Intended for healthcare professionals

Endgames Case report

Abdominal pain and swelling

BMJ 2009; 339 doi: (Published 05 August 2009) Cite this as: BMJ 2009;339:b2870
  1. Saeed Mirsadraee, specialist registrar in radiology,
  2. David Kessel, consultant radiologist
  1. 1Radiology Academy, Leeds General Infirmary, Leeds LS1 3EX
  1. niloogan{at}

    Case history

    A 78 year old woman presented with a sudden onset tender palpable lump just to the right of the midline in the infraumbilical region. The patient was taking warfarin for previous prosthetic heart valve surgery. No history of trauma was present. An ultrasound examination showed a cystic mass with echogenic sediment in the rectus abdominis muscle. Two days later, the patient’s abdominal pain increased, her abdomen became distended, and she became hypotensive with a blood pressure of 75/45 mm Hg despite fluid resuscitation. Blood tests showed a drop in haemoglobin concentration—from 100 g/l to 70 g/l—and an increase in serum creatinine—from normal (45-90 μmol/l) to 230 μmol/l over the two day period. The patient had an international normalised ratio (INR) of 7.


    • 1 What is the diagnosis?

    • 2 What was the cause of the hypotension and haemoglobin drop?

    • 3 What investigations should be requested after detecting haemodynamic deterioration?

    • 4 Which medical teams should this patient be discussed with?

    • 5 What is the management of such a patient following haemodynamic deterioration?


    Short answers

    • 1 The initial clinical diagnosis is rectus sheath haematoma.

    • 2 The patient had ongoing haemorrhage that was significant enough to cause anaemia and haemodynamic instability.

    • 3 Urgent investigations include monitoring clotting profile and angiography (computerised tomography angiography or catheter angiography).

    • 4 Specialists from several disciplines should be involved in this case:

    • a) Cardiologists—to …

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