Rectus sheath hematoma (RSH) is a rare cause of abdominal pain that is often overlooked when patients present for evaluation. The disease can mimic almost any other type of abdominal pathology, and thus the diagnosis is frequently delayed.

As the population ages, and more patients are taking prescription anticoagulants, it is likely that the incidence of RSH will continue to rise.

Emergency physicians must include RSH on the differential of acute abdominal pain with a palpable mass, particularly if predisposing risk factors are present.

Ultrasound may be a useful screening test, particularly in unstable, pediatric, or pregnant patients, but CT scan should be employed if there is no contraindication.

Clinical factors such as the extent of hematoma, degree of coagulopathy or anemia, and level of hemodynamic compromise should be used to guide management and disposition.

IV fluid resuscitation, pain control, and when indicated, reversal of anticoagulation and blood transfusion, should be initiated in the emergency department.

All but the smallest hematomas will require admission and surgical consultation, though patients can be reassured that the condition is treatable and most often self-limited.

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