Rectus sheath hematoma from spontaneous inferior epigastric artery bleeding without conventional risk factors, possibly precipitated by sneezing: a case report

<p style="font-weight: 400;"><strong>Background:</strong> Rectus sheath hematoma (RSH) resulting from inferior epigastric artery (IEA) injury is an uncommon cause of acute abdominal pain. It is typically associated with trauma, anticoagulant therapy, coagulopathy, or iatrogenic vascular injury. Spontaneous IEA bleeding in the absence of these risk factors is rare and can mimic other causes of acute abdomen, potentially delaying diagnosis.</p> <p style="font-weight: 400;"><strong>Case Presentation: </strong>A 62-year-old male with no history of trauma, anticoagulation use, or coagulopathy presented with sudden-onset suprapubic pain radiating to the right lower quadrant. The pain was preceded by a bout of sneezing and was associated with new-onset abdominal wall ecchymosis. Laboratory workup revealed a mild drop in hemoglobin, with an otherwise normal coagulation profile. Contrast-enhanced CT abdomen with a bleeding protocol demonstrated a left rectus abdominis intramuscular hematoma with active arterial contrast extravasation, consistent with left IEA bleeding. The patient underwent emergent transcatheter embolization of the left IEA, achieving successful hemostasis. He was discharged the following day in stable condition. At one-month follow-up, he had complete symptom resolution and interval improvement of the hematoma on imaging.</p> <p style="font-weight: 400;"><strong>Conclusion: </strong>Spontaneous IEA bleeding should be considered in the differential diagnosis of acute abdominal pain, even in patients without conventional risk factors, particularly when preceded by a Valsalva-type trigger such as sneezing. Early recognition with contrast-enhanced CT and prompt endovascular embolization enable effective, minimally invasive management and favorable outcomes.</p>