• Isaac Cheruiyot, Prabjot Sehmi, Vincent Kipkorir, Jeremiah Munguti, and Julius Ogeng'o.
• Department of Human Anatomy and Medical Physiology, Faculty of Health Sciences, University of Nairobi, Nairobi, Kenya.
• Medicine (Baltimore). 2024 Oct 25; 103 (43): e40198e40198.

RationaleRectus sheath hematoma (RSH) is an unusual cause of acute abdominal pain. It is more common in elderly patients on anticoagulation. The diagnosis is often challenging, as it mimics other more common causes of acute abdomen. No standard treatment guidelines exist, presenting therapeutic dilemmas. Herein, we describe a case of spontaneous RSH complicated by deep venous thrombosis (DVT).Patient ConcernsThe patient was a 58-year-old female on follow-up for end-stage renal failure, admitted for management of uremic gastritis, fluid overload state, and bronchopneumonia. On the third day of admission, she developed worsening abdominal pains, associated with dizziness, headaches, hypotension, tachycardia, and desaturation. Abdominal examination revealed tender swelling, with localized guarding.DiagnosesAn urgent abdominal computed tomography scan demonstrated a large complex collection of approximately 12 cm × 10 cm in the left rectus sheath with intraperitoneal extension, consistent with RSH.InterventionsShe underwent laparotomy with evacuation of 1.5 L of hematoma. Her postoperative recovery was complicated by the development of DVT on the sixth postoperative day. Due risk of rebleed, the inferior vena cava filter was favored over therapeutic anticoagulation. Her postoperative hospital stay was thereafter unremarkable.Outcomes And LessonsAlthough rare, RSH is a potential cause of acute abdomen, particularly among patients on anticoagulation, and can be life-threatening. A high index of suspicion is therefore important for early diagnosis. Clinicians should also appreciate the heightened risk of DVT in the immediate postoperative period despite mechanical anticoagulation.Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.

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