Description

A 64-year-old Caucasian man with a history of smoking, chronic obstructive pulmonary disease (COPD), hypertension and diabetes mellitus presented with increasing shortness of breath and cough. While being treated for COPD exacerbation, he developed atrial fibrillation with rapid ventricular response. Treatment with intravenous diltiazem was started. Serum electrolyte levels, two-dimensional echocardiogram and thyroid function tests were normal. Antiplatelet therapy with subcutaneous enoxaparin was initiated. After the first dose, he complained of gradually worsening lower abdominal pain. A complete blood count showed decreased haemoglobin and coagulation studies was normal. He gradually developed a small swelling in the right supra-pubic area, which was tender to palpation. Both Fothergill and Carnett's signs were positive. An abdominal ultrasonogram showed a 14.4 × 4.7 × 5.5 cm cystic mass with fluid levels in the right lower quadrant of the rectus sheath (figure 1, arrow). Enoxaparin was stopped and he was treated conservatively. A follow-up CT scan of the abdomen showed a right rectus sheath haematoma (RSH; figure 2, asterisk).

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Figure 1

An ultrasonogram of the anterior abdominal wall.

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Figure 2

A CT scan of the abdomen.

RSH results from bleeding into the rectus sheath, frequently due to anticoagulation. Clinical examination helps to differentiate between abdominal wall and retroperitoneal haematoma.1 Ultrasonography is 85–96% and CT scan is 100% sensitive in diagnosing RSH. RSH is usually managed conservatively but surgical intervention is warranted if the patient is unstable or conservative treatment fails.2