What is the management approach for a patient with a suspected rectus sheath hematoma, particularly after abdominal surgery or trauma, and with a history of anticoagulation therapy?

Management of Rectus Sheath Hematoma

Most patients with rectus sheath hematoma, even those on anticoagulation therapy, should be managed conservatively with reversal of coagulopathy, hemodynamic support, and close monitoring, reserving surgical intervention only for those with hemodynamic instability despite resuscitation, abdominal compartment syndrome, or failure of conservative measures. 1, 2, 3

Initial Diagnostic Approach

Imaging

• Obtain urgent CT scan of the abdomen and pelvis with IV contrast immediately to confirm the diagnosis and characterize the hematoma—this is the diagnostic modality of choice with 100% sensitivity 1
• CT will classify the hematoma type (Type I: intramuscular and unilateral; Type II: intramuscular with preperitoneal extension; Type III: bilateral with preperitoneal extension) which guides management intensity 1
• Ultrasound is often inconclusive and should not delay CT imaging 4

Laboratory Assessment

• Measure hemoglobin, coagulation panel (PT/INR, aPTT), platelet count, fibrinogen level 5
• Obtain serum lactate and base deficit to assess severity of bleeding and shock—these are more reliable than isolated hematocrit values 5, 6
• Type and crossmatch blood products immediately 5

Clinical Evaluation

• Document anticoagulation history (warfarin, direct oral anticoagulants, low-molecular-weight heparin, antiplatelet agents) as this is the most common predisposing factor 4, 1, 2
• Assess for recent trauma, abdominal injections, coughing episodes, or muscle strain 1, 2
• Measure bladder pressure if abdominal compartment syndrome is suspected (pressure >20 mmHg indicates ACS) 2

Conservative Management (First-Line for Most Patients)

Hemodynamic Support

• Target systolic blood pressure 80-100 mmHg using permissive hypotension strategy until bleeding control is achieved 6
• Establish large-bore IV access and initiate crystalloid resuscitation cautiously—avoid aggressive fluid resuscitation to normal blood pressure as this disrupts clot formation 6, 7
• Transfuse packed red blood cells to maintain hemoglobin >7-8 g/dL; Type III hematomas typically require transfusion 1

Reversal of Anticoagulation

• Immediately discontinue all anticoagulant and antiplatelet medications 1, 3
• For warfarin: administer vitamin K 10 mg IV and prothrombin complex concentrate (PCC) or fresh frozen plasma 15 ml/kg if INR >1.5 7, 2
• For low-molecular-weight heparin: administer protamine sulfate (1 mg per 100 units of enoxaparin given in last 8 hours, maximum 50 mg) 2
• For direct oral anticoagulants: use specific reversal agents if available (idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors) 5
• Maintain fibrinogen >1 g/L using cryoprecipitate or fibrinogen concentrate 7
• Maintain platelet count >75 × 10⁹/L with platelet transfusion 7

Adjunctive Pharmacotherapy

• Administer tranexamic acid 1 g IV over 10 minutes, followed by 1 g over 8 hours if given within 3 hours of symptom onset 6, 7

Monitoring

• Admit to intensive care unit for continuous monitoring 7, 3
• Serial hemoglobin measurements every 4-6 hours initially 1
• Repeat lactate and base deficit every 30-60 minutes to assess adequacy of resuscitation 6
• Monitor bladder pressure every 4 hours if large hematoma or abdominal distension present 2

Indications for Interventional or Surgical Management

Angiographic Embolization

• Pursue interventional radiology consultation for selective arterial embolization if hemodynamic instability persists despite initial resuscitation or if CT angiography demonstrates active arterial extravasation 7, 2
• Target the inferior or superior epigastric artery with microcoils using superselective, distal-to-proximal technique 7, 2
• Correct coagulopathy before embolization (INR <1.5, platelets >50 × 10⁹/L) to optimize success 2

Surgical Intervention

• Proceed to emergency laparotomy for patients with:

  • Deep hemorrhagic shock unresponsive to resuscitation 5
  • Abdominal compartment syndrome (bladder pressure >20 mmHg with organ dysfunction) 2
  • Failure of angiographic embolization or when embolization is unavailable 7, 2
  • Ongoing bleeding with coagulopathy, hypothermia, or acidosis 5

• Surgical approach includes evacuation of hematoma, ligation of bleeding vessels, packing, and temporary abdominal closure if damage control surgery is required 2

• Return to OR for removal of packing and definitive closure once coagulopathy is corrected and patient is stabilized 2

Post-Acute Management

Resumption of Anticoagulation

• Anticoagulation can be safely resumed once the hematoma is stable, bleeding has ceased, and the patient has returned to clinical baseline—rectus sheath hematoma is not a permanent contraindication to anticoagulation 3
• For patients with mechanical heart valves or other high thrombotic risk, consider bridging with unfractionated heparin once hemostasis is secured 5
• Timing varies by indication: typically 5-14 days for venous thromboembolism prophylaxis, individualized for mechanical valves based on thrombotic risk 5

Venous Thromboembolism Prophylaxis

• Initiate mechanical prophylaxis (intermittent pneumatic compression devices) immediately 5, 8
• Start pharmacological prophylaxis with low-dose low-molecular-weight heparin once hemostasis is documented (typically 24-48 hours after bleeding cessation with repeat imaging showing stability) 5, 7
• Consider inferior vena cava filter placement if deep venous thrombosis develops before anticoagulation can be safely resumed 8

Critical Pitfalls to Avoid

• Do not delay CT imaging for laboratory results if the patient is stable enough for transport—diagnosis must be established rapidly 9
• Do not perform unnecessary laparotomy—conservative management is successful in 90% of cases, particularly for spontaneous RSH in anticoagulated patients 1
• Do not rely on ultrasound alone as it is frequently inconclusive 4
• Do not miss abdominal compartment syndrome—measure bladder pressure in all patients with large hematomas or abdominal distension 2
• Do not aggressively fluid resuscitate to normal blood pressure before achieving hemostasis—this worsens bleeding 6
• Do not forget DVT prophylaxis—patients develop prothrombotic state after hemorrhage and are at heightened risk despite the recent bleed 7, 8