Who should be consulted for a rectal sheath hematoma?

Management of Rectus Sheath Hematoma: Specialist Consultation

For rectus sheath hematoma, consultation with interventional radiology is recommended as the first-line specialist, followed by general surgery if the patient is hemodynamically unstable or if conservative management fails. 1, 2

Initial Assessment and Specialist Consultation

• Rectus sheath hematoma (RSH) should be managed with a multidisciplinary approach, with interventional radiology as the primary specialist consultation for diagnosis confirmation and potential intervention 1, 3
• General surgery consultation should be obtained for patients with hemodynamic instability, expanding hematomas, or those who fail conservative management 2, 3
• Hematology consultation is recommended for patients on anticoagulation therapy to manage reversal strategies and subsequent anticoagulation plans 1, 4

Diagnostic Approach

• Computed tomography (CT) is the gold standard diagnostic modality for RSH, with 100% diagnostic accuracy, and should be performed promptly when RSH is suspected 1, 3
• Classification of RSH severity guides management decisions:
  • Type I: Intramuscular hematoma without fascial dissection
  • Type II: Hematoma between muscle and fascia without extension into prevesical space
  • Type III: Hematoma extending into prevesical space and peritoneum 1, 2
• Ultrasonography may be used for initial screening and follow-up monitoring but is less sensitive than CT for definitive diagnosis 3

Management Algorithm Based on Severity

Hemodynamically Stable Patients (Type I and II)

• Conservative management is effective in 90% of cases and should include:
  • Bed rest and activity restriction
  • Intravenous fluid resuscitation
  • Analgesia for pain control
  • Discontinuation of anticoagulants if applicable 1, 5
• Follow-up imaging should be performed to monitor hematoma resolution 3

Hemodynamically Unstable Patients (Type III)

• Immediate surgical consultation is mandatory 2
• Blood transfusion is required for all patients with Type III hematomas 1
• Interventional radiology consultation for potential embolization of the inferior epigastric artery should be considered before surgical intervention 3
• Surgical intervention (vessel ligation) is reserved for patients with continued hemodynamic instability despite conservative measures 3

Special Considerations

• Anticoagulation therapy is the most common predisposing factor for RSH, requiring careful management of coagulation parameters 1, 5
• Elderly patients on anticoagulants with acute abdominal pain and a palpable mass should be evaluated for RSH to avoid unnecessary surgical procedures 1
• Grade 3 hematomas can lead to abdominal compartment syndrome with potentially fatal outcomes, requiring urgent surgical evaluation 2
• Hemostatic agents such as tranexamic acid may be considered as adjunctive therapy in the conservative management approach 4

Prevention Strategies

• Careful attention to abdominal administration of low-molecular-weight heparin is essential to prevent traumatic RSH 1
• During laparoscopic procedures, trocar insertion under direct vision is recommended to avoid vessel injury 1
• Early recognition and diagnosis are crucial to prevent morbidity and unnecessary surgical interventions 1, 5