What is the appropriate work-up for a patient presenting with a spontaneous abdominal hematoma without a history of trauma?

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Work-up for Spontaneous Abdominal Hematoma

Begin with immediate contrast-enhanced CT scan of the abdomen and pelvis, which is the diagnostic test of choice for detecting, localizing, and characterizing spontaneous abdominal hemorrhage. 1

Initial Clinical Assessment

Hemodynamic Status Determination

  • Assess blood pressure, heart rate, and signs of shock immediately upon presentation 2
  • Obtain baseline hemoglobin/hematocrit, though recognize that initial values may not reflect acute blood loss due to lack of hemodilution 3
  • Measure serum lactate or base deficit as sensitive markers to estimate extent of bleeding and shock 3
  • Serial hemoglobin monitoring every 4-6 hours is essential to detect ongoing hemorrhage 3

Key History Elements

  • Document all anticoagulant and antiplatelet medications, as these are the most common cause of spontaneous abdominal wall and intra-abdominal hematomas 4, 5
  • Identify any recent minor trauma triggers (coughing, sneezing, straining) that can precipitate bleeding in anticoagulated patients 5
  • Screen for underlying coagulopathies, liver disease, or malignancy 6

Imaging Algorithm

Primary Imaging: Contrast-Enhanced CT

  • CT is the technique of choice for detection, localization, and extension of spontaneous abdominal bleeding 1
  • Perform immediately in hemodynamically stable patients to characterize the hematoma and identify active extravasation 2, 6
  • CT can identify specific locations: rectus sheath (most common), mesenteric, retroperitoneal, psoas, intestinal wall, or solid organ hematomas 4
  • Active contrast extravasation ("blush") indicates ongoing arterial bleeding requiring intervention 3

Ultrasound Role

  • FAST examination has limited utility in spontaneous hematoma as it only detects free intraperitoneal fluid, not solid organ injuries or contained hematomas 7
  • Ultrasound can be used for serial monitoring of rectus sheath hematomas during conservative management 5
  • Do not rely on negative ultrasound to exclude significant pathology 7

MRI Consideration

  • Reserve MRI for cases where CT findings are equivocal or to further characterize lesions initially suspicious for tumor 6
  • MRI can help differentiate hematoma from neoplasm in duodenal or other gastrointestinal wall lesions 6

Laboratory Work-up

Essential Tests

  • Complete blood count with serial hemoglobin measurements every 4-6 hours 3, 2
  • Coagulation profile: PT/INR, aPTT to assess anticoagulation status 4
  • Type and crossmatch blood products in case transfusion becomes necessary 2
  • Serum lactate or base deficit for shock assessment 3
  • Comprehensive metabolic panel to assess renal function and electrolytes 6

Pitfall to Avoid

  • Do not use single hematocrit measurements as an isolated marker for bleeding severity, as initial values do not accurately reflect blood loss 3

Risk Stratification and Disposition

Hemodynamically Stable Patients

  • Admit for close monitoring with serial abdominal examinations every 4-6 hours 3
  • Continue serial hemoglobin monitoring to detect delayed bleeding 3, 4
  • Conservative management is successful in 90.6% of cases with anticoagulant-related hematomas 4

Hemodynamically Unstable Patients

  • If active arterial extravasation is identified on CT, emergent angioembolization should be considered as first-line therapy to reduce morbidity and mortality 3
  • Interventional radiology consultation for transcatheter arterial embolization if available 4
  • Surgical consultation for potential exploratory laparotomy if angioembolization unavailable or unsuccessful 2

Common Etiologies to Identify

Most Common Causes

  • Anticoagulant/antiplatelet therapy (most frequent) 4, 5
  • Rectus sheath hematoma (37.2% of cases) 4
  • Mesenteric hematoma from vascular tree bleeding 2
  • Duodenal or intestinal wall hematoma 6
  • Retroperitoneal, psoas, or pelvic hematomas 4

Critical Pitfall

  • Rapidly expanding mesenteric hematomas can present initially with benign examination but progress to hypovolemic shock within hours, requiring aggressive serial imaging 2
  • Mortality occurs in 4.6% of cases, typically in patients with delayed recognition or inadequate monitoring 4

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Research

Spontaneous abdomen and abdominal wall hematomas due to anticoagulant/antiplatelet use: Surgeons' perspective in a single center.

Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma & emergency surgery : TJTES, 2020

Guideline

Focused Assessment with Sonography for Trauma (FAST) Recommendations

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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