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Acquired Abnormalities

Rectus Abdominis Diastasis


Rectus abdominis diastasis (or diastasis recti) describes a clinically evident separation
of the rectus abdominus muscle pillars, generally as a result of decreased tone of the
abdominal musculature. The characteristic bulging of the abdominal wall in the
epigastrium is sometimes mistaken for a ventral hernia, despite the fact that the
.midline aponeurosis is intact and no hernia defect is present
Diastasis may be congenital, as a result of a more lateral insertion of the rectus
muscles to the ribs and costochondral junctions, but is more typically an acquired
condition with advancing age, obesity, or following pregnancy. In the postpartum
setting, rectus diastasis tends to occur in women of 1- advanced maternal age,2- after
multiple or twin pregnancies, or 3-in women who deliver high-birth-weight infants.
Diastasis is usually easily identified on physical examination (Fig. 34-6). Computed
tomography (CT) scanning provides an accurate means of measuring the distance
between the rectus pillars and will differentiate rectus diastasis from a true ventral
hernia if clarification is required. Surgical correction of a severe rectus diastasis by
plication of the anterior rectus sheath may be undertaken for cosmetic indications, or
.if it is associated with disability of abdominal wall muscular function

Rectus Sheath Hematoma


The terminal branches of the superior and inferior epigastric arteries course deep to
the posterior aspect of the left and right rectus pillars and penetrate the posterior
rectus sheath. Injury to these vessels or to any of the network of collateralizing vessels
.within the rectus sheath and muscles can result in a rectus sheath hematoma
Although there may be a history of significant blunt trauma, less-obvious events also
have been reported to cause this condition, such as
sudden contraction of the rectus muscles with coughing, sneezing, or any-1
.vigorous physical activity
Spontaneous rectus sheath hematomas have been described in the elderly and in-2
.those on anticoagulation therapy
Patients frequently describe the sudden onset of unilateral abdominal pain that
may be confused with lateralized peritoneal disorders such as appendicitis.
Below the arcuate line, a hematoma may cross the midline and cause bilateral
.lower quadrant pain
History and physical examination alone may be diagnostic. Pain typically increases
with contraction of the rectus muscles and a tender mass may be palpated. The ability
to appreciate an intra-abdominal mass is ordinarily degraded with contraction of the
rectus muscles. Fothergill's sign is a palpable abdominal mass that remains
unchanged with contraction of the rectus muscles and is classically associated with
rectus hematoma. A hemoglobin/hematocrit level and coagulation studies should be
obtained. Abdominal ultrasonography may show a solid or cystic mass within the
abdominal wall, depending on the chronicity of the bleeding event. Computed
tomography is the most definitive study for establishing the correct diagnosis and
excluding other intra-abdominal disorders. Magnetic resonance imaging (MRI) also
.has been employed for this purpose
Specific treatment depends on the severity of the hemorrhage. Small, unilateral, and
contained hematomas may be observed without hospitalization. Bilateral or large
hematomas will likely require hospitalization, as well as potential resuscitation. The
need for a red blood cell or coagulation factor transfusion is determined by the clinical
circumstances. Reversal of warfarin (Coumadin) anticoagulation in the acute setting is
frequently, but not always, necessary. Emergent operative intervention or
angiographic embolization is required infrequently, but may be necessary if
hematoma enlargement, free bleeding, or clinical deterioration occur. Surgical therapy
consists of evacuation of the hematoma and ligation of any bleeding vessel identified.
Mortality in this condition is rare, but has been reported in patients requiring surgical
treatment and in the elderly

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