What is the appropriate management of a rectus sheath hematoma, including assessment, conservative treatment, and indications for interventional or surgical therapy?

Management of Rectus Sheath Hematoma

Most rectus sheath hematomas (86%) should be managed conservatively with symptom control, reversal of anticoagulation, and blood transfusion as needed, reserving angiographic embolization or surgery only for hemodynamically unstable patients or those with ongoing bleeding despite conservative measures. 1

Initial Assessment and Risk Stratification

Clinical Recognition

• Suspect rectus sheath hematoma in patients presenting with abdominal pain (84% of cases) and a palpable abdominal wall mass (63% of cases), particularly in elderly patients on anticoagulation 1
• Key risk factors include female sex, older age (mean age 68 years), anticoagulation therapy (69% of cases), and recent cough or minor abdominal trauma (48% of cases) 1
• The condition can mimic acute intraabdominal surgical emergencies, making rapid diagnosis critical to avoid unnecessary laparotomy 2

Hemodynamic Assessment

• Immediately assess for hemorrhagic shock using serum lactate and base deficit, which are superior to single hematocrit measurements for estimating bleeding severity 3
• Establish large-bore IV access in patients showing signs of active hemorrhage 4
• Activate major hemorrhage protocol if the patient demonstrates hypotension, tachycardia, or altered mental status 5

Diagnostic Imaging

CT of the abdomen and pelvis is the diagnostic modality of choice, establishing the diagnosis in 100% of cases and helping classify hematoma severity. 2

• CT should be performed immediately in hemodynamically stable patients to confirm diagnosis and guide management 1
• CT allows classification into three types: Type I (intramuscular, unilateral), Type II (intramuscular with blood between muscle and transversalis fascia), and Type III (bilateral with blood tracking into prevesical space) 2
• Type III hematomas uniformly require blood transfusion and warrant closer monitoring 2
• Ultrasound can identify the hematoma between aponeurotic sheaths of the rectus muscle but is less comprehensive than CT 6

Conservative Management (First-Line for Most Patients)

Conservative treatment is successful in 90% of cases and should be the initial approach for all hemodynamically stable patients, including those on anticoagulation. 2

Anticoagulation Reversal

• Immediately reverse anticoagulation in patients with elevated INR (mean 2.6 in affected patients) or prolonged aPTT (mean 64.2 seconds) 1
• Administer fresh frozen plasma (15 ml/kg) if PT/aPTT >1.5 times normal 5
• Maintain fibrinogen >1 g/L and platelet count >75 × 10⁹/L 5

Supportive Care

• Provide symptom management with analgesia and bed rest 1, 7
• Administer blood transfusions as needed, particularly for Type III hematomas which uniformly require transfusion 2
• Begin resuscitation with warmed blood products (not crystalloids alone) if hemodynamically unstable 4
• Monitor coagulation parameters, hemoglobin, and vital signs closely 4

Tranexamic Acid Consideration

• Administer tranexamic acid (1 g IV over 10 minutes, followed by 1 g over 8 hours) if given within 3 hours of bleeding onset for mortality benefit 4, 5

Interventional Management (Reserved for Specific Indications)

Only 7.9% of patients require surgery or angiographic embolization, specifically those with hemodynamic instability despite conservative measures or ongoing bleeding. 1

Angiographic Embolization (Preferred Intervention)

• Perform selective angiographic embolization for patients with identified arterial bleeding on CT angiography or ongoing hemodynamic instability despite resuscitation 5
• Embolization targets the epigastric vessels, which are the usual bleeding source 7, 6
• This approach is highly effective and may eliminate the need for surgery 4

Surgical Intervention

• Reserve surgery for patients who fail angiographic embolization or when embolization is unavailable 5
• Surgical goals include evacuating the hematoma and ligating bleeding epigastric vessels 6
• Mortality from rectus sheath hematoma is rare (1.6%) but can occur with massive bleeding 1

Prevention of Complications

Avoiding Unnecessary Laparotomy

• Rapid diagnosis with directed history, physical examination, and CT helps decrease unnecessary laparotomy 1
• The condition frequently mimics intraabdominal disorders, leading to delays in treatment or unnecessary surgery if not properly diagnosed 2

Thromboprophylaxis

• Start venous thromboprophylaxis as soon as bleeding is controlled, as patients develop a prothrombotic state after hemorrhage 5

Prevention Strategies

• Use trocar insertion under direct vision during laparoscopic surgery 2
• Exercise careful attention when administering subcutaneous low-molecular-weight heparin to the abdominal wall, as severe hematomas can develop from injection trauma 2

Key Clinical Pitfalls

• Do not delay CT imaging in elderly anticoagulated patients with abdominal pain and a palpable mass, as this is the classic presentation 1, 2
• Do not perform unnecessary laparotomy based on clinical suspicion alone without imaging confirmation 1
• Do not continue anticoagulation without reversal in the acute setting 1
• Do not use crystalloids alone for resuscitation in hemodynamically unstable patients 4