What is Abdominal Hematoma (Abdominal Bruising)?
A hematoma happens when blood collects outside the blood vessels. This usually occurs due to bleeding from a broken blood vessel. The name of a hematoma usually describes where it is, such as in the brain, chest, pelvis, or abdomen. Hematomas can gather in areas outside blood vessels near the site of bleeding, where there’s room for the blood to pool. An abdominal hematoma could either be within the abdomen or on the abdominal wall. Hematomas on the abdominal wall are typically a result of bleeding within the muscle layers, especially the rectus muscle. There’s a type of this hematoma known as a rectus sheath hematoma. This article will focus on this particular hematoma.
A rectus sheath hematoma is simply bleeding into the rectus sheath, which is a confined space where blood can accumulate, usually forming a localized hematoma. This bleeding can be traced to the upper or lower epigastric arteries and veins, or their branches. In some individuals, a rectus hematoma can happen all on its own. However, it generally occurs after an injury to the upper or lower epigastric vessels or their branches. Though this condition usually gets better by itself, sometimes the hematoma can grow large and cause a drop in blood volume, potentially leading to a condition called hypovolemic shock.
What Causes Abdominal Hematoma (Abdominal Bruising)?
Rectus sheath hematomas are caused by bleeding from certain blood vessels or branches within the muscle sheath of the stomach. Although these hematomas are rarely life-threatening, they can cause severe health problems, including unstable blood pressure. Generally, however, they tend to resolve on their own over time.
There are various causes for this type of bleeding—it could be due to a tendency to bleed, blood thinners, or damage to the blood vessels. The injuries to the vessels can happen due to physical injury to the stomach, surgical complications, or intense muscle contractions during activities that are linked with intense pressure in the chest – this can happen during heavy retching, vomiting, or straining.
In most cases, the hematoma, or bruise, is localized. But, in some situations, especially with people who have a lot of loose connective tissue, the bruise can spread above the belly button, to the opposite side, or even within the belly. Potential risk factors for developing a rectus sheath hematoma include advanced age, being female, doing intense physical activity, and the use of blood-thinning medications. It’s worth noting that with increasingly common use of blood thinners, the occurrence of rectus sheath hematomas appears to be on the rise.
Risk Factors and Frequency for Abdominal Hematoma (Abdominal Bruising)
Rectus sheath hematomas are a rare condition. The exact number of cases isn’t known because it is often either misdiagnosed or not diagnosed. Some analysis, though, puts the figure at about 1.5% to 2% of all hospitalized patients.
- Rectus sheath hematoma affects more females than males.
- This is believed to be due to their lower muscle mass.
- Pregnancy can raise a woman’s risk, while for men, trauma, and exercise are the usual causes.
- These hematomas are most often found on the right side of the abdomen.
- They are typically situated in the lower part of the abdomen, below the arcuate line.
Signs and Symptoms of Abdominal Hematoma (Abdominal Bruising)
Rectus sheath hematoma is a condition that is typically characterized by sudden, sharp abdominal pain that does not spread to other areas. Alongside this pain, a person might also experience symptoms such as nausea and vomiting. In rare cases, the hematoma can be so large that it causes low blood volume, rapid heart rate, and rapid breathing. A physical examination often reveals a firm, localized lump in the abdominal wall that doesn’t throb with your pulse. This is known as the Fothergill sign.
The Fothergill sign is when there is a lump in your abdomen that doesn’t move across your belly’s midline and doesn’t change when you flex your abdominal muscles. This is a good indication that the lump is a rectus sheath hematoma. However, this sign might not be as clear in people who are overweight.
Healthcare providers should take a detailed medical history to uncover any potential risk factors for this condition. These can include:
- Recent surgeries
- Frequent coughing
- Constipation
- Asthma
- Bronchitis
- Anticoagulation therapy
- Use of oral anticoagulants
- Use of corticosteroids
Testing for Abdominal Hematoma (Abdominal Bruising)
When doctors suspect a rectus sheath hematoma, which is a collection of blood in the muscle wall in the abdomen, they start by ordering basic blood tests and checking how well your blood is clotting. After these tests, an ultrasound is often carried out. This test uses sound waves to create an image of the inside of the body, and in this case, it can reveal the presence of a hematoma as a specific type of image within the wall of the abdomen’s muscles. The ultrasound can also provide information about the exact size and location of the bleeding.
If the ultrasound isn’t clear enough, a CT scan might be carried out next. This type of imaging can provide more details regarding the location, size, and extension of the hematoma. If a special dye (or “contrast”) is used with the CT scan, it could even show if there is active bleeding inside the hematoma.
It’s important not to overlook other reasons for fluid collection in the muscle wall of the abdomen. If there’s uncertainty after these imaging tests, the doctors might use a needle to take a sample from the suspected hematoma to see if it’s blood or an abscess. This procedure, known as needle aspiration, carries some risks, including the potential to puncture the bladder, bowel, or a hernia.
Evaluating the hematoma isn’t done in isolation. It’s a part of the overall assessment of a patient’s condition, including addressing any other factors or related conditions that might have caused or complicate the hematoma. Taking care of these underlying conditions, as well as any possible complications, is vital for successful treatment.
Treatment Options for Abdominal Hematoma (Abdominal Bruising)
How doctors treat rectus hematomas depends on a few things: how bad the symptoms are, how big the hematoma is, if the hematoma is stable, and the underlying issue that caused it. The main aim of treatment is to ease symptoms, stop any complications from happening, and treat the original issue. It’s important to first assess the patient’s condition, replace any lost fluids and correct problems with blood clotting before more intensive treatments are considered.
If the hematoma is getting bigger or causing significant blood loss, it’s crucial to stop the bleeding. This is usually done first by localizing and blocking the blood vessel that’s bleeding through a process called embolization, which is done by a type of doctor called an interventional radiologist. In most cases, this is enough to stop the bleeding. This is mainly because the space where the bleeding is happening is confined and the pressure from the hematoma can counteract the blood flow.
However, in a small amount of cases, if the bleeding can’t be stopped with this procedure, or if it’s not possible to do, it may be necessary to have surgery to control the bleeding and remove the hematoma. This is done by tying off the bleeding blood vessel, usually the epigastric vessel, during surgery.
Generally, bleeding will stop when there is enough pressure inside the rectus sheath, a part of your stomach area. How big the hematoma gets depends on how big and pressured the bleeding vessel is, how much the rectus space can expand, and if there are any blood clotting issues. Once the bleeding has stopped and the hematoma is not getting any bigger, treatment usually focuses on easing symptoms. There’s no rush to remove the hematoma. Actually, keeping the pressure inside the hematoma initially is key to prevent more bleeding. After the patient has recovered from this stage, large hematomas can be drained. On the other hand, small ones can be left alone and will usually be reabsorbed naturally, which avoids unnecessary treatment.
As long as patients with a rectus sheath hematoma are stable and their blood count is normal, they can be treated at home. But patients who are taking blood thinners should be admitted to the hospital to make sure that the hematoma doesn’t get bigger.
What else can Abdominal Hematoma (Abdominal Bruising) be?
There are a few specific conditions that can cause a mass in the abdomen. These include tumors in the abdominal wall (which can be benign, meaning they’re not cancerous, or malignant, meaning they are), an abscess (infection that’s filled with pus) in the abdominal wall, or a hernia in the abdominal wall.
Similarly, there are several conditions that can cause abdominal pain, or in severe cases, an acute abdomen which means severe, sudden-onset abdominal pain. These conditions include:
- Peptic ulcer disease (which causes sores in the lining of the stomach)
- Bowel perforation (a hole in the wall of your stomach or intestinal tract)
- A tubo-ovarian abscess (a pus-filled pocket involving a fallopian tube and an ovary)
- Appendicitis (an inflammation of the appendix)
- Cholecystitis (an inflammation of the gallbladder)
- Diverticulitis (an inflammation or infection in one or more small pouches in the digestive tract)
- Urinary tract infection (commonly known as UTI)
- Pancreatitis (an inflammation of the pancreas)
For an accurate diagnosis, a comprehensive medical history, a physical exam, and a general awareness of these common conditions will help doctors pinpoint the cause of the problem and decide on the best course of treatment.
What to expect with Abdominal Hematoma (Abdominal Bruising)
In general, rectus hematomas, which are collections of blood in the abdominal wall, are not severe and can be managed effectively with minimal treatment. While there have been fatal cases, most of these were discovered during an autopsy.
It’s worth noting that the fatality rate is higher in older individuals who are taking blood thinners, and in pregnant women. Historically, there have been reports indicating a 15% mortality rate in the mother and nearly 50% in the fetus.
However, these figures come from a time before sophisticated imaging techniques like ultrasound and CT scans were widely available. Thanks to these tools, doctors can now quickly and accurately diagnose rectus hematomas, aiding in more effective management and lowering the risks associated with the condition.
Possible Complications When Diagnosed with Abdominal Hematoma (Abdominal Bruising)
If a rectus hematoma, or a collection of blood outside of a blood vessel, isn’t diagnosed or treated appropriately, it may lead to pain. Besides pain, severe bleeding is a significant concern. It can be dangerous and even life-threatening. Thus, it’s crucial to identify severe bleeding quickly and treat it diligently. Another possible issue is the formation of an abscess, which is a pocket of pus that can develop. Like any situation where blood collects and isn’t drained, an infection can take hold and cause an abscess. If an abscess does develop, it will need to be drained.
Highly Common Side Effects:
- Pain
- Severe bleeding that can be life-threatening
- Abscess formation which may need draining when developed
Recovery from Abdominal Hematoma (Abdominal Bruising)
It’s important for patients to have regular check-ups and to adjust their physical activities to avoid causing more damage to their tissues. It’s typically recommended that they stay away from strenuous workouts. Making a decision to begin oral blood-thinning medication again requires careful consideration. This decision needs to balance the need for the blood-thinning treatment against the risk of a rebleed within the sheet of muscles in the front of the abdomen.
