Is an abdominal ultrasound (US) still necessary for a patient with a history of large left rectal sheath hematoma, now presenting with ongoing left lower quadrant (LLQ) pain and a bruised, hardened area, after being transferred to a rehabilitation facility?

No Additional Ultrasound is Necessary

You do not need to order an abdominal ultrasound for this patient with a known rectus sheath hematoma that was already diagnosed on CT scan. The CT scan has already established the diagnosis with 100% accuracy, and ultrasound would provide no additional clinically useful information for ongoing management at this stage 1, 2.

Why Ultrasound is Not Indicated

CT Already Provided Definitive Diagnosis

• CT scan is the gold standard diagnostic modality for rectus sheath hematoma with 100% diagnostic accuracy, making repeat imaging with an inferior modality unnecessary 2, 3
• The ACR Appropriateness Criteria explicitly state that ultrasound has significant limitations for evaluating retroperitoneal and abdominal wall structures, particularly in detecting smaller volumes of blood products and determining if bleeding is active 1

Ultrasound Cannot Answer Relevant Clinical Questions

• Ultrasound cannot reliably determine if bleeding is currently active or has resolved, which is the key clinical question in a patient with ongoing symptoms 1
• Anatomical evaluation of deep structures is difficult with ultrasound due to patient positioning limitations and lack of sufficient acoustic windows 1
• The presence of bruising and a hardened area are expected physical examination findings during the resolution phase of a rectus sheath hematoma and do not require imaging confirmation 4, 3

What You Should Do Instead

Clinical Monitoring is Appropriate

• Conservative management with symptom control is successful in 86-90% of rectus sheath hematoma cases, particularly in spontaneous hematomas related to anticoagulation 2, 3
• Monitor for signs of active bleeding: hemodynamic instability, dropping hemoglobin, expanding abdominal mass, or increasing pain 5, 3
• Serial hemoglobin measurements are more useful than repeat imaging for detecting ongoing bleeding 3

Indications for Repeat CT (Not Ultrasound)

• Order repeat CT with IV contrast only if there are clinical signs suggesting active rebleeding: new hypotension, significant hemoglobin drop (>2 g/dL), acute expansion of the mass, or hemodynamic instability 5, 2
• CT can detect contrast extravasation indicating active arterial bleeding that might require interventional radiology embolization 5, 3

Pain Management Considerations

• Ongoing pain at the rehab facility is expected and typically managed conservatively with analgesics 4, 2
• Patients treated conservatively require more analgesics and have longer hospital stays compared to surgical patients, but this is the appropriate management for stable hematomas 4

Common Pitfalls to Avoid

• Do not order ultrasound simply because the patient has ongoing symptoms - bruising and firmness can persist for weeks during hematoma resolution 4, 3
• Do not assume ultrasound is "less invasive" or "safer" when it provides no actionable information - the radiation from the initial CT has already been administered 1
• Review anticoagulation status carefully, as patients on anticoagulants develop larger hematomas and more frequently require intervention 4, 2, 3
• Surgery or interventional radiology is indicated only for hemodynamic instability, continued bleeding despite reversal of coagulopathy, or development of abdominal compartment syndrome 5, 2