Figure 1. Day 3: Mild ecchymosis
Acute left lower quadrant abdominal pain developed in a previously healthy, postmenopausal, 52-year-old woman on the second day of a lower respiratory tract infection associated with severe coughing. Her past medical history was significant for stage 1 hypertension and cough-variant asthma. Her past surgical history included 2 cesarean sections. Her medications consisted of lisinopril/hydrochlorothiazide, 20/25 mg/d, and fluticasone propionate/salmeterol inhalation powder, 250/50 µg twice daily. Penicillin was her only known drug allergy.
On the third day of the patient’s bronchitis, she noted a small ecchymosis in her left groin (Figure 1) and continued sharp pain in the left lower quadrant. She denied dizziness, fever, nausea, vomiting, diarrhea, or any genitourinary or gynecologic symptoms.
Five days later, the patient noted increased ecchymosis in the left inguinal region (Figure 2) and a distinct bulge in the area of initial pain (Figure 3). At this time, she presented to her primary care physician.
Figure 2. Day 8: Increased ecchymosis Figure 3. Day 8: Left lower quadrant abdominal bulge
On physical examination, the patient was afebrile and her vital signs were stable. Cardiorespiratory findings were normal. There was tenderness in the left lower quadrant that corresponded with the 4 x 4-cm bulge that was evident only with forward flexion. Ecchymosis in the left inguinal region was noted.
A CT scan and complete blood cell count were ordered, but the patient refused them because she had no medical insurance. Conservative measures—rest, local heating pad application, and acetaminophen—were continued. The patient’s condition improved over the following week, and the bulge and ecchymosis likewise resolved completely.
The diagnosis was rupture of the rectus abdominis muscle with subsequent rectus sheath hematoma (RSH)—an uncommon and often misdiagnosed cause of acute abdominal pain. The associated ecchymosis is caused by sudden forceful contraction of the rectus abdominis muscle that produces acute shearing forces and results in vascular injury to the superior or inferior epigastric arteries. The resultant hemorrhage into the rectus sheath then dissects inferiorly into the space of Retzius and the anterior thigh.
Patients typically present with acute abdominal pain, an abdominal wall mass, or both. Pain may worsen when the muscles of the abdominal wall are tensed by lifting the head and shoulders or lifting both legs with bent knees (a positive Carnett sign).1
