A 69-year-old woman comes to the emergency department due to increasing abdominal pain for the past several hours that is worsened by cough or movement. She has had no nausea, vomiting, or diarrhea. For the past 2 days, the patient has had cough and wheezing due to an asthma exacerbation, for which she has been taking an oral glucocorticoid and using inhaled bronchodilators. Other medical conditions include hypertension and atrial fibrillation, for which she takes lisinopril, diltiazem, and apixaban. Surgical history includes abdominal hysterectomy 15 years ago. Temperature is 37 C (98.6 F), blood pressure is 110/60 mm Hg, pulse is 92/min, and respirations are 16/min. BMI is 29 kg/m². There is mild expiratory wheezing bilaterally. Heart sounds are normal. Abdominal examination reveals localized fullness with tenderness and guarding just lateral to the umbilicus on the left side. Bowel sounds are normal in all quadrants. Leukocyte count is 12,000/mm³ and hemoglobin is 10.8 g/dL. Which of the following is the most likely underlying cause of this patient's abdominal symptoms?

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11ec25c8_d919_3ee8_bc81_79065c443696_MD0003_00 This patient taking apixaban developed acute abdominal pain associated with a palpable abdominal mass and anemia, suggesting the development of a rectus sheath hematoma (RSH). RSH typically occurs due to rupture of the inferior epigastric artery, which supplies blood to the lower aspect of the rectus abdominis muscle. The rectus sheath, which contains this muscle, does not extend posteriorly below the arcuate line; therefore, bleeding below this line (eg, lower aspect of rectus abdominis muscle) is relatively uncontained and can result in significant hemorrhage with hematoma formation. RSH is often seen with blunt trauma or forceful abdominal contractions (eg, severe coughing in asthma exacerbation), particularly in patients receiving anticoagulation therapy. Other risk factors include older age and female sex. rectus sheath Manifestations include acute abdominal pain, often associated with rebound or guarding, and a palpable abdominal wall mass. Tenderness may worsen with abdominal contraction (Carnett sign). Nausea, vomiting, and fever may also occur. Laboratory findings usually include anemia and leukocytosis (likely due to inflammation). Abdominal CT confirms the diagnosis. Hemodynamically stable patients are usually managed conservatively (eg, serial monitoring of CBC, reversal of anticoagulation when appropriate); however, those with significant bleeding or hemodynamic instability (eg, shock) may require angiography with embolization or surgery. (Choice A) Diverticular abscess also causes leukocytosis and abdominal pain and may cause a palpable abdominal mass. However, fever and nausea/vomiting usually precede the development of the abscess. The onset is generally less acute, and anemia is unexpected. (Choice B) Ovarian torsion is associated with pain and a palpable mass; however, it causes severe pelvic (rather than periumbilical) pain and an adnexal mass. In addition, it would not cause anemia and is more common in women in their 20s and 30s. (Choice D) Sigmoid volvulus presents with abdominal pain and vomiting. However, onset is typically insidious (days) and is associated with severe, diffuse, abdominal pain and tympany on examination. Blood counts are usually normal unless perforation has occurred. (Choice E) Although paraumbilical hernias can occur after abdominal surgery and may cause a painful abdominal mass (particularly if strangulation occurs), patients typically have a history of a palpable bulge that enlarges with increased intraabdominal pressure (eg, coughing). Furthermore, anemia is unexpected. Educational objective: Rectus sheath hematomas are characterized by acute abdominal pain with a palpable abdominal wall mass, often associated with anemia and leukocytosis. They usually occur due to rupture of the inferior epigastric artery from blunt trauma or forceful abdominal contractions (eg, severe coughing), particularly in those receiving anticoagulation therapy. References: Rectus sheath hematoma: a review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/25529279)

A 69-Year-Old Woman Comes to the Emergency Department Due to Increasing