Imagine you’re just going about your day, maybe bending down to tie your shoe or having a good laugh, and suddenly—ouch! A sharp, surprising pain hits your belly. It’s not just a little twinge; it’s persistent and makes you stop in your tracks. This kind of sudden onset can be quite alarming, and one of the less common culprits we consider, especially if other factors are at play, is something called a rectus sheath hematoma. It’s a bit of a mouthful, I know.
So, What Exactly Is a Rectus Sheath Hematoma?
Alright, let’s break this down. Your tummy, or abdomen, has muscles, right? The main ones running down the front, often called the “six-pack” muscles, are the rectus abdominis muscles. These muscles, along with a smaller one called the pyramidalis, are wrapped in a tough, fibrous casing called the rectus sheath. Think of it like a protective sleeve. This sheath has a front and back wall and also houses important blood vessels, specifically the epigastric arteries, which feed your abdominal muscles.
Now, a hematoma is basically a collection of blood, like a deep bruise, that forms within your body’s tissues. So, a rectus sheath hematoma happens when there’s bleeding from one of those epigastric arteries, or even the muscle itself, and the blood collects inside that rectus sheath.
There’s a particular spot in your lower abdomen, a kind of anatomical landmark we call the arcuate line (it’s about a third of the way between your belly button and your pubic bone), below which the back wall of this sheath is missing. If bleeding occurs from the inferior epigastric artery (the lower one) in this area, the blood can spread more easily because there’s less tissue to contain it. That can make things a bit more serious.
These hematomas aren’t incredibly common, thankfully. They account for maybe 1-2% of sudden abdominal pain cases we see. They tend to affect women a bit more than men and are more often seen in folks over 60.
What Might You Feel? Signs and Symptoms
The main thing people report is that sudden, sharp abdominal pain. It’s usually quite persistent and can get worse if you move or tense your tummy muscles. Sometimes, you might even be able to feel a tender lump or mass in your abdomen.
Other things you might experience include:
- Feeling queasy or even vomiting.
- Running a fever.
- Noticing bruising on your abdomen (though this might take a bit to show up).
- If there’s significant bleeding, you might develop anemia (low red blood cell count), which can make you feel tired and weak.
- Your heart might race (tachycardia).
- Your blood pressure could drop (hypotension).
What Causes a Rectus Sheath Hematoma?
Most often, a rectus sheath hematoma is triggered by some kind of trauma to the abdominal wall. This could be a direct blow, or even something less obvious like a really forceful coughing fit, especially if other risk factors are present. The trauma can injure an epigastric artery or its branches, or the muscle itself, leading to bleeding.
The biggest risk factor we see in practice? Taking blood thinners (anticoagulants). A large majority, something like 70% of people who develop this, are on these medications. It makes sense, right? If your blood doesn’t clot as easily, any little bleed can become bigger.
Other things that can increase your risk include:
- Chronic kidney disease (a surprisingly high number of patients with this also have kidney issues).
- Having had recent abdominal surgery.
- Undergoing steroid or immunosuppressant therapy.
- Antiplatelet therapy (like aspirin).
- Pregnancy (due to the stretching and changes in the abdomen).
- Chronic conditions like hypertension (high blood pressure) or atherosclerosis (hardening of the arteries).
How We Figure Out What’s Going On: Diagnosis
Diagnosing a rectus sheath hematoma can be a little tricky because, honestly, abdominal pain can be caused by so many different things! When you come in, we’ll listen carefully to your story and do an examination.
To get a clearer picture, we’ll likely suggest some tests:
- Blood tests: We’ll check your hemoglobin and hematocrit levels to see if you’ve lost a significant amount of blood. Many people with this condition will have noticeably low levels.
- Abdominal Ultrasound: This is often our first go-to imaging test. It’s quick, non-invasive, and can show us if there’s a collection of fluid (the hematoma) within the abdominal wall and give us an idea of its size.
- CT Scan: If the ultrasound isn’t clear or we need more detail, a CT scan is very helpful. We often use one with contrast dye (given through an IV). This dye lights up your blood vessels, and if one is actively bleeding, we can sometimes see the dye leaking out, which pinpoints the source of the problem.
Getting You Better: Treatment Approaches
Here’s some good news: most of the time, about 80% of cases, a rectus sheath hematoma will actually get better on its own without needing major medical intervention.
For these cases, treatment is usually conservative and focuses on comfort and letting your body heal:
- Rest: Avoiding activities that strain your abdominal muscles.
- Ice or cold compresses: Applied to the painful area to help reduce swelling and bleeding.
- Pain relief: Over-the-counter analgesics (painkillers) can help manage discomfort.
If the hematoma is large, keeps growing, or conservative measures aren’t enough, we have other options. One is a procedure called angioembolization. It sounds complicated, but it’s a minimally invasive technique where a specialist (usually an interventional radiologist) uses imaging to guide a tiny catheter to the bleeding artery and then blocks it off to stop the bleeding. Pretty neat, huh?
Surgery is rarely needed, but if angioembolization isn’t successful or appropriate, an operation might be done to remove the hematoma and tie off the bleeding vessel.
No matter the approach, we’ll keep a close eye on you with follow-up blood tests and sometimes repeat ultrasounds to make sure the bleeding has stopped and there are no signs of infection. We’ll discuss all options and what’s best for your specific situation.
What to Expect: The Outlook
For most folks, the outlook is quite good. These hematomas typically resolve on their own over two to three months, and many people recover fully without any further issues.
However, we do need to be honest. In some situations, particularly for individuals on blood thinners or those who are very frail, a rectus sheath hematoma can become serious and, rarely, even life-threatening. The most recent numbers suggest this is less than 2% of cases. Like with so many things in medicine, catching it early and getting the right treatment makes a huge difference. So, if you experience that sudden, sharp abdominal pain, especially if you have any of the risk factors we talked about, please don’t just tough it out. Come and see us.
Key Takeaways for Rectus Sheath Hematoma
Here’s a quick rundown of what to remember about rectus sheath hematoma:
- It’s a collection of blood in the sheath around your main abdominal muscles.
- Sudden, sharp abdominal pain is the most common symptom.
- It’s often linked to trauma or straining, especially if you’re on blood thinners.
- Diagnosis usually involves an ultrasound or CT scan.
- Most cases resolve with rest, ice, and pain relief, but sometimes procedures like angioembolization are needed.
- Early diagnosis generally leads to a good outcome.
You’re not alone in figuring these things out. If something feels off, especially new or severe pain, getting it checked is always the best first step. We’re here to help.