleeding and the intensity of anticoagulation.Randomized clinical trials show that high-intensity warfarintherapy (INR � 3.0) doubles the risk of major hemorrhageas compared to warfarin therapy with INR between 2.0 and3.0 (1,2).

Rectus sheath hematoma is usually a self-limiting con-dition, but can present as a life-threatening emergency.RSH results from hemorrhage into the rectus muscle due torupture of the superior or inferior epigastric arteries or theirbranches, or a tear of the rectus abdominis muscle (1). Ages a predisposing factor for RSH. The protection providedy the anatomy of the rectus sheath may be compromisedy decreased muscle and age-related changes from arterio-clerosis, or hypertension may render the vessels moreusceptible to injury (4). Many causes of RSH have been

described in the literature, including anticoagulation therapy(AT), trauma, hematologic disorders, coughing, and spon-taneous without a discernible cause. However, AT is themain risk factor, and the most important precipitating factoris coughing (2–7). The most constant features are abdom-inal pain and a mass on palpation. Carnett’s test helps todifferentiate pain originating from the abdominal wall frompain arising from intra-abdominal disorders. The site ofmaximal abdominal tenderness is palpated while the patientis lying supine. If tenderness increases when the patient sitshalfway up, the test is said to be positive. In RSH, Carnett’stest is positive because the contraction of the rectus musclecompresses the hematoma and worsens the tenderness (1).

he presentation of RSH is more likely to be atypical in thelderly than in younger patients. Abdominal pain may note present. RSH has been reported in elderly patients withhief symptoms of dyspnea, confusion, and urinary reten-ion. US of the abdomen is one of the first-line investiga-ions, with a sensitivity of 80–90%. However, the goldtandard for diagnosis of RSH is computed tomography,ith 100% sensitivity and specificity (5).Management is essentially conservative, with suspen-

ion of AT, fresh frozen plasma, and blood transfusion, if

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e18 Letters to the Editor

needed. Surgery is indicated only for cases that do notrespond to supportive management, with progressive andlarge hematoma, or in uncontrolled hemodynamic patients(2–9). AT must be reintroduced when the hemodynamicstability of the patient has been achieved, with intravenousheparin or low-molecular-weight heparin according to thecoagulation parameters. Warfarin usually is restarted 7–9days after restarting heparin; in our patients, it was delayed5–6 months due to the hematologist’s decision (2). The

orbidity of RSH is primarily the result of incorrect diag-osis leading to unnecessary surgical interventions, delay inessation of anticoagulant therapy, or in fluid resuscitationnd blood transfusion (3,4). RSH is rarely fatal, but oneust be aware of this possibility, especially in frail elderly

atients on chronic anticoagulation therapy or in those withn underlying clotting disorder (9).

Juan Marti, MD

Department of Internal MedicineHospital Zumarraga

Zumarraga, Guipúzcoa, Spain

doi:10.1016/j.jemermed.2009.07.006

REFERENCES

1. Jabr FI. Rectal sheath hematoma in an elderly woman after antico-agulation treatment. J Am Geriatr Soc 2006;54:871–2.

2. Berna JD, Zuazu I, Madrigal M, García-Medina V, Fernández C,Guirado F. Conservative treatment of large rectus sheath hematomain patients undergoing anticoagulant therapy. Abdom Imaging 2000;25:230–4.

3. Cherry WB, Mueller P. Rectus sheath hematoma: review of 126cases at single institution. Medicine 2006;85:105–10.

4. Chang WT, Knight WA IV, Werdehoff SG, Blomkalns AL. Rectussheath hematoma. emedicine from WebMD (Nov 2007). Availableat: http://emedicine.medscape.com/article/776871-overview.

5. Luhmann A, Williams EV. Rectus sheath hematoma: a series ofunfortunate events. World J Surg 2006;30:2050–5.

6. Sharma H, Shekhawat NS, Bhandari S, Memon B, Memon MA.Rectus sheath haematoma: a rare presentation of non-contact stren-uous exercises. Br J Sports Med 2007;41:688–90.

7. Maharaj D, Ramdass M, Teelucksingh S, Perry A, Naraynsingh V.Rectus sheath haematoma: a new set of diagnostic features. PostMed J 2002;78:755–6.

8. Basile A, Garcia Medina J, Mundo E, Garcia Medina V, Leal V.Transcatheter arterial embolization of concurrent spontaneoushematomas of the rectus sheath and psoas muscle in patientsundergoing anticoagulation. Cardiovasc Intervent Radiol 2004;27:658 – 62.

9. Rajagopal AS, Shinkfield M, Voight S, Hamdan K. Massive rectus

sheath hematoma. Am J Surg 2006;191:126–7.