Massive rectus sheath hematoma following anticoagulation requiring operative hemorrhage control: a case report.

INTRODUCTION: Rectus sheath hematoma (RSH) is an uncommon complication of anticoagulation that can rapidly progress to hemorrhagic shock and may require operative management. PRESENTATION OF CASE: We report a case, in accordance with the SCARE criteria, of a 75-year-old patient with acute-on-chronic lower limb ischemia who developed a Type III RSH while receiving a therapeutic heparin infusion and awaiting a delayed vascular bypass. The patient was hypotensive and developed acute tense distension of the lower abdomen. The patient was resuscitated, and computed tomography (CT) with IV contrast was performed, demonstrating a Type III RSH measuring 18.9 × 10.1 × 15.2 cm with suspected active extravasation near the pelvic side wall. CLINICAL DISCUSSION: Given shock physiology and an acute change on exam, the patient was taken to the operating room, where active bleeding from the inferior epigastric artery was identified. Severe RSH may be intermittently tamponaded and lack a clear angiographic target. CONCLUSION: In unstable patients, escalation should be driven by bedside physiology and serial examination rather than by imaging alone.