Abstract | November 18, 2023
Strenuous Cough Causing Bilateral Rectus Sheath Hematoma Secondary to Warfarin Coagulopathy
Learning Objectives
- Identify the life-threatening causes of acute abdominal pain when patients present to the Emergency Department.
- Discuss in detail with the patient the past medical history, medications and recent surgeries they have had.
- Diagnose rectus sheath hematoma in a patient that presents with acute abdominal pain.
Introduction:
Rectus sheath hematoma is a rare but important cause of abdominal pain. It should be always on the differential when patients present with acute abdominal pain. It typically occurs after bouts of coughing, but it is usually unilateral on presentation. It is a known complication of anticoagulation therapy and combined with the patient’s initial presentation, it can be a source of potential morbidity and mortality. Here we present a rare case of bilateral rectus sheath hematoma secondary to Warfarin coagulopathy.
Case presentation:
An 81-year-old male with a PMH of A-fib on Warfarin, HTN, HLD, DM2, bilateral carotid artery stenosis and CAD s/p bypass surgery presented to the hospital with complaints of abdominal pain. The abdominal pain has been present for the past week and had associated loss of appetite. He had presented to the emergency department one day prior with similar complaints of weakness, abdominal pain and coughing that started that same day. At that time, he tested positive for Influenza A and abdomen/pelvis CT was not showing any acute findings to correlate his abdominal pain. He was then discharged home on antibiotics after being diagnosed with pneumonia 2/2 Influenza A infection. He then returned to the ED the next day with complaints of worsening rib pain. On physical exam, he was hypotensive and tachycardic, but was otherwise normal. Labs also demonstrated acute anemia with a hemoglobin drop from 13.4 to 10.4, points. INR showed supratherapeutic levels at 7.7. Repeat CT of the abdomen at that time demonstrated a bilateral rectus sheath hematoma with active extravasation. All the findings together suggested acute blood loss anemia due to findings on CT scan.
Final diagnosis:
Bilateral rectus sheath hematoma with active extravasation and acute blood loss anemia secondary to Warfarin coagulopathy
Management/Follow-up:
Interventional Radiology was consulted and the patient underwent bilateral inferior epigastric artery embolization that same day. He also received Prothrombin complex concentrate and vitamin K for reversal of warfarin. INR eventually went down to 0.97. His hemoglobin and INR were monitored closely in the hospital for several days until normalization.
References and Resources
- Titone C Lipsius M Krakauer JS . ‘Spontaneous’ hematoma of the rectus abdominis muscle: critical review of 50 cases with emphasis on early diagnosis and treatment. Surgery 1972; 72: 568–572.
- Cherry WB, Mueller PS. Rectus sheath hematoma: review of 126 cases at a single institution. Medicine (Baltimore). 2006; 85: 105–110.
- Branera J. Percutaneous arterial embolization in the management of rectus sheath hematoma. Am J Roentgenol. 2007; 188: W497–W502.
