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