Surgery MCQ Answer 63

Answer: b, c

Rectus sheath hematoma results from arterial or venous bleeding into the rectus sheath, most commonly from arterial bleeding. Rectus sheath hematomas predominate in women by a ratio of about 3:1. The mean age of incidence is in the late fifth decade. Although spontaneous formation of a rectus hematoma is rare, it can occur with vasculitis, arterial venous malformations, a severe coagulopathy, or with the administration of anticoagulants. The usual cause is trauma. Events as trivial as sneezing, coughing, or twisting to the side have initiated a rectus hematoma. Abdominal pain is almost always described at presentation. Pain is often described as severe and usually is exacerbated by movements that require muscular contraction of the abdominal wall. On examination, there is tenderness over the rectus sheath, voluntary guarding, and often a diffuse mass sensation in the area of tenderness. Contraction of the rectus muscle exacerbates the pain and tenderness. Peritoneal signs are absent. Ecchymosis may occur but usually appears several days after the onset of pain. In cases where the hematoma dissects or originates inferiorly and expands into the prevessicle and preperitoneal space, the hematocrit may fall significantly; however, hemodynamic instability is distinctly unusual. When the intraabdominal source of pain is unknown, ultrasound and particularly computed tomography can delineate the hematoma and localize it to the abdominal wall in almost all cases.

Treatment must take into consideration the cause, if known, and whether the hematoma is stable or progressive. Coagulopathy should be corrected when possible. For patients in whom the hematoma is stable, pain medication and avoidance of muscular stress on the abdominal wall are sufficient. For patients with progressive hematoma, the treatment of choice is evacuation of the hematoma from within the rectus sheath and hemostasis, sometimes requiring ligation of the epigastric vessels above and below the hematoma.

Category: Surgery MCQs