外傷(Trauma)シリーズ19 RESIDENT COURSE 解答 【症例 TR 91】

外傷性腹直筋鞘血腫.Traumatic rectus sheath hematoma








↑は腹直筋内血腫である.下腹部では外側から背側へ波及している(図9〜図12:白矢印) .図1と図2の△は晩期相(Delayed:図5と図6)で大きさと形に変化を示さないので仮性動脈瘤の可能性が高い.Extravasationだとしても,スライス数が少ないし,また腹直筋鞘は強靱なので自然止血が大いに期待できる.安静のみで疼痛と膨隆が徐々に軽減した.Hb:13.4→9.9g/dl.




参考症例1(外傷性皮下血腫):脚立から転落し左側腹部を打撲した30歳男性.
↑は皮下血腫を示しており,図2〜図4の△はextravasationの可能性があるがdouble phase 造影CTでないと正確な診断はできない.
翌日400mlの血液を穿刺吸引し,その後は安静のみで順調に経過した.Hb:13.0→9.9g/dl.



参考症例2(外傷性皮下血腫):59歳男性.追突事故で下腹部を打撲し,下腹部痛を訴えて来院した.下腹部に 圧痛を伴う腫瘤を触れた.
CTは皮下血腫(▲)を示している.経過中に腹腔内臓器の損傷所見を認めなかった.



文献考察:腹直筋鞘血腫(Rectus sheath hematoma).126例中,原因は外傷性が最も多く:48%,次いで咳:29%.7.9%に手術またはTAEを要した.リスクfactorは女性,高齢者,抗凝固剤服用者,咳と外傷であった.
Medicine (Baltimore). 2006 Mar;85(2):105-10.
Rectus sheath hematoma: review of 126 cases at a single institution.
Cherry WB, Mueller PS.

Rectus sheath hematoma (RSH) is an uncommon condition characterized by abdominal pain and an abdominal wall mass. We reviewed the clinical features, treatment, and outcomes of 126 patients treated for RSH at Mayo Clinic from January 1, 1992, to December 31, 2002. Most patients (64%) were women and the mean +/- SD age was 67.9 +/- 16.5 years. Most patients (69%) were on some form of anticoagulation therapy. The mean international normalized ratio was 2.6 +/- 2.4, and mean activated partial thromboplastin time was 64.2 +/- 42.7 seconds. No patients were pregnant or had a peritoneal dialysis catheter at the time of diagnosis. Approximately half of the patients (48%) had nonsurgical abdominal trauma around the time of diagnosis, with 37 patients (29%) having a cough. The most common presenting signs and symptoms were abdominal pain (84%) and an abdominal wall mass (63%). CT of the abdomen and pelvis was the most commonly used method to establish the diagnosis (83%). Most patients (86%) were successfully treated with symptom management and blood transfusion. Ten patients (7.9%) underwent surgery or endovascular embolization of bleeding vessels, and 2 patients (1.6%) died as a result of RSH bleeding. Although RSH is rarely fatal, the clinician should be aware of important risk factors that lead to RSH including female sex, older age, anticoagulation therapy, and cough or other abdominal trauma. Rapid diagnosis with directed history, physical examination, and CT of the abdomen and pelvis may help decrease unnecessary laparotomy and lead to better triage of patients who present with RSH.PMID: 16609349

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