腹直肌鞘血肿的临床特征及预后分析
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摘要
目的分析腹直肌鞘血肿(RSH)的临床特征及预后,以提高临床对RSH的认识和早期临床诊断率。方法收集2005年1月——2015年12月在济宁医学院附属医院诊治的33例RSH患者的临床资料,回顾性分析其病因、临床表现、影像学检查及实验室检查、治疗与预后。结果 17例患者接受抗凝、抗血小板治疗后发生RSH,其中接受抗凝治疗13例、抗血小板治疗7例。30例患者临床表现为突发的腹部疼痛。30例患者体格检查发现腹壁固定肿物且伴有局部触痛,其余3例仅有局部触痛,并未发现腹壁固定肿物。33例RSH患者中29例患者在腹部疼痛出现48 h内行腹部CT检查(其中18例患者CT检查前行腹部超声检查,正确诊断15例)。33例RSH患者中,3例患者保守治疗血肿液化后行超声引导下穿刺引流,血肿完全吸收;26例RSH患者保守治疗后血肿完全吸收;1例因出血过多血流动力学不稳定建议患者手术治疗时,患者家属由于经济原因放弃治疗后死亡。结论 RSH多发于老年人,尤其是接受抗凝、抗血小板治疗的患者,临床多表现为突发腹痛并腹壁包块,CT检查有助于早期明确诊断,大多患者经保守治疗后可取得良好的效果,从而避免手术治疗。
Objective To analyze the clinical features and prognosis of rectus sheath hematoma(RSH) to improve clinical awareness of RSH and its rate of early diagnosis.Methods Clinical data from 33 patients with RSH,who were treated in the Departments of Nephrology,Cardiology,Respiratory Medicine,Pediatric Surgery,General Surgery,and Obstetrics & Gynecology of the Affiliated Hospital of Jining Medical University between January 2005 and December 2015,were collected for a retrospective analysis of the etiology and clinical manifestations of RSH and its imaging examination,therapeutic method,treatment methods and prognosis.Results Of the 33 patients with RSH,17 patients received anticoagulation(13 cases)or antiplatelet(7 cases) therapy;30 patients shared the clinical manifestation of abrupt abdominal pain;30 patients had physical examination findings of fixed hematomas in the abdominal wall accompanied by local tenderness;and the remaining 3 cases were found to have only local tenderness in the absence of fixed hematomas. Within 48 hours after the onset of abdominal pain,29 patients underwent abdominal CT examination(18 patients had undergone abdominal ultrasound examination before CT examination,and 15 were correctly diagnosed);3 patients underwent ultrasound-guided puncture drainage after conservative treatment of hematoma liquefaction,and the hematoma was fully absorbed;in 26 patients,the hematoma was completely absorbed after conservative treatment;and 1 patient died after the family members declined(because of economic concerns) surgery offered as a treatment because of unstable hemodynamics due to excessive hemorrhage.Conclusion RSH is a common disease in elderly patients,especially in those receiving anticoagulation and antiplatelet therapy.The typical clinical manifestations are sudden abdominal pain and the presence of abdominal masses.CT examinations are helpful for early diagnosis,and conservative treatment can achieve favorable therapeutic effects for most patients in the absence of unnecessary surgeries.
Objective To analyze the clinical features and prognosis of rectus sheath hematoma(RSH) to improve clinical awareness of RSH and its rate of early diagnosis.Methods Clinical data from 33 patients with RSH,who were treated in the Departments of Nephrology,Cardiology,Respiratory Medicine,Pediatric Surgery,General Surgery,and Obstetrics & Gynecology of the Affiliated Hospital of Jining Medical University between January 2005 and December 2015,were collected for a retrospective analysis of the etiology and clinical manifestations of RSH and its imaging examination,therapeutic method,treatment methods and prognosis.Results Of the 33 patients with RSH,17 patients received anticoagulation(13 cases)or antiplatelet(7 cases) therapy;30 patients shared the clinical manifestation of abrupt abdominal pain;30 patients had physical examination findings of fixed hematomas in the abdominal wall accompanied by local tenderness;and the remaining 3 cases were found to have only local tenderness in the absence of fixed hematomas. Within 48 hours after the onset of abdominal pain,29 patients underwent abdominal CT examination(18 patients had undergone abdominal ultrasound examination before CT examination,and 15 were correctly diagnosed);3 patients underwent ultrasound-guided puncture drainage after conservative treatment of hematoma liquefaction,and the hematoma was fully absorbed;in 26 patients,the hematoma was completely absorbed after conservative treatment;and 1 patient died after the family members declined(because of economic concerns) surgery offered as a treatment because of unstable hemodynamics due to excessive hemorrhage.Conclusion RSH is a common disease in elderly patients,especially in those receiving anticoagulation and antiplatelet therapy.The typical clinical manifestations are sudden abdominal pain and the presence of abdominal masses.CT examinations are helpful for early diagnosis,and conservative treatment can achieve favorable therapeutic effects for most patients in the absence of unnecessary surgeries.
引文
[1]SALEMIS N S,GOURGIOTIS S,KARALIS G.Diagnostic evaluation and management of patients with rectus sheath hematoma.A retrospective study[J].Int J Surg,2010,8(1)﹕290-293.DOI:10.1016/j.ijsu.2010.02.011.
[2]BERNA J D,GARCIA-MEDINA V,GUIRAO J,et al.Rectus sheath hematoma﹕diagnostic classification by CT[J].Abdom Imaging,1996,21(1)﹕62-64.
[3]TESKE J M.Hematoma of the rectus abdominis muscle;report of a case and analysis of 100 cases from the literature[J].Am J Surg,1946,71(1):689-695.
[4]CHERRY W B,MUELLER P S.Rectus sheath hematoma:review of 126 cases at a single institution[J].Medicine(Baltimore),2006,85(1):105-110.
[5]TOLCHER M C,NITSCHE J F,ARENDT K W,et al.Spontaneous rectus sheath hematoma pregnancy:case report and review of the literature[J].Obset Gynecol Surv,2010,65(1):517-522.DOI:10.1097/OGX.0b013e3181f87eaf.
[6]SMITHSON A,RUIZ J,PERELLO R,et al.Diagnostic and management of spontaneous rectus sheath hematoma[J].Eur J Intern Med,2013,24(1):579-582.DOI:10.1016/j.ejim.2013.02.016.
[7]SAVAGE P E,JOSEPH A E,ADAM E J.Massive abdominal wall hematoma:real-time ultrasound of bleeding[J].J Ultrasound Med,1985,4(3):157-158.
[8]SHOKOOHI H,BONIFACE K,REZA TAHERI M,et al.Spontaneous rectus sheath hematoma diagnosed by point-of-care ultrasonography[J].CJEM,2013,15(2):119-122.
[9]SAHIN M,COSKUN S,COBANOGLU M,et al.Rapidly onseet rectus sheath hematoma mimicking cholecystitis[J].Am J Emerg Med,2011,29(6):698.e5-8.DOI:10.1016/j.ajem.2010.08.003.
[10]DAG A,OZCAN T,TORKMENOGLU O,et al.Spontanesous rectus sheath hematoma in patients on anticogulation therapy[J].Ulus Travma Acil Cerrahi Derg,2011,17(3):210-214.
[11]MOBIN M,WIN K E,KESHAVA S.Rapidly enlarging rectus sheath hematomas:the value of CT angiolgraphy in the identification of active bleeding[J].Vascular Disease Management,2007,4(5):156-158.
[12]BASILE A,MEDINA J G,MUNDO E,et al.Transcatheter arterial emobolization of concurrent spontaneous hematoma of the rectus sheath and psoas muscle in patients undergoing anticoagulation[J].Cardiovasc Intervent Radiol,2004,27(6):659-662.
[13]AUTEN J D,SCHOFER J M,BANKS S L,et al.Exerciseinduced bilateral rectus sheath hematomas presenting as acute abdominal pain with scrotal swelling and pressure:case report and review[J].J Emerg Med,2010,38(1):e9-12.
[14]BERNá-SERNA J D,SáNCHEZ-GARRE J,MADRIGAL M,et al.Ultrasound therapy in rectus sheath hematoma[J].Phys Ther,2005,85(4):352-357.
[15]HILDRETH D H.Anticoagulant therapy and rectus sheath hematoma[J].Am J Surg,1972,124(1):80-86.
[16]黄书然,孙占国,马艾英.腹直肌鞘血肿的诊断与治疗[J].临床急诊杂志,2014,15(8):469-472.DOI:10.13201/j.issn.1009-5918.2014.08.007.
[2]BERNA J D,GARCIA-MEDINA V,GUIRAO J,et al.Rectus sheath hematoma﹕diagnostic classification by CT[J].Abdom Imaging,1996,21(1)﹕62-64.
[3]TESKE J M.Hematoma of the rectus abdominis muscle;report of a case and analysis of 100 cases from the literature[J].Am J Surg,1946,71(1):689-695.
[4]CHERRY W B,MUELLER P S.Rectus sheath hematoma:review of 126 cases at a single institution[J].Medicine(Baltimore),2006,85(1):105-110.
[5]TOLCHER M C,NITSCHE J F,ARENDT K W,et al.Spontaneous rectus sheath hematoma pregnancy:case report and review of the literature[J].Obset Gynecol Surv,2010,65(1):517-522.DOI:10.1097/OGX.0b013e3181f87eaf.
[6]SMITHSON A,RUIZ J,PERELLO R,et al.Diagnostic and management of spontaneous rectus sheath hematoma[J].Eur J Intern Med,2013,24(1):579-582.DOI:10.1016/j.ejim.2013.02.016.
[7]SAVAGE P E,JOSEPH A E,ADAM E J.Massive abdominal wall hematoma:real-time ultrasound of bleeding[J].J Ultrasound Med,1985,4(3):157-158.
[8]SHOKOOHI H,BONIFACE K,REZA TAHERI M,et al.Spontaneous rectus sheath hematoma diagnosed by point-of-care ultrasonography[J].CJEM,2013,15(2):119-122.
[9]SAHIN M,COSKUN S,COBANOGLU M,et al.Rapidly onseet rectus sheath hematoma mimicking cholecystitis[J].Am J Emerg Med,2011,29(6):698.e5-8.DOI:10.1016/j.ajem.2010.08.003.
[10]DAG A,OZCAN T,TORKMENOGLU O,et al.Spontanesous rectus sheath hematoma in patients on anticogulation therapy[J].Ulus Travma Acil Cerrahi Derg,2011,17(3):210-214.
[11]MOBIN M,WIN K E,KESHAVA S.Rapidly enlarging rectus sheath hematomas:the value of CT angiolgraphy in the identification of active bleeding[J].Vascular Disease Management,2007,4(5):156-158.
[12]BASILE A,MEDINA J G,MUNDO E,et al.Transcatheter arterial emobolization of concurrent spontaneous hematoma of the rectus sheath and psoas muscle in patients undergoing anticoagulation[J].Cardiovasc Intervent Radiol,2004,27(6):659-662.
[13]AUTEN J D,SCHOFER J M,BANKS S L,et al.Exerciseinduced bilateral rectus sheath hematomas presenting as acute abdominal pain with scrotal swelling and pressure:case report and review[J].J Emerg Med,2010,38(1):e9-12.
[14]BERNá-SERNA J D,SáNCHEZ-GARRE J,MADRIGAL M,et al.Ultrasound therapy in rectus sheath hematoma[J].Phys Ther,2005,85(4):352-357.
[15]HILDRETH D H.Anticoagulant therapy and rectus sheath hematoma[J].Am J Surg,1972,124(1):80-86.
[16]黄书然,孙占国,马艾英.腹直肌鞘血肿的诊断与治疗[J].临床急诊杂志,2014,15(8):469-472.DOI:10.13201/j.issn.1009-5918.2014.08.007.