What is the initial approach to managing a rectus sheath hematoma?

Approach to Rectus Sheath Hematoma

Conservative management is the primary treatment for rectus sheath hematoma in hemodynamically stable patients, with close monitoring of hemoglobin levels, reversal of anticoagulation, and supportive care including analgesia and blood transfusion as needed. 1, 2

Initial Assessment and Diagnosis

Clinical Presentation

• Suspect rectus sheath hematoma in elderly women (mean age 67-74 years) presenting with the classic triad: acute abdominal pain (87.5%), infraumbilical mass (83.3%), and anemic syndrome 2, 3
• Most patients (87.5%) are on anticoagulant therapy (oral anticoagulants, unfractionated heparin, or low-molecular-weight heparin) 2, 3
• Triggering factors are present in 75% of cases, with coughing being most common (70.8%) 3
• Other predisposing factors include hypertension (79.1%) and prior abdominal surgery (50%) 3

Diagnostic Imaging

• CT scan with IV contrast is the preferred imaging modality for confirming diagnosis, identifying location, size, and potential active bleeding 1
• CT demonstrates the hematoma in 100% of cases, while ultrasonography detects only 75% 2
• Obtain baseline blood tests including complete blood count, coagulation studies (PT/INR, PTT), and type and cross-match 1

Management Based on Hemodynamic Status

For Hemodynamically Stable Patients (79.1% of cases)

Conservative management is effective in the majority of patients and should be the initial approach: 2, 3

• Reverse anticoagulation immediately if present, targeting INR <1.4 in warfarin-treated patients and platelet count >100 × 10⁹/L 4
• Administer vitamin K1 and fresh frozen plasma to normalize coagulation 2, 5
• Provide adequate analgesia for pain control 1
• Monitor hemoglobin levels serially to detect ongoing bleeding 1, 2
• Transfuse blood products as needed—all type III (severe) hematomas require blood transfusion 2
• Consider hemostatic agents (carbazochrome and tranexamic acid) to control bleeding expansion 6
• Apply rest, ice, compression, and elevation principles to limit further bleeding 1

For Hemodynamically Unstable Patients (20.8% requiring intervention)

Patients with hypovolemic shock (37.5% of cases) or those failing conservative management require escalation of care: 3

• Secure large-bore intravenous access (8-Fr central access ideal in adults) 1
• Administer high FiO2 and actively warm the patient and all transfused fluids 1
• Initiate blood product resuscitation with warmed blood and blood components 1
• Consider invasive blood pressure monitoring for patients with significant comorbidities 1

Interventional radiology is the first-line intervention for failed conservative management: 3

• Perform arteriography with selective embolization of the epigastric arteries if active bleeding is identified on imaging 1, 3
• This is particularly important for patients on low-molecular-weight heparin, who have higher rates of requiring intervention (80% of intervention cases) 3
• Ultrasound-guided aspiration may be considered for large hematomas causing significant pain or functional impairment 1

Surgical management should be reserved only for hemodynamic instability despite resuscitation and interventional approaches 1

Monitoring and Follow-up

• Perform serial hemoglobin measurements to detect ongoing bleeding 1
• Mean hospital stay is approximately 13.6 days for uncomplicated cases 5
• Follow-up CT scan at 4 days can confirm hematoma reduction 6
• Once bleeding is controlled and hematoma stability confirmed on serial imaging, commence standard venous thromboprophylaxis as patients rapidly develop a prothrombotic state 4
• Rectus sheath hematoma is not a contraindication to resuming anticoagulation once adequately managed and patient has returned to stable clinical baseline 7

Critical Pitfalls to Avoid

• Do not perform unnecessary surgical intervention—early and accurate diagnosis with CT allows successful medical treatment in 79.1% of cases 2, 3, 5
• Do not delay reversal of anticoagulation—excessive anticoagulation is present in two-thirds of cases and requires immediate correction 2
• Do not underestimate mortality risk—rectus sheath hematoma carries 4-15% mortality, particularly in elderly patients with multiple comorbidities 3, 5
• Do not miss the diagnosis—this condition is frequently misdiagnosed, leading to unnecessary laparotomy 5