Does COVID-19 increase the incidence of spontaneous rectus sheath hematoma?

BACKGROUND: The COVID-19 pandemic started to affect Turkey in March 2020. In this study, we retrospectively investigated spontaneous rectus sheath hematoma (S-RSH) in patients with COVID-19 presenting with acute abdominal pain during the ongoing pandemic.
METHODS: The demographic characteristics, laboratory findings, length of hospital stay, and treatment processes of COVID-19 cases with S-RSH detected between March and December 2020 were recorded. The rectus sheath hematoma diagnosis of the patients was made using abdominal computed tomography, and the patients were followed up. Low-molecular-weight heparin treatment, which was initiated upon admission, was continued during the follow-up.
RESULTS: S-RSH was detected in 13 out of 220 patients with COVID-19 who were referred to general surgery for consultation due to acute abdominal pain. The mean age of these patients was 78±13 years, and the female-to-male ratio was 1.6. Mechanical ven-tilation support was applied to three patients, all of whom were followed up in the intensive care unit. Two patients died for reasons independent of rectus sheath hematoma during their treatment. Among the laboratory findings, the activated partial thromboplastin time (aPTT) values did not deviate from the normal range. While there was no correlation between the international normalized ratio (INR) and aPTT (p>0.01), a significant correlation was found between INR and interleukin-6 (IL-6) (p<0.002). None of the patients required surgical or endovascular interventional radiology procedures.
CONCLUSION: In the literature, the incidence of S-RSH in patients presenting with acute abdominal pain is 1.8%. However, in our series, this rate was approximately 3 times higher. Our patients’ normal INR and aPTT values suggest that coagulopathy was mostly secondary to endothelial damage. In addition, the significantly higher IL-6 values (p<0.002) indicate the development of vasculitis along with the acute inflammatory process. S-RSH can be more commonly explained the high severity of vasculitis and endothelial damage due to viral infection.

COVID-19 spontan rektus kýlýf hematom insidansýný arttýrýr mý?

AMAÇ: COVID-19 pandemisi Türkiye’yi Mart 2020’de etkilemeye baþladý. Bu çalýþmada, devam eden pandemi sýrasýnda akut karýn aðrýsý ile baþvu-ran COVID-19 hastalarýnda spontan rektus kýlýf hematomunu (S-RSH) geriye dönük olarak araþtýrdýk.
GEREÇ VE YÖNTEM: Mart–Aralýk 2020 tarihleri arasýnda S-RSH saptanan COVID-19 olgularýnýn demografik özellikleri, laboratuvar bulgularý, has-tanede kalýþ süreleri ve tedavi süreçleri kaydedildi. Hastalarýn rektus kýlýf hematomu tanýsý tüm batýn bilgisayarlý tomografisi ile konuldu ve hastalar izleme alýndý. Baþvuru sýrasýnda baþlanan düþük molekül aðýrlýklý heparin tedavisine izlemde de devam edildi.
BULGULAR: Akut karýn aðrýsý nedeniyle genel cerrahiye sevk edilen 220 COVID-19 hastasýnýn 13’ünde S-RSH tespit edildi. Bu hastalarýn yaþ ortala-masý 78±13 yýl, kadýn erkek oraný 1.6 idi. Tamamý yoðun bakýmda takip edilen üç hastaya mekanik ventilasyon desteði uygulandý. Ýki hasta tedavileri sýrasýnda rektus kýlýf hematomundan baðýmsýz nedenlerle öldü. Laboratuvar bulgularýndan aktive parsiyel tromboplastin zamaný (aPTT) deðerleri normal aralýktan sapmadý. INR ile aPTT (p>0.01) arasýnda iliþki bulunmazken, INR ile interlökin-6 (IL-6) arasýnda anlamlý bir iliþki bulundu (p<0.002). Hiçbir hastada cerrahi veya endovasküler giriþimsel radyoloji prosedürü gerekmedi.
TARTIÞMA: Literatürde akut karýn aðrýsý ile baþvuran hastalarda S-RSH insidansý %1.8’dir. Ancak bizim çalýþmamýzda bu oran yaklaþýk üç kat daha fazlaydý. Hastalarýmýzýn normal INR ve aPTT deðerleri, koagülopatinin çoðunlukla endotel hasarýna sekonder olduðunu düþündürmektedir. Ek olarak, anlamlý derecede yüksek IL-6 deðerleri (p<0.002), akut enflamatuvar süreçle birlikte vaskülit geliþimini de göstermektedir. S-RSH, daha yaygýn olarak viral enfeksiyona baðlý vaskülit ve endotel hasarýnýn yüksek ciddiyeti ile açýklanabilir.