UOTW: Abdominal Pain & Cough
Authors: Christopher Parker, DO and Arielle Port, MD
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: Point-of-care ultrasound of the abdomen, right upper quadrant view.
Video 2: Point-of-care ultrasound of the abdomen, bladder sagittal view.
Video 3: Point-of-care ultrasound of the abdomen, bladder transverse view.
Video 4: Point-of-care ultrasound of the abdomen, left upper quadrant sagittal view.
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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).
PEARLS & CONCLUSION
Cherry WB, Mueller PS. Rectus sheath hematoma: Review of 126 cases at a single institution. Med. 2006;85(2):105-10.