From the Research
The management of rectus sheath hematoma should primarily be conservative, with the use of hemostatic agents such as carbazochrome and tranexamic acid, as evidenced by a recent case report in 2025 1. This approach is supported by the most recent and highest quality study available, which highlights the effectiveness of conservative treatment in managing rectus sheath hematoma. The key components of conservative management include:
- Bed rest to reduce further strain on the abdominal wall
- Analgesia with medications such as acetaminophen, avoiding NSAIDs if the patient is on anticoagulation therapy
- Application of ice packs to the affected area to help reduce bleeding and discomfort
- Close monitoring of vital signs and hemoglobin levels to quickly identify any signs of hemodynamic instability For patients on anticoagulation therapy, reversal may be necessary using specific agents such as protamine sulfate for heparin, vitamin K or prothrombin complex concentrate for warfarin, or specific reversal agents for direct oral anticoagulants, as discussed in earlier studies 2, 3, 4. However, the most recent study 1 suggests that the use of hemostatic agents like carbazochrome and tranexamic acid can be an effective adjunct to conservative management, potentially reducing the need for anticoagulation reversal in some cases. In severe cases with ongoing bleeding, interventional approaches such as arterial embolization or surgical evacuation may be necessary, as noted in other studies 5. Surgery is typically reserved for cases with hemodynamic instability despite conservative measures, expanding hematomas, or abdominal compartment syndrome. The underlying pathophysiology involves bleeding into the rectus sheath, often from torn epigastric vessels or rectus muscle tears, which can occur spontaneously in anticoagulated patients or following trauma, excessive straining, or coughing. Given the potential for high morbidity and mortality associated with rectus sheath hematoma, especially in patients with additional comorbidities, early diagnosis and sufficient supportive treatment are crucial for management, as emphasized in the recent case report 1.