What is the management for rectus sheath hematoma?

Management of Rectus Sheath Hematoma

Primary Management Approach

Conservative management is the treatment of choice for rectus sheath hematoma in hemodynamically stable patients, with surgical or interventional radiology intervention reserved exclusively for those with hemodynamic instability. 1, 2, 3, 4

Initial Assessment and Diagnosis

Diagnostic Imaging

• Computed tomography (CT) of the abdomen is the gold standard for diagnosis, establishing the diagnosis in 100% of cases and allowing classification of hematoma type 3, 4
• Ultrasonography can be used for follow-up monitoring after initial CT diagnosis 1, 3
• CT imaging should be obtained promptly in elderly patients on anticoagulation presenting with acute abdominal pain and a palpable abdominal mass 4

Risk Stratification

• Anticoagulation or antiplatelet therapy is the most common predisposing factor, present in approximately 75% of cases 3, 4
• Type III hematomas (bilateral or extending below the arcuate line) carry higher risk and typically require blood transfusion 4
• Elderly patients with multiple comorbidities have higher morbidity and mortality risk 5

Conservative Management Protocol

Hemostatic Therapy

• Administer hemostatic agents including tranexamic acid and carbazochrome to control bleeding expansion 5
• Suspend anticoagulation therapy in the acute setting until the hematoma is adequately managed and clinical stability is achieved 2
• Correct coagulopathy by reversing anticoagulation (normalize INR if elevated) 1

Supportive Care

• Close monitoring of hemoglobin levels and vital signs is essential to detect early hemodynamic deterioration 5, 1
• Blood transfusion should be provided for significant anemia, particularly in Type III hematomas 4
• Pain management using multimodal analgesia with acetaminophen and NSAIDs (if not contraindicated by bleeding risk) 6
• Average hospital stay is approximately 6 days with conservative management 3

Monitoring Parameters

• Serial hemoglobin measurements in the first 72 hours 1
• Continuous assessment of vital signs for hemodynamic stability 5
• Follow-up imaging (ultrasonography or CT) at 3-4 days to confirm hematoma reduction 5

Operative Intervention Criteria

Indications for Surgery or Embolization

• Hemodynamic instability despite adequate resuscitation is the sole indication for operative intervention 1, 3, 4
• Surgical options include ligation of the bleeding vessel (superior or inferior epigastric artery) 3
• Interventional radiology with selective arterial embolization is an alternative to surgery 3
• Mortality rate of 17% has been reported in patients requiring surgery for hemodynamic instability 1

Contraindications to Conservative Management

• Persistent hemodynamic instability despite blood transfusion and hemostatic therapy 3, 4
• Development of abdominal compartment syndrome (rare complication) 2
• Consumption coagulopathy unresponsive to medical management 1

Resumption of Anticoagulation

Anticoagulation can be safely resumed once the hematoma is adequately managed and the patient has returned to stable clinical baseline 2

• RSH is not a contraindication to resuming anticoagulation after appropriate management 2
• Timing should be individualized based on hematoma size reduction on follow-up imaging and clinical stability 5

Common Pitfalls to Avoid

• Do not perform unnecessary surgery in hemodynamically stable patients, as conservative management is effective in 90% of cases 3, 4
• Do not delay diagnosis by failing to consider RSH in elderly patients on anticoagulation with acute abdominal pain 4
• Do not continue anticoagulation during acute bleeding phase, as this prevents hematoma stabilization 2
• Do not rely solely on clinical examination without confirmatory CT imaging, as RSH can mimic other intra-abdominal pathology 4
• Do not underestimate bleeding severity in patients with Type III hematomas, as they typically require transfusion 4

Prevention Strategies

• Exercise caution with abdominal administration of low-molecular-weight heparin to avoid traumatic RSH 4
• Use trocar insertion under direct vision during laparoscopic surgery to prevent iatrogenic injury to epigastric vessels 4
• Monitor INR closely in patients on warfarin therapy 1

5, 1, 2, 3, 4