Rectus sheath haematomata in patients with renal disease

Satishkumar A. Jayawardene and David J. A. Goldsmith

Renal Unit, Guy's Hospital, London, UK

Keywords: anti-coagulation; cardiovascular; elderly; end-stage renal failure; rectus sheath haematomata



   Introduction
 Top
 Introduction
 Case 1
 Case 2
 Case 3
 Discussion
 References
 
Rectus sheath haematomata (RSH) are very rarely described—and especially unusual in the renal literature. We present three cases of severe RSH in three clinical settings—one complicating nephrotic syndrome, one after insertion of a peritoneal dialysis cannula, and one in a haemodialysis patient.



   Case 1
 Top
 Introduction
 Case 1
 Case 2
 Case 3
 Discussion
 References
 
An 81-year-old Caucasian female was diagnosed with nephrotic syndrome and renal impairment (oedema, albumin 33 g/l (NR 35–46 g/l); 24 h protein 2.25 g; creatinine 166 µmol/l). Her renal function rapidly worsened (urea 40.6 mmol/l and serum creatinine 384 µmol/l). A renal biopsy minimal change glomerulopathy. Her blood clotting studies were normal, although plasma fibrinogen was elevated (6.7 g/l (NR 2.0–4.0 g/l)). She was started on 40 mg prednisolone once a day. There was a prompt diuresis and renal function improved over 2 weeks to a urea level of 30.2 mmol/l and a creatinine level of 175 µmol/l, while the plasma albumin level increased to 26 g/l. As she seemed to respond promptly to steroid therapy a decision was taken not to use the anti-coagulant warfarin, anticipating a rapid resolution of her nephrotic syndrome.

Ten days later she presented with 48 h anuria and rapid weight gain, but feeling well apart from vague left-sided abdominal pain. The patient underwent emergency haemodialysis because of hyperkalaemia. Aching discomfort in the abdominal wall just to the left and below the umbilicus became worse, and the next day there was a small ecchymosis at the site of her pain. Her abdominal pain worsened and she became hypotensive. A large left-sided abdominal mass rapidly became palpable. A CT scan of her abdomen was performed and revealed a large RSH with a fluid level indicating layering of blood and serous fluid (Figure 1Go). At laparotomy a huge left RSH, which extended to the right and trans-peritoneally, was evacuated. There was no obvious abnormality of, or bleeding from, the inferior epigastric artery but there was oozing around the left inferior epigatric vein so both vessels were ligated. The patient made a slow post-operative recovery, but died suddenly. A post-mortem examination was not performed.



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Fig. 1.  An unenhanced CT scan of the abdomen showing a large mass in the anterior abdominal wall, containing a ‘fluid level’. This was the RSH.

 



   Case 2
 Top
 Introduction
 Case 1
 Case 2
 Case 3
 Discussion
 References
 
A 59-year-old male with end-stage renal failure due to IgA nephropathy had a peritoneal dialysis cannula inserted under general anaesthesia. There were no complications at insertion, and the patient was discharged home the next day. Dialysis was not due to start for 2 weeks post-insertion. On about the fifth day after insertion the patient noticed severe pain in and to the left of the midline at the level of the insertion scar. The pain increased in intensity, and 2 days later the patient presented to hospital. A large palpable tender lump was found in the anterior abdominal wall, with a lot of skin bruising over this. An ultrasound confirmed a RSH (Figure 2Go, top and bottom). Blood clotting studies were normal. The symptoms settled over the course of the next week, and the swelling resolved without incident. Peritoneal dialysis has continued without complication.



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Fig. 2.  Extensive skin bruising and a bulge in the anterior abdominal wall seen 1 week after insertion of a peritoneal dialysis cannula.

 



   Case 3
 Top
 Introduction
 Case 1
 Case 2
 Case 3
 Discussion
 References
 
An 18-year-old female presented with symptoms of an upper respiratory tract infection and haemoptysis. She was known to have end-stage renal failure secondary to nephronophthisis. She had been on long-term anti-coagulation due to repeated episodes of renal transplant and vascular access thrombosis, commenced prior to her third renal transplant. At the time of presentation she was on haemodialysis via a permacath and was taking warfarin.

This patient had been treated for a chest infection 3 weeks previously with two courses of antibiotics. It was noted that she had mild tenderness in the upper half of her abdomen. Investigations showed her haemoglobin (Hb) was low (7.3 g/dl (NR 11–15 g/l)). Her INR was elevated at 8.46. Her Hb fell rapidly over 48 h to 3.9 g/dl. Her clotting also was deranged with her INR more than 10 and APTT 6.75. At this time on examination, she was not haemodynamically compromised. There was a palpable tender mass in the epigastrium. An urgent CT scan of the abdomen was performed and showed multiple fluid collections with air/fluid levels including one consistent with a RSH. The patient was haemofiltered after her CT scan and transfused with blood and fresh frozen plasma. She underwent surgical drainage of the midline anterior fluid collection. There was pus mixed with blood and culture of the abdominal fluid grew Staphylococcal aureus. The patient was treated with i.v. antibiotics and she made a good recovery.



   Discussion
 Top
 Introduction
 Case 1
 Case 2
 Case 3
 Discussion
 References
 
Uraemic bleeding is multifactorial and suggested causes include: platelet abnormalities (including reduction in intracellular ADP and serotonin) and abnormal platelet arachidonic acid metabolism [1]. The nephrotic state of course is usually associated with venous (rarely arterial) thrombosis due to hypercoagulability, and often patients are anti-coagulated with warfarin.

RSH are extremely rare and are due to rupture of the epigastric vessels, usually in the lower quadrant. Muscle haematomas have been reported in the literature associated with anti-coagulant therapy [24], subcutaneous abdominal injections of insulin [5] or of goserelin [6], after severe coughing bouts [7], pregnancy [8], connective tissue disorders [9], haematological problems [10] with alcoholic liver disease [11], and following haemodialysis or peritoneal access procedures [12].

Typically, patients with the rare spontaneous RSH (six out of 33 cases in a large series) are elderly [13]. In a recent report of three spontaneous cases, all three patients were female, over 80 years of age, and had cardiovascular disease [14]. Spontaneous haemorrhagic episodes including RSH are more common in patients with end-stage renal failure.

There have been several reports of spontaneous abdominal haemorrhage in end-stage renal failure patients but these have tended to be in haemodialysis patients [1517]. This preponderance may be related to the anti-coagulation required for haemodialysis.

Campisi et al. [17] described one case of a spontaneous iliopsoas haematoma causing haemoperitoneum occurring in a patient on continuous ambulatory peritoneal dialysis. The patient developed the haematoma after a violent bout of coughing. A fatal retroperitoneal haematoma secondary to an external iliac artery puncture has been reported as a complication of femoral vascular access for haemofiltration [18]. Similar to our second case, Thiruventhiran et al. [19] describe a patient developing a RSH secondary to a peritoneal dialysis cannula insertion.

Only the first patient in this report was typically at risk for a RSH being elderly with a history of cardiovascular problems. The haematoma enlarged rapidly when the patient was briefly heparinized to permit emergency haemodialysis for hyperkalaemia (2500 IU non-fractionated heparin as a bolus at the start of dialysis, with an infusion of heparin set at 500 IU/h for 3 h; total dose given was 4000 U). Similarly, in the third case there was over anti-coagulation with warfarin.

Muscle trauma during peritoneal dialysis cannula insertion was the cause in the second case, and over anti-coagulation, and a protracted cough, the cause in the third case. As has been noted previously, spontaneous ecchymoses over the site of the haematoma can give early warning of the underlying problem, which regularly presents a significant diagnostic challenge. Had our first case been electively anti-coagulated for her nephrotic state, the outcome could have been much less favourable.

Management of these cases depends first on accurate prompt diagnosis (CT scanning being the easiest and most accurate imaging modality for diagnostic confirmation), and then the decision to treat conservatively or to operate will depend on any underlying causation, the age and co-morbidity of the patient, and the extent and speed of the bleeding [13].

RSH are rare but potentially serious problems that can occur particularly in dialysis patients, although none of the previous reported series RSH has ever mentioned renal disease as a risk factor. Diagnostic vigilance and rapid imaging are important for successful management.



   Notes
 
Correspondence and offprint requests to: Dr David J. A. Goldsmith, Consultant Nephrologist, Guy's Hospital, London SE1 9RT, UK. Email: david.goldsmith{at}gstt.sthames.nhs.uk Back



   References
 Top
 Introduction
 Case 1
 Case 2
 Case 3
 Discussion
 References
 

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Received for publication: 11.12.01
Accepted in revised form: 22. 5.02





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