1 INTRODUCTION

Rectus sheath hematoma (RSH), accumulation of blood in the sheath of rectus abdominis, is a rarely occurring condition. It may be due to rupture of epigastric arteries or the muscle within the rectus sheath.^{1, 2} Significant risk factors of rectus sheath hematoma include female gender, older age, anticoagulant therapy, antiplatelet therapy, abdominal injections, violent cough, and abdominal trauma.³ Rectus sheath hematoma is usually seen to develop in the lower quadrants of the abdominal wall, and it rarely crosses the midline.⁴ It follows a benign course, but severe outcomes, including mortality, have also been reported.²

In this case report, we report a case where rectus sheath hematoma develops in a patient diagnosed with chronic obstructive pulmonary disease (COPD) due to increased intra-abdominal pressure resulting from chronic coughing. There is a lack of literature and data regarding the development of rectus sheath hematoma secondary to acute exacerbation of COPD, but case reports have been published in this regard. This case report aims to add to it.

This case report is in line with CARE guidelines.⁵

2 CASE REPORT

A 58-year-old male, with a past medical history of chronic obstructive pulmonary disease (COPD), a resident of a remote village of Nepal, presented to the emergency department of Karnali Academy of Health Sciences (KAHS) with the issues of increased shortness of breath, cough since 7 days and lower abdominal pain since 2 days back. He had started experiencing shortness of breath even at rest, and his coughs were more violent than before, disturbing his sleep and daily activities. The cough had acute onset, and its sputum was yellowish-whitish in color. Lower abdominal pain had started acutely 2 days back (from the day of presentation), and it was severe enough to affect his daily activities. The patient also reported having swollen lower limbs, fever on and off, and non-radiating epigastric pain for a week. However, history of trauma, changes in bowel and bladder habits, burning micturition, retention of urine, paroxysmal nocturnal dyspnea, orthopnea, palpitation, and chest pain were negative.

Thorough history taking revealed that the patient was diagnosed with COPD 8 years back, for which he is under medication. He gave up smoking cigarettes after the diagnosis of COPD and is on complete abstinence at present. There is no other significant medical and drug history. There is no family history for any chronic illnesses, but there is a practice of using wood fuel for heat at his home during the winter season.

2.1 Timeline

The patient presented to our emergency department on November 16, 2021, with clinical features of acute exacerbation of COPD. Later, he was diagnosed to have rectus sheath hematoma. It was first treated conservatively but the patient had to be operated on due to its failure. The patient recovered well and was discharged on December 24, 2021 Figure 1.

3 DISCUSSION

In this case report, we have reported a case of a 58-year-old gentleman who developed rectus sheath hematoma secondary to acute exacerbation of COPD due to the associated violent cough spells. Cough-induced abdominal wall hematoma is rare, and hematoma can occur in other abdominal wall muscles.^{2, 3} Rectus sheath hematoma develops due to rupture of one of the epigastric arteries or tear of the rectus abdominis muscle itself. Injury can be caused either by direct abdominal trauma or violent, forceful contraction of the rectus abdominis. The inferior epigastric artery is usually involved, and rectus sheath hematoma is usually seen in the lower abdomen.⁶

The incidence of rectus sheath hematoma increases with age and is more common in females than males. This is believed to be due to decreased muscle mass. In addition, several risk factors such as atherosclerosis, hypertension atherosclerosis, vasculitis, hematologic disorders, direct trauma to the abdomen, surgical intervention, anticoagulation therapy, coughing/intense rectus abdominis muscle contraction, and pregnancy have been identified predispose patients to develop rectus sheath hematoma.⁶ Rectus sheath hematoma is generally seen as a self-limiting condition, but it can prove to be fatal, and mortality can rise from 4% to 25% in patients under anticoagulation therapy.^{6, 7} However, our patient was not under anticoagulation therapy. Commonly patients with rectus sheath hematoma present with abdominal pain, abdominal cramping, abdominal wall mass, abdominal wall ecchymosis, abdominal distention, decreased hemoglobin, fever, nausea, vomiting, tachycardia, and peritoneal irritation.³ Fothergill's and Carnett's are positive in the case of rectus sheath hematoma, which differentiates this condition from intraabdominal pathologies. Fothergill's sign is positive when the hematoma does not cross the midline, and Carnett's sign is positive when there is increased pain and tenderness over the hematoma on rectus abdominis contraction. Moreover, externally visible ecchymosis may be seen over the abdomen causing Grey Turner's sign and Cullen's sign.⁴ Our patient's signs were present (Figure 2), but he had no ecchymosis over his flanks.

To confirm the case, we made use of ultrasound and computed tomography (Figures 3 and 4). Ultrasound has a high sensitivity rate and is commonly used as it is time and cost-effective. Computed tomography is considered more sensitive; so, it is used in doubtful and inconclusive ultrasound cases. Magnetic resonance imaging is another less commonly used measure for confirming the diagnosis.⁸ Patients who are hemodynamically stable and have non-expanding hematomas can be treated conservatively. Conservative treatment includes rest, analgesia, cough suppression, compression of hematoma, ice treatment, intravenous fluid maintenance, and stopping the anticoagulation therapy (if needed). Invasive intervention is needed if the patient becomes hemodynamically unstable if hematoma enlarges or signs of abdominal compartment syndrome.⁶ Angiography and embolization or surgical ligation of bleeding vessels are treatment choices due to the lack of angiography and arterial embolization in our facility. (Figures 5 and 6).

Presentation of rectal sheath hematoma can mask other conditions such as appendicitis and pancreatitis. Thorough history taking and diagnostic assessments are crucial for diagnosing this condition. Moreover, rectus sheath hematoma can occur in patients having no history of abdominal trauma, strain, or anticoagulant therapy. Rectus sheath hematoma should always be looked for in patients with a COPD history presenting with abdominal pain.

4 CONCLUSION

Rectal sheath hematoma should be in the mind of the health professionals when a patient having a history of chronic obstructive pulmonary disease presents with abdominal pain. Thorough history taking, diagnostic tests, and ultrasonography are essential for the early diagnosis of the condition. This saves the patient from invasive diagnostic procedures and decreases morbidity and mortality.

CONFLICT OF INTEREST

No conflict of interests.

AUTHOR CONTRIBUTIONS

Prashant Pant (PP) and Oshan Shrestha (OS) contributed to the conception and design of the study. PP, Nebula Devkota (ND), and Pawan Budhathoki (PB) contributed to acquiring patients’ detailed information. OS performed the literature review and contributed to initial manuscript drafting. Sanjit Adhikari (SA) and Dhan Bahadur Shrestha (DBS) guided throughout the study and edited intellectually. All authors were involved in drafting and revising the manuscript and approved the final version.

CONSENT

Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

PATIENT PERSPECTIVE

The patient was surprised to know that his cough spells caused hematoma in his abdominal wall. He is intrigued by the anatomy and complexity of the human body. The patient and his family understand the risk of exacerbation of COPD and are willing to follow all that they are counselled about.