bocytopenia. The SRSH was therefore possibly attributable to mild thrombocytopenia, inhibited platelets from aspirin, and clopidogrel and continued anticoagulation with hepa- rin. The use of multiple anti-thrombotic agents substantially increases the risk of bleeding complications when compared to a single agent. Vasculitis as a cause of SRSH is relatively uncommon. To our knowledge, only one case of SRSH was described with PR3-ANCA-(Proteinase-3-Antineutrophil Cytoplasmic Antibody) associated vasculitis. 4 PR3 is the most common antigen target for ANCA in Wegeners Granulomatosis. Other vasculitides that have been associated with SRSH include mixed cryoglobulinemia in hepatitis C infection. 3 Our second patient was not on anticoagulation. Al- though her platelet counts were normal, it was postulated that she probably had mildly dysfunctional platelets be- cause of her renal failure. The presence of vasculitis and concomitant coughing were risk factors that probably led to the SRSH. As in both cases described above, SRSHusually presents as abdominal pain and swelling. Both ultrasound and ab- dominal CT can be used for the diagnosis of SRSH, with CT being the gold standard for the diagnosis with a sensitivity and specificity of 100%. 7 Most SRSH can be managed conservatively with dis- continuation of anticoagulation, volume resuscitation, blood transfusion, and observation. 8 With conservative measures, small and uncomplicated SRSH usually resolves spontane- ously. 9 Even in the setting of a large hematoma, conservative management is still an option, as long as there is no evidence of active bleeding and the resultant anemia is corrected. Active bleeding and hemodynamic compromise are indications for aggressive intervention. Open surgery with evacuation of the hematoma is often not recommended, as there is a theoretical propensity for more bleeding secondary to the reduced tamponade effect from the removal of the hematoma. 10 In spite of CT-confirmed contrast extravasa- tion, the first patient did not have recurrent bleeding with the placement of a wound vac, which provides the exact op- posite effect of tamponade, establishing a negative pressure around the vessels. Our patient had a wound vac without any detrimental hemodynamic effects, which questioned the theoretical need for tamponade. Mortality from SRSH ranges between 4% and 25%. The more severe the hemodynamic effects, larger the hematoma, and less aggressive the management of severe SRSH, the more the mortality. 11,12 CONCLUSION Peri-procedural anticoagulation with multiple anti- platelet agents and anticoagulants during cardiac catheter- ization is a risk factor for SRSH. With more diseases being treatedwith antithrombotic agents and presence of multiple new and old agents in the market, SRSH may occur more commonly than before. SRSH should be in the differential diagnosis of elderly patients who present with abdominal
pain in the setting of anticoagulation. On the other hand, although vasculitis-related SRSH is uncommon, diagnosis is facilitated by high clinical suspicion and imaging of the abdomen by CT scan. Clinicians should be aware of typical and atypical presentations of SRSH and its variant manage- ment options. REFERENCES 1. Bear G, Robles M, Cernuda B et al. [Spontaneous Hematoma of the Sheath of the Rectus Abdominis Muscle: a Challenge for the Diagnosis]. Emergencias 2000; 4:269–71. Spanish 2. Dag A, Ozcan T, TurkmenogluO et al. Spontaneous Rectus Sheath Hematoma in Patients on Anticoagulation Therapy. Ulus Travma Acil Cerrahi Derg 2011; 3:210-4 3. Moschella CM, Palmieri I, Bartolucci P et al. Spontaneous rectus sheath hematoma in HCV mixed cryoglobulinemia requiring emergency treatment. G Chir 2002; 8-9:331-3 4. Sakaguchi Y, Niihata K, Yasuda K et al. [Autopsy case of PR3- ANCA-associated vasculitis complicated with rectus muscle hematoma]. Nihon Jinzo Gakkai Shi 2009; 5:550-6. Japanese 5. Fujikawa T, Kawato M, Tanaka A. Spontaneous rectus sheath haematoma caused by warfarin-induced over anticoagulation. BMJ Case Rep. Advance online publication. doi: 10.1136/ bcr.07.2011.4533 6. Salemis NS. Spontaneous rectus sheath hematoma presenting as acute surgical abdomen: an important differential in elderly coagulopathic patients. Geriatr Gerontol Int. 2009; 2:200-2 7. Gallego A Aguayo JL, Flores B et al. Ultrasonography and computed tomography reduce unnecessary surgery in abdominal rectus sheath haematoma. Br J Surg 1997;84:1295–7 8. Berna JD, Zuazu I, Madrigal M et al. Conservative treatment of large rectus sheath hematoma in patients undergoing anticoagulant therapy. Abdom Imaging 2000; 3:230–234 9. 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- 72 10. Donaldson J, Knowles CH, Clark SK et al. Rectus sheath haematoma associatedwith lowmolecular weight heparin: a case series. Ann R Coll Surg Engl 2007; 3:309–312 11. Smithson A, Ruiz J, Perello R et al. Diagnostic and management of spontaneous rectus sheath hematoma. Eur J Intern Med 2013; Advance online publication. doi: 10.1016/j.ejim.2013.02.016 12. Hildreth DH. Anticoagulation therapy and rectus sheath hematoma. Am J Surg 1972;124: 80–6
Drs. Sivagnanam and Ladia are Residents in the Department of Internal Medicine at East Tennessee State University in Johnson City, Tennessee. Dr. Bhavsar is a Fellow in the Department of Cardiology, Dr. Summers is a Professor in the Department of Internal Medicine, and Dr. Paul is Assistant Professor and Director of Cardiac Rehabilitation and Prevention at East Tennessee State University.
J La State Med Soc VOL 166 September/October 2014 199
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