What is the recommended management for a rectal sheath (perirectal) hematoma?

Management of Rectus Sheath Hematoma

Conservative management is the treatment of choice for rectus sheath hematoma in hemodynamically stable patients, with surgical or interventional radiology intervention reserved exclusively for those with hemodynamic instability or failure of conservative measures. 1, 2

Initial Assessment and Diagnosis

• Obtain computed tomography (CT) scan with intravenous contrast immediately – this is the gold standard for diagnosis and will guide all subsequent management decisions 1, 2
• Check complete blood count, coagulation parameters (PT/INR, aPTT), and type and crossmatch blood products 3
• Assess hemodynamic stability using vital signs, serum lactate, and base deficit as sensitive markers of hemorrhagic shock 3
• Ultrasonography can be used for follow-up monitoring but should not replace initial CT diagnosis 1

Management Algorithm Based on Hemodynamic Status

For Hemodynamically Stable Patients (>90% of cases):

Conservative management is definitive treatment 1, 2:

• Admit for observation with serial hemoglobin monitoring every 6-8 hours 1
• Reverse anticoagulation immediately if the patient is on anticoagulants – hold warfarin, reverse with vitamin K and fresh frozen plasma as needed; hold direct oral anticoagulants 4, 1
• Provide adequate analgesia for pain control 1
• Transfuse packed red blood cells to maintain hemoglobin >7-8 g/dL 1
• Bed rest until hematoma stabilizes (typically 3-5 days) 1
• Average hospital stay is 6 days 1
• Do not perform laparotomy – this is a self-limited condition that resolves spontaneously in stable patients 1, 2

For Hemodynamically Unstable Patients:

Proceed directly to interventional or surgical management 1, 2:

• First-line intervention: Selective arteriography with percutaneous angioembolization of the inferior epigastric artery or bleeding vessel 5, 1
• This approach is less invasive and highly effective when performed by experienced interventional radiologists 5
• Second-line if angioembolization fails or is unavailable: Surgical exploration with direct ligation of the bleeding vessel 1
• Surgical approach should be targeted based on CT localization of the hematoma 5

Critical Decision Points from CT Imaging

The contrast-enhanced CT scan determines management strategy 5:

• Active contrast extravasation ("blush") on CT indicates ongoing bleeding and may warrant earlier intervention even in borderline stable patients 5
• Large hematoma size (>10 cm) with hemoglobin drop >3 g/dL suggests higher risk for decompensation and requires closer monitoring 5, 2
• Hematoma location and relationship to surrounding structures guides surgical approach if needed 5

Common Pitfalls to Avoid

• Never perform exploratory laparotomy in stable patients – this was historically done due to misdiagnosis as acute abdomen, but CT diagnosis has eliminated this need 4, 1, 2
• Do not restart anticoagulation until hematoma is completely stable (typically 7-14 days) and only after careful risk-benefit assessment with hematology consultation 1, 2
• Do not rely on physical examination alone – the classic Fothergill sign (mass that remains palpable with rectus contraction) is not always present, and CT is mandatory 2
• Do not discharge patients on the same day even if initially stable – delayed bleeding can occur and requires 24-48 hour observation minimum 1

Special Considerations

• Patients on anticoagulation account for 75% of cases, making this the most important risk factor to identify 1, 2
• Mortality with conservative management in stable patients is essentially zero, while unnecessary surgery carries operative risks 1, 2
• Thromboembolic complications from holding anticoagulation are rare during the acute management period 1