UOTW: Abdominal Pain & Cough

Authors: Christopher Parker, DO and Arielle Port, MD

Case Presentation

A 54-year-old man presented to the emergency department with left-sided abdominal pain. He had tested positive for COVID-19 two weeks prior and subsequently had a persistent, dry cough. His medical history was pertinent for atrial fibrillation and mitral valve replacement requiring warfarin. Abdominal examination demonstrated left flank ecchymosis with focal tenderness to palpation (Figure 1). Labs showed a hemoglobin of 10.4 g/dL and INR of 8.3. Point-of-care ultrasound was performed of right upper quadrant (Video 1), pelvis (Video 2-3) and left upper quadrant (Video 4).

What do you see in the following images? What is the most likely diagnosis?

Figure 1: Physical examination of the abdomen.

Video 1.avi

Video 1: Point-of-care ultrasound of the abdomen, right upper quadrant view.

Video 2.avi

Video 2: Point-of-care ultrasound of the abdomen, bladder sagittal view.

Video 3.avi

Video 3: Point-of-care ultrasound of the abdomen, bladder transverse view.

Video 4.avi

Video 4: Point-of-care ultrasound of the abdomen, left upper quadrant sagittal view.


Spontaneous rectus sheath hematoma. Point-of-care ultrasound revealed a well-defined anechoic region with layering and fibrous septations within the abdominal wall musculature, consistent with a rectus sheath hematoma (Figure 2). Computer tomography (CT) revealed a 12 cm x 15 cm hematoma within the left anterolateral abdominal wall musculature (Figure 3).

Figure 2. Point-of-care ultrasound identifying a well-defined anechoic region (arrow), with layering and fibrous septations (star), consistent with rectus sheath hematoma, left upper quadrant sagittal view.

Figure 3. CT with axial view demonstrating a rectus sheath hematoma (arrow).



Spontaneous rectus sheath hematoma is becoming more prevalent as anticoagulant therapy is increasingly prescribed in the outpatient setting. Rectus sheath hematoma is caused by injury to the epigastric vessels or tears in the abdominal wall musculature and can be life threatening.1 Risk factors include coughing, repeated Valsalva maneuver, anticoagulation or hematologic disease, pregnancy, advanced age, female gender, trauma, invasive procedures, or vascular disease.2,3

Presentation includes abdominal pain, distention, and abdominal wall mass. Bedside ultrasound can provide a rapid diagnosis.4 Evaluation with POCUS will often reveal a hypoechoic fluid collection in the abdominal wall with a negative FAST exam.4,5 Color Doppler can screen for a pulsatile arterial bleed. 4 CT provides the definitive diagnosis and evaluates for active bleeding. Labs are necessary to assess for acute blood loss anemia and coagulopathy.

Surgical consult is often indicated. Small hematomas are usually treated conservatively with bedrest, analgesia, ice, compression, and serial hemoglobin monitoring. Larger hematomas may require blood transfusion, anticoagulant reversal, arterial embolization, or laparotomy.3


General surgery was consulted, and the patient’s warfarin was held. The patient was admitted to surgery for trending of his hemoglobin and monitoring for a persistent bleeding. The patient remained stable and was discharged without intervention.


  1. Cherry WB, Mueller PS. Rectus sheath hematoma: Review of 126 cases at a single institution. Med. 2006;85(2):105-10.

  2. Karapolat B, Tasdelen HA, Korkmaz HAA. Conservative Treatment of Spontaneous Rectus Sheath Hematomas: Single Center Experience and Literature Review. Emerg Med Int. 2019;2019:2406873.

  3. Smithson A, Ruiz J, Perello R, Valverde M, Ramos J, Garzo L. Diagnostic and management of spontaneous rectus sheath hematoma. Eur J Intern Med. 2013;24(6):579-82.

  4. Carr C, Rhyne R. Diagnosis of Rectus Sheath Hematoma by Point-of-Care Ultrasound. J Emerg Med. 2019;56(6):680-3.

  5. Lewiss RE, Wu S. Ultrasound diagnosis of rectus sheath hematoma. Journal of Emergency Medicine. 2012 Nov 1;43(5):e337-8.