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Br J Sports Med. Oct 2007; 41(10): 688–690.
Published online May 11, 2007. doi:  10.1136/bjsm.2007.036087
PMCID: PMC2465161
Rectus sheath haematoma: a rare presentation of non‐contact strenuous exercises
Hemant Sharma, Narayan Singh Shekhawat, Sudhir Bhandari, Breda Memon, and Muhammed Ashraf Memon
Narayan Singh Shekhawat, Sudhir Bhandari, Department of Surgery, Sawai Mansingh Medical College, Jaipur, India
Hemant Sharma, Breda Memon, Muhammed Ashraf Memon, Department of Surgery, Whiston Hospital, Prescot, Merseyside, UK
Correspondence to: Dr M A Memon
Astley House, Whitehall Road, Darwen, Lancashire BB3 2LH, UK; mmemon@yahoo.com
Accepted April 19, 2007.
Abstract
Rectus sheath haematoma (RSH) is a well‐documented but uncommon clinical condition. It is usually a self‐limiting condition but can present as a life‐threatening emergency. RSH after non‐contact vigorous exercise is unknown. Two such cases secondary to yoga and laughter therapy sessions, respectively, are reported. One of them required surgical intervention, whereas the other was successfully treated conservatively.
Keywords: exercise, rectus sheath haematoma, yoga, laughter therapy
Rectus sheath haematoma (RSH) is an uncommon but well‐documented clinical entity.1,2 It results from haemorrhage into the rectus muscle due to rupture of the superior or inferior epigastric arteries, their branches or a tear of the rectus abdominis muscle.1,3 It is a known complication of abdominal trauma and anticoagulation.1,2,3,4,5,6,7 Other rare associations include exertion, pregnancy, insulin injection, paroxysmal coughing and abdominal surgery.2,4,5 RSH is often misdiagnosed and can mimic various intra‐abdominal diseases.3,4,6 Although it is generally self‐limiting, it can cause life‐threatening clinical conditions such as hypovolaemic shock, leading to morbidity and mortality.1,3,7 Abdominal wall injuries are rarely reported but more often perceived by sports medicine practitioners.8 We present two unique non‐contact sport‐related presentations of RSH, one after yoga and the other as a consequence of laughter therapy exercises. RSH secondary to these conditions has not been reported in the English literature to our knowledge.
Case 1
A 61‐year‐old woman presented to the accident and emergency department with severe, lower abdominal pain and abdominal distension. She had attended a pranayama session of a yoga course nearly 6 hours before and had to stop in between owing to abdominal discomfort. She had a past history of hypertension and was taking bendrofluazide and aspirin. On admission she was hypotensive with a blood pressure of 84/46 mm Hg, and tachycardic with a heart rate of 128 beats/min. The ECG showed sinus tachycardia. She was actively resuscitated with intravenous crystalloids, catheterised and given adequate analgesia. Abdominal examination disclosed generalised peritonitis and a smooth tender mass over the left iliac fossa extending up to the midline (fig 11).). Routine blood tests showed low haemoglobin 84 g/l. Her clotting test, however, showed a slightly raised international normalised ratio of 1.6 and activated partial thromboplastin time of 32 seconds. She was transfused with 2 units of whole blood and an urgent CT scan of the abdomen was performed. This showed an RSH 10×12×8 cm in size over the left lower quadrant of the abdomen (fig 22).). Despite blood transfusion, her blood pressure dropped further and therefore an emergency surgical exploration was undertaken. A large RSH consisting of about 750 ml of dark blood with clots was drained and the actively bleeding left inferior epigastric artery was ligated. The patient recovered well and was discharged home on the fourth postoperative day.
figure sm36087.f1
Figure 1 Abdominal distension in case 1.
figure sm36087.f2
Figure 2 CT scan of abdomen in case 1 showing a rectus sheath haematoma.
Case 2
A 67‐year‐old woman presented to the accident and emergency department with gradually worsening pain in the left lower quadrant over the past 3 days. She had been attending laughter therapy sessions for the past month after reading about it in a health and sport magazine. The last session was 3 days before developing niggling pain over the left lower quadrant. She was otherwise healthy and was taking prophylactic aspirin prescribed by her family physician. At presentation, her blood pressure was 128/76 mm Hg and her heart rate 86 beats/min. Abdominal examination disclosed an ill‐defined tender mass in the left iliac fossa with localised peritonism. All her routine blood tests were normal. A CT scan of the abdomen showed an RSH of 10×6×5 cm size (fig 33).). Because the patient was stable, she was treated with analgesia and was discharged home. Subsequent review in the outpatient clinic showed complete resolution of her left lower quadrant mass.
figure sm36087.f3
Figure 3 CT scan of abdomen in case 2 showing rectus sheath haematoma.
RSH is more common in women,1 probably owing to lean rectus muscle mass in comparison with men. This leads to a greater likelihood of bleeding in response to trivial abdominal wall trauma. Anticoagulation and trauma are the two most common predisposing factors in its development.1,2,3,4,5,6,7 None of the patients in the present report were receiving anticoagulants and their clotting profile was normal. However, both these patients were taking a small dose of aspirin, which might have aggravated bleeding because of platelet dysfunction.
Severe abdominal wall injury due to strenuous exercises is rare.8Pranayama is a special exercise in yoga. It is done with continuous actions of inhaling and exhaling air, keeping the abdomen taut and relaxed alternately9 (fig 44).). Laughter therapy sessions involve forced laughing for abdominal exercise and stress management. Forced laughing raises transdiaphragmatic pressure10 and as a result there is an increase in abdominal pressure. Thus the plausible explanation for RSH in the present report is vigorous abdominal contractions in Pranayama and laughter therapy exercises.
figure sm36087.f4
Figure 4 Pranayama technique of yoga.
What is already known on this topic
  • It is an uncommon cause of abdominal pain which is often misdiagnosed
  • It occurs because of bleeding into the rectus sheath from damage to the superior or inferior epigastric arteries or their branches or from rectus muscle tear.
  • A number of risk factors have been identified and include anticoagulant treatment, vigorous coughing, contact sports, pregnancy, abdominal surgery, abdominal wall trauma, vigorous rectus muscle contractions, and certain medical conditions such as leukaemia and blood disorders.
  • Ultrasound scan and CT are the two best imaging modalities for an accurate diagnosis.
  • The patient's clinical condition determines the type of treatment. For a haemodynamically stable patient, treatment of the primary cause together with conservative management is appropriate. Emergency radiologically guided embolisation or surgery is reserved for those patients who are haemodynamically unstable and unresponsive to initial fluid resuscitation.
Abdominal pain and abdominal mass not only occur in RSH but also in numerous intra‐abdominal emergencies. RSH is therefore often misdiagnosed.1,2,3,4,5,6,7 The absence of any pathognomonic features renders imaging modalities as the sole non‐invasive alternative for the diagnosis of this condition. Although ultrasound, CT and magnetic resonance imaging of the abdomen have been used for diagnosis of RSH, a CT scan is the preferred radiological modality.1,4,5,7 Both our patients were correctly diagnosed with a CT scan. Stable patients should be managed conservatively, but unstable patients will require active resuscitation and surgical control of bleeding if further deterioration occurs.1,3
What this study adds
  • Both of our cases occurred in patients taking part in non‐contact sports activities—yoga and laughter therapy—which has not been described previously.
  • Aspirin treatment might have predisposed our patients to this uncommon condition.
Conclusion
Strenuous abdominal exercises may lead to RSH. Clinicians therefore need to be aware of this complication after non‐contact strenuous exercises such as yoga and laughter exercises. The clinical condition of the patient dictates the approach to treatment: conservative or surgical.
Footnotes
Conflict of interest: None declared.
Informed consent was obtained for publication.
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