420
Journal of the Royal Society of Medicine Volume 85 July 1992
also marked interindividual variation in susceptibility to irradiation such that a dosage that would be without effect in the majority could have adverse effect in an idiosyncratic case2.
Figure 2. Skin biopsy showing prominent telangiectasia
Radiation, both solar and ionizing are known to cause telangiectasia. Our patient has only a minor degree of solar damage, both clinically and histologically, and the vascular changes seem disproportionate to this. His total exposure to ionizing radiation is impossible to calculate. The nuclear tests he witnessed were several hundred times more powerful than Hiroshima and the bombs tested were thought to be 'dirty' in terms of radioactivity4. Our knowledge of the effects of ionizing radiation on human skin comes from three major sources; clinical use, wartime use in Hiroshima and Nagasaki and nuclear tests. In clinical use cutaneous sde effects of irradiation are well recognized to include telangictaia which is a charc feature of chronic radiodermatitisP. In patients treated with whole body electron beam therapy, wideadtel sia may lead to an appearance similarto that seen in our patient. Investigations into the survivors oHirsima also sugg that vascular damage maybe seen many years later in those who were apparently uniijured. However our patient was exposed to a fusion as opposed to a fission bomb. Studies of servicemen exposed to nuclear' weapons tests have not commented on cutaneous vascular changes, however the largest studies have not included cliical examination and have concentrated -on cancer mOrtality7. The is
'Spontaneous' rectus sheath haematoma a rare cause of abdominal pain
M N SiddiqUi FRCS' Q Abid MB BS' T Qaseem MRCP2 S Hameed MRCP2 M Ahmed FRCS' Departments of 'Surgery and 2Medicine, The Aga Khan University Hospital, Stadium Road, PO Box 3500, Karachi, Pakistan Keywords: rectus sheath; haematoma; acute abdomen; diagnosis
Rectus sheath haematoma is an uncommon cause of acute abdominal pain. An estimated 60-93% are initially mis-diagnosedl2. Awareness of this entity may not only help in early diagnosis but prevent unnecessary surgical intervention2. Ultrasound has been recommended as an aid to diagnosis3 4. We present two cases of this interesting condition which ultrasound scanning failed to diagnose and was clearly shown using computerized tomographic scanning (CT).
In addition to telangiectasia our patient had numerous stucco keratoses which were in a similar distribution to the vascular changes. This type of seborrhoeic wart is not uncommon but are not usually as numerous as those seen in our patient. These lesions are not a recognized feature of radiation damage, however other keratotic lesions, both pre-malignant' and benign"0 are reported as a postirradiation finding. It is impossible to establish a definite causative link between this man's exposure to ionizing irradiation and his skin findings. However our patient shows an unusual degree and pattern of both telangiectasia and stucco keratoses for which we are unable to find any other cause. References 1 Goldman MP, Bennett RG. Treatment oftelangiectasia: a review. J Am Acad Dermatol 1987;17:167-82 2 Gatti RA, Boder E, Vinters HV, et aL Ataxia telangiectasia: an interdisciplinary approach to pathogenesis. Medicine 1991; 70:99-117 3 Shelley WB. Essential progressive telangiectasia. JAMA 1971; 216:13434 4 M iken R. No conceivable injury. Australia: Penguin, 1986:143 5 didtH, Sherwin WK. Reactions to ionizing radiation. JAm Acad Dermatol 1980;3:551-79 6 T1iy A, Wakano Y, Otake M, Dock D. Capillary microscopic obswvdtion on the superficial minute vessels of atomic bomb surdivors Hiroshima, 1972-73. Radiat Res 1977;72:353-63 7 SDaSC, Kendall GM, Fell TP, et aL A summary of mortality and incidence of cancer in the men from the United Kingdom's qb nuclear weapon tests and experimental prgrammes. BMJ 198836:332-8 8 Pearce N, 3Prior I, Methven D, et al. Follow up of New Zealand paricipants in British atmospheric nuclear weapons tests in the PcifI; 31.1J 1990;300:1161-6 9 Vastq JP, Hunter JAA, Mallet RB, Rodger A. Post irradiation conca lkeratoses. J R Soc Med 1989;82:166-7
(Accepted 5 February 1992)
Case reports Case 1 A 57-year-old woman was admitted via the accident and emergency department. She gave a few hour history of sudden onset of severe epigastric pain radiating to the chest after lifting a bed. She was a known, poorly-controlled hypertensive. On examination she was in-pain with a pulse of 90/min and a blood pressure of 200/100 mmHg. This was associated with tenderness in the epigastrium. Initial diagnosis included a possible myocardial infarct, perforated duodenal ulcer or pancreatitis. Electoardiogram, chest/abdominal X-rays, cardiac enzymes and serum amylase, were normal. Haemoglobin was 12.8 gldl, white blood count (WBC) 18.6x109/l, platelet (Pt) 265x 100/l, prothrombin time (T) 17/13, activated partial thromboplastin time (APE 42/33. Abdominal ultrasound scan failed to reveal any abnormality. Within 12 h she became pyrexial (390C) and a surgical consultation was sought. She was found to be tachycardic and markedly tender in the epigastrium with vague epigastric fullness. Bowel sounds were normal. A possible diagnosis of a liver abscess was made and a CT scan was ordered. The CT scan clearly demonstrated a haematoma ofthe left rectus abdominis muscle (Figure-- 1). Ultrasound-guided aspiration yielded 10 cm3 of blood-stained fluid which failed to yield any organisms. Treatment was conservative and all her symptoms settled within 6 days.
0141-0768/92/
070420-02/$02.00/0 o 1992 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 85 July 1992 Discussion
Figure 1. CT scan of the abdomen showing a haematoma in the left rectus abdominis muscle
Figure 2. CT scan of the abdomen shoting a 3 cm size lesion fiee of adhesions to the adjacent intraperitonil structures. This represents a right rectus sheath haematoma
Case 2 A 68-year-old man with myasthenia gravis was admittd with acute urinary retention. Before,admission he had a syncope attack while micturating and fell to the floor. Despite repeated attempts he was unable to lift himself. When seen in the hospital he was found to have an illd tender mass in the right iliac fossa. Blood e rewas. 130/85 mmHg, pulse 100/min, haemoglobin 15.4 -g/dl, WBC 12 200/mm3, Pt 241000/mm3, PT 16/13, APTT 44/33. Despite no bowel complaints and negative faecal occult. bloods, a barium enema was ordered because one in 1984 had shown two polyps in the splenic colon. The barium enema was unremarkable and a CT scal was ordered. This showed a right lower rectus sheet haematom& 3 cm in size (Figure 2). Treatment was conservativ and the patient made a complete recovery.
Rectus sheath haematoma is an uncommon cause of acute abdominal pain and initial mis-diagnosis is common in up to 93% of cases','. This can be explained by the relatively rare occurrence ofthis condition and, because ofits location, the clinician is misled to diagnose more common intraabdominal disorders. Male to female ratio in one large collective series of 50 cases was reported as 1: 2.52. In the same series features which were common were acute oughing attacks 56%, anticoagulant therapy 22%, muscular exertion and trauma 12%, hypertension 12%. The most common cause of haematoma in young women was pregnancy and trauma/exercise in young males. Common presentation is with acute localized abdominal pain. A palpable tender abdominal mass is present in the majority of cases (92% in one series). As was the case in our two patients, nausea, vomiting, rebound tenderness or absence of bowel sounds are not generally observed. Common mis-diagnosis as reported by Titone et al 2 have been idiopathic or post incisional strangulated hernia (12%), twisted ovarian cyst (10%), intestinal obstruction (8%), abdoiinal neoplasm (4%), perforated colon (4%) or appendicitis (4%). A careful history of precipitating factors and a palpable abdominal mass should make the clinician suspect the condition. Carnet's test may aid in differentiating between abdominal wall pain and pain of visceral origin5. The test is carried out by asking the patient to tense the abdominal wall by raising the head off the bed. If the tenderness is decreased on repeat palpation the pain is more likely to be of visceral origin. Ultrasound scanng ha also been reported as an aid to diagnosing thia _da . However, in our experience ultrasound failed tb reveal ematoma. This may be owing to lack of awarenes of 1tis condition at early presentation. As shown by our cases diagnosis can be made aratel by CT nning. Treatment Was conservative in both cases. Haematoma resolve ontaneously ini the majority of cases2. In the rare case of a large expanding haematoma or infected haematoma surgical intervention is justified. References 1 Backwinkel L. Rupture of the rectus abdominis muscle. Arch Surg 1965;90:35 2 Titone C, Lipsius M, Krakauer JS. Spotaneous hematomfthe rectus abdominis muscle: Critical review of 50 cases with emphasis on early diagnosis and ttment. Surgery 1972;
72:568-72 3 George M Wyatt. Ultrasound in the diagnoss f rectus sheath hematoma. Topics in radiology/ultrasound. JAMA 1979;241: 1499-500 4 Spitz HB, Wyatt GM. Rectus sheath hatoma J Clin Urasound
1977;5:413-15 5 Carnett JB. Intercostal neuralgia as a cause of abdomina pain
and tenderness. Surg Gynaecol Obstet 1926;42:625-32
(Accepted 24 September 1991)
421
Journal of the Royal Society of Medicine Volume 85 July 1992
also marked interindividual variation in susceptibility to irradiation such that a dosage that would be without effect in the majority could have adverse effect in an idiosyncratic case2.
Figure 2. Skin biopsy showing prominent telangiectasia
Radiation, both solar and ionizing are known to cause telangiectasia. Our patient has only a minor degree of solar damage, both clinically and histologically, and the vascular changes seem disproportionate to this. His total exposure to ionizing radiation is impossible to calculate. The nuclear tests he witnessed were several hundred times more powerful than Hiroshima and the bombs tested were thought to be 'dirty' in terms of radioactivity4. Our knowledge of the effects of ionizing radiation on human skin comes from three major sources; clinical use, wartime use in Hiroshima and Nagasaki and nuclear tests. In clinical use cutaneous sde effects of irradiation are well recognized to include telangictaia which is a charc feature of chronic radiodermatitisP. In patients treated with whole body electron beam therapy, wideadtel sia may lead to an appearance similarto that seen in our patient. Investigations into the survivors oHirsima also sugg that vascular damage maybe seen many years later in those who were apparently uniijured. However our patient was exposed to a fusion as opposed to a fission bomb. Studies of servicemen exposed to nuclear' weapons tests have not commented on cutaneous vascular changes, however the largest studies have not included cliical examination and have concentrated -on cancer mOrtality7. The is
'Spontaneous' rectus sheath haematoma a rare cause of abdominal pain
M N SiddiqUi FRCS' Q Abid MB BS' T Qaseem MRCP2 S Hameed MRCP2 M Ahmed FRCS' Departments of 'Surgery and 2Medicine, The Aga Khan University Hospital, Stadium Road, PO Box 3500, Karachi, Pakistan Keywords: rectus sheath; haematoma; acute abdomen; diagnosis
Rectus sheath haematoma is an uncommon cause of acute abdominal pain. An estimated 60-93% are initially mis-diagnosedl2. Awareness of this entity may not only help in early diagnosis but prevent unnecessary surgical intervention2. Ultrasound has been recommended as an aid to diagnosis3 4. We present two cases of this interesting condition which ultrasound scanning failed to diagnose and was clearly shown using computerized tomographic scanning (CT).
In addition to telangiectasia our patient had numerous stucco keratoses which were in a similar distribution to the vascular changes. This type of seborrhoeic wart is not uncommon but are not usually as numerous as those seen in our patient. These lesions are not a recognized feature of radiation damage, however other keratotic lesions, both pre-malignant' and benign"0 are reported as a postirradiation finding. It is impossible to establish a definite causative link between this man's exposure to ionizing irradiation and his skin findings. However our patient shows an unusual degree and pattern of both telangiectasia and stucco keratoses for which we are unable to find any other cause. References 1 Goldman MP, Bennett RG. Treatment oftelangiectasia: a review. J Am Acad Dermatol 1987;17:167-82 2 Gatti RA, Boder E, Vinters HV, et aL Ataxia telangiectasia: an interdisciplinary approach to pathogenesis. Medicine 1991; 70:99-117 3 Shelley WB. Essential progressive telangiectasia. JAMA 1971; 216:13434 4 M iken R. No conceivable injury. Australia: Penguin, 1986:143 5 didtH, Sherwin WK. Reactions to ionizing radiation. JAm Acad Dermatol 1980;3:551-79 6 T1iy A, Wakano Y, Otake M, Dock D. Capillary microscopic obswvdtion on the superficial minute vessels of atomic bomb surdivors Hiroshima, 1972-73. Radiat Res 1977;72:353-63 7 SDaSC, Kendall GM, Fell TP, et aL A summary of mortality and incidence of cancer in the men from the United Kingdom's qb nuclear weapon tests and experimental prgrammes. BMJ 198836:332-8 8 Pearce N, 3Prior I, Methven D, et al. Follow up of New Zealand paricipants in British atmospheric nuclear weapons tests in the PcifI; 31.1J 1990;300:1161-6 9 Vastq JP, Hunter JAA, Mallet RB, Rodger A. Post irradiation conca lkeratoses. J R Soc Med 1989;82:166-7
(Accepted 5 February 1992)
Case reports Case 1 A 57-year-old woman was admitted via the accident and emergency department. She gave a few hour history of sudden onset of severe epigastric pain radiating to the chest after lifting a bed. She was a known, poorly-controlled hypertensive. On examination she was in-pain with a pulse of 90/min and a blood pressure of 200/100 mmHg. This was associated with tenderness in the epigastrium. Initial diagnosis included a possible myocardial infarct, perforated duodenal ulcer or pancreatitis. Electoardiogram, chest/abdominal X-rays, cardiac enzymes and serum amylase, were normal. Haemoglobin was 12.8 gldl, white blood count (WBC) 18.6x109/l, platelet (Pt) 265x 100/l, prothrombin time (T) 17/13, activated partial thromboplastin time (APE 42/33. Abdominal ultrasound scan failed to reveal any abnormality. Within 12 h she became pyrexial (390C) and a surgical consultation was sought. She was found to be tachycardic and markedly tender in the epigastrium with vague epigastric fullness. Bowel sounds were normal. A possible diagnosis of a liver abscess was made and a CT scan was ordered. The CT scan clearly demonstrated a haematoma ofthe left rectus abdominis muscle (Figure-- 1). Ultrasound-guided aspiration yielded 10 cm3 of blood-stained fluid which failed to yield any organisms. Treatment was conservative and all her symptoms settled within 6 days.
0141-0768/92/
070420-02/$02.00/0 o 1992 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 85 July 1992 Discussion
Figure 1. CT scan of the abdomen showing a haematoma in the left rectus abdominis muscle
Figure 2. CT scan of the abdomen shoting a 3 cm size lesion fiee of adhesions to the adjacent intraperitonil structures. This represents a right rectus sheath haematoma
Case 2 A 68-year-old man with myasthenia gravis was admittd with acute urinary retention. Before,admission he had a syncope attack while micturating and fell to the floor. Despite repeated attempts he was unable to lift himself. When seen in the hospital he was found to have an illd tender mass in the right iliac fossa. Blood e rewas. 130/85 mmHg, pulse 100/min, haemoglobin 15.4 -g/dl, WBC 12 200/mm3, Pt 241000/mm3, PT 16/13, APTT 44/33. Despite no bowel complaints and negative faecal occult. bloods, a barium enema was ordered because one in 1984 had shown two polyps in the splenic colon. The barium enema was unremarkable and a CT scal was ordered. This showed a right lower rectus sheet haematom& 3 cm in size (Figure 2). Treatment was conservativ and the patient made a complete recovery.
Rectus sheath haematoma is an uncommon cause of acute abdominal pain and initial mis-diagnosis is common in up to 93% of cases','. This can be explained by the relatively rare occurrence ofthis condition and, because ofits location, the clinician is misled to diagnose more common intraabdominal disorders. Male to female ratio in one large collective series of 50 cases was reported as 1: 2.52. In the same series features which were common were acute oughing attacks 56%, anticoagulant therapy 22%, muscular exertion and trauma 12%, hypertension 12%. The most common cause of haematoma in young women was pregnancy and trauma/exercise in young males. Common presentation is with acute localized abdominal pain. A palpable tender abdominal mass is present in the majority of cases (92% in one series). As was the case in our two patients, nausea, vomiting, rebound tenderness or absence of bowel sounds are not generally observed. Common mis-diagnosis as reported by Titone et al 2 have been idiopathic or post incisional strangulated hernia (12%), twisted ovarian cyst (10%), intestinal obstruction (8%), abdoiinal neoplasm (4%), perforated colon (4%) or appendicitis (4%). A careful history of precipitating factors and a palpable abdominal mass should make the clinician suspect the condition. Carnet's test may aid in differentiating between abdominal wall pain and pain of visceral origin5. The test is carried out by asking the patient to tense the abdominal wall by raising the head off the bed. If the tenderness is decreased on repeat palpation the pain is more likely to be of visceral origin. Ultrasound scanng ha also been reported as an aid to diagnosing thia _da . However, in our experience ultrasound failed tb reveal ematoma. This may be owing to lack of awarenes of 1tis condition at early presentation. As shown by our cases diagnosis can be made aratel by CT nning. Treatment Was conservative in both cases. Haematoma resolve ontaneously ini the majority of cases2. In the rare case of a large expanding haematoma or infected haematoma surgical intervention is justified. References 1 Backwinkel L. Rupture of the rectus abdominis muscle. Arch Surg 1965;90:35 2 Titone C, Lipsius M, Krakauer JS. Spotaneous hematomfthe rectus abdominis muscle: Critical review of 50 cases with emphasis on early diagnosis and ttment. Surgery 1972;
72:568-72 3 George M Wyatt. Ultrasound in the diagnoss f rectus sheath hematoma. Topics in radiology/ultrasound. JAMA 1979;241: 1499-500 4 Spitz HB, Wyatt GM. Rectus sheath hatoma J Clin Urasound
1977;5:413-15 5 Carnett JB. Intercostal neuralgia as a cause of abdomina pain
and tenderness. Surg Gynaecol Obstet 1926;42:625-32
(Accepted 24 September 1991)
421
