Teaching Case

An old lady presented with acute onset of abdominal pain and tenderness, paleness and decrease of hematocrit five days after a fall on her right side with a fracture of the right radius.

A 84-year old woman presented to the emergency unit after a fall on her right side with a displaced fracture of radius wich had to be reduced surgically. Five days later she showed sudden onset of abdominal pain and tenderness, paleness, the hematocrit has decreased to 26,9, the hemoglobine to 9.1, hemoccult test was positive. Abdominal plain films followed by a CT-scan were performed. Because of these imaging findings combined with the increasing ileus symptoms and hemodynamic decompensation of the patient the indication for surgical intervention was set immediately. At Laparotomy there was found a large hematoma of the left rectus sheath, caused by a rupture of the inferior epigastric artery, containing about one litre of coagulated blood and a mobile descending colon, herniated through a hole of the inner layers of the rectus sheath. The herniated parts of the colon did not show ischemic damage, so a resection had not to be performed. The colon was mobilized back and the layers of the abdominal wall closed with interrupted sutures. The old lady got well and was discharged two weeks after operation.

Abdominal wall herniation resulting from blunt trauma is an uncommon entity with only a few cases reported. The usual pathophysiology of traumatic abdominal wall hernia may involve a considerable blunt force that is distributed over a surface area sufficiently large enough to prevent penetration but small enough to remain focal, such as a handle bar [1-2]. Rectus sheath hematoma is an uncommon condition caused by a tear in a epigastric vessel and characterized by sudden onset of severe abdominal pain and a palpable mass. A history of trauma, anticoagulant therapy and in some cases something as trivial as coughing, straining, or twisting to one side have been documented [3-5]. Rectus sheath hematoma nearly always present acutely, with abdominal pain of sudden onset, and on occasion may mimic an acute abdomen process [4]. There was no case found in literature showing these two entities occurring in combination. However, if CT-scans show a hematoma of abdominal wall, which includes parts of bowel, there has to be thought of this rare condition of herniation of bowel into a rectus sheath hematoma. In this case indication for surgical intervention had to be set immediately to prevent ischemic damage of the bowel.