Rectus Sheath Hematoma 

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Rectus Sheath Hematoma 

Description

  • Rectus sheath hematoma is a rare cause of acute abdominal pain caused by rupture of the superior or inferior epigastric artery due to direct blunt trauma or forceful contraction of the rectus abdominis muscle, frequently in association with anticoagulant use.(1,2,3)
  • Spontaneous rectus sheath hematoma can occur without an obvious source of direct trauma, and may be associated with anticoagulant use, microtrauma (closed glottis straining, isometric muscle contractions), and/or an underlying microangiopathy (Diagn Interv Imaging 2015 Jul;96(7-8):789full-text).

Also Called

  • Abdominal wall hematoma

Definitions

  • American College of Cardiology (ACC) expert consensus definition of major bleed includes ≥ 1 of the following:
    •  Hemodynamic instability
    • Overt bleeding defined by ≥ 1 of:
      • Hemoglobin drop ≥ 2 g/dL (20 g/L)
      • Transfusion of ≥ 2 units of packed red blood cells
    • Bleeding in a critical site (bleeds that compromise organ function; intraluminal gastrointestinal bleeding is not considered a critical site bleed) such as:
      •  Retroperitoneal bleed
      •  Intracranial hemorrhage and other central nervous system bleeds (for example, intraocular and spinal hemorrhages)
      •  Thoracic bleed
      • Intra-abdominal bleed
      •  Intra-articular bleed
      •  Intramuscular bleed
      •  Pericardial tamponade
      •  Airway bleed, including posterior epistaxis
      •  Hemothorax
    • Reference – J Am Coll Cardiol 2017 Dec 19;70(24):3042

Types

  • Rectus sheath hematoma is classified according to computed tomography (CT) findings, which have implications for clinical presentation and management.
    • Type 1:
      • This is a unilateral hematoma within the rectus abdominis muscle that does not dissect along fascial planes.
      • It does not typically cause a drop in hemoglobin level.
      • Management is usually conservative, with an outpatient follow-up only.
    • Type 2:
      • Type 2 is a bilateral rectus abdominis muscle hematoma with expansion to the fascial plane between the rectus abdominis muscle and the transversalis fascia that does not extend into the prevesical space.
      • It is associated with a minor drop in hematocrit.
      • Management may involve observation and a short hospital stay, and may potentially require blood transfusion.
    • Type 3:
      • This type is a large bilateral rectus abdominis muscle hematoma with expansion to the fascial plane between the rectus abdominis muscle and the transversalis fascia, prevesical space, and peritoneum.
      • It is associated with a severe drop in hemoglobin and hemodynamic instability.
      • Management involves blood transfusion, the reversal of anticoagulants, and embolization as needed.
    • Reference – West J Emerg Med 2010 Feb;11(1):76full-text

Epidemiology

Incidence/Prevalence

  • Rectus sheath hematoma is relatively rare, and is reported to be present in 1.8% of patients presenting with acute abdominal pain.(1)
  • Incidence likely increases with age, which may be due to the use of anticoagulants, sarcopenia, and vascular comorbidities.(1)
  • It is reported more commonly in female individuals (female to male ratio 2-3:1), likely due to the lower muscle mass present in female individuals compared to male individuals and the effects of pregnancy.(1,3)

Risk Factors

Etiology and Pathogenesis

Causes

  • Rectus sheath hematoma occurs due to a rupture of the superior or inferior epigastric arteries or intramuscular vessels from direct trauma or forceful contraction of the rectus abdominis muscle, frequently in association with anticoagulant use.(1,2,3)
  • Predisposing factors for rectus sheath hematoma can include:(1)
    • Trauma
    • Iatrogenic injury from abdominal surgery
    • Use of anticoagulants
    • Coughing or other causes of intense abdominal muscle contraction
    • Pregnancy
    • Hypertension
    • Atherosclerosis
    • Vasculitis
    • Hematologic disorders

Pathogenesis

  • Arcuate line – Normal anatomy cross-section illustration of rectus abdominis muscles above (a) and below (b) arcuate line. Rectus muscles are surrounded by fascial sheath anteriorly and posteriorly above arcuate line whereas below arcuate line rectus abdominis fascial sheath is absent posteriorly.Copyright ©2021 EBSCO Information Services.
  • The anatomy of the abdominal wall:(1,2)
    • 2 parallel vertically aligned rectus abdominis muscles, which are located to the left and right of the midline, originate from the costal cartilages of the fifth to seventh ribs and insert into the pubis.
    • The rectus abdominis muscles are surrounded by a fascial sheath arising from the aponeuroses of the external oblique, internal oblique, and transversus abdominis muscles.
      • Above the arcuate line of Douglas, which is the horizontal line between the umbilicus and the pubis, the rectus abdominis muscle is surrounded by the fascial sheath anteriorly and posteriorly, which acts to tamponade epigastric artery hemorrhage.
      • Below the arcuate line of Douglas, the rectus abdominis fascial sheath is absent posteriorly and is only covered by the relatively weak transversalis fascia and peritoneum.
    • The arterial supply to the rectus abdominis muscle comes from the superior and inferior epigastric arteries.
      • The superior epigastric artery is a terminal branch of the internal thoracic artery and runs along the posterior border of the rectus abdominis muscle.
      • The inferior epigastric artery originates from the external iliac artery, moves loosely along the posterior border of the rectus abdominis muscle, and enters the fascial sheath at the arcuate line of Douglas before anastomosing with the superior epigastric vessels.
  • Direct abdominal trauma or forceful contraction or stretching of the rectus abdominis muscle can result in tearing of the superior or inferior epigastric arteries or intramuscular vessels, resulting in a hematoma.(1,2)
    • During forceful contraction or stretching of the rectus abdominis muscle, the blood vessels need to slide to avoid tearing.
    • Superior epigastric artery tearing usually results in small hematomas due to the tamponading effect by the rectus sheath.
    • The inferior epigastric artery is prone to more frequent injury due to its fixed attachment to the rectus abdominis muscle and greater expansion of bleeding posteriorly due to the absence of a posterior rectus sheath.
    • Large hematomas may rarely cause urinary tract obstruction, bladder irritability, or abdominal compartment syndrome .

History and Physical

Clinical Presentation

  • The presentation of a patient with a rectus sheath hematoma will vary significantly depending on the size and location of the hematoma and the severity of the peritoneal irritation.(1,2)
    • Patients with small hematomas usually have no drop in hemoglobin and have minimal signs or symptoms because the peritoneal irritation is minimal.
    • Patients with large hematomas typically have a significant drop in hematocrit and have more severe classic signs and symptoms, particularly acute abdominal pain.
      • Patients with large hematomas may be hypovolemic and present with hypotension, tachycardia, tachypnea, dizziness, and paleness.
      • A large rectus sheath hematoma may rarely present with signs and symptoms of urinary tract obstruction, bladder irritability, or abdominal compartment syndrome .
  • Classic signs and symptoms of a rectus sheath hematoma include:(1,2)
    • Abdominal pain, which is reported in 84%-97%:
      • Pain may be acute or develop over hours.
      • Pain is usually described as severe, sharp, persistent, and nonradiating.
      • Pain can be unilateral or occur in 1 of the abdominal quadrants.
      • Pain usually worsens with movements and is associated with a palpable abdominal mass.
    • A palpable abdominal wall mass, which is reported in 63%-92%:
      • The mass is usually tender, nonpulsating, and in right lower quadrant.
      • It may occur bilaterally.
      • The palpable abdominal wall mass can extend posteriorly, especially if the bleed is in the lower abdomen which may cause peritoneal irritation, making palpation difficult and pain more atypical.
    • Abdominal tenderness, which is reported in 71%
    • Abdominal guarding, which is reported in 49%
    • Nausea, which is reported in 23%
    • Vomiting, which is reported in 15%
    • Fever and chills, rate not reported

History

Past Medical History (PMH)

  • Ask about past medical history, particularly:
    • Abdominal surgery, either laparoscopic or open(1)
    • Medical procedures, including:(1)
      • Intra-abdominal injections
      • Paracentesis
      • Peritoneal catheter insertion
    • Medical conditions, including:(1,2)
      • Hypertension
      • Atherosclerosis
      • Vasculitis
      • Hematological disorders

Physical

General Physical

  • Assess for:(1)
    • Hypotension
    • Tachycardia
    • Tachypnea

Abdomen

  • In patients with acute abdominal pain, perform a palpation examination to localize any tenderness, and to identify masses, guarding, and peritonitis.
    • Assess for involuntary guarding, which is present if the abdominal wall tone is rigid throughout the respiratory cycle. Involuntary guarding may be lacking in older adults due to the laxity of the abdominal musculature.
    • Perform rebound testing to assess for peritonitis.
      • Rebound testing is reported to have a high sensitivity but lower specificity for peritonitis.
      • Apply slow gentle pressure over the abdominal wall for 15-30 seconds, followed by a sudden release.
      •  A positive rebound test is indicated by patient pain on release.
    • Perform a cough test to help identify peritoneal irritation. A positive test is defined as either of the following:
      • Patient reporting sharp, localized pain upon coughing
      • Signs of pain upon coughing such as flinching, grimacing, or moving hands to the abdomen
    •  Reference – Int J Gen Med 2012;5:789full-text
  • Specialized signs and maneuvers to help determine the origin of abdominal tenderness include the Carnett sign or Fothergill sign.(1)
    • The Carnett sign helps to determine if abdominal tenderness is from the abdominal wall or deeper. In the supine position, the patient lifts their head and shoulders off the exam table, which contracts the rectus abdominis muscles.
      • If abdominal tenderness is increased or unchanged, then suspect an abdominal wall pathology.
      • If abdominal tenderness is decreased, then suspect a pathology below the abdominal wall.
    • The Fothergill sign helps to determine if a mass is from the abdominal wall or deeper.
      • In the supine position, the patient lifts their head and shoulders off the exam table, which contracts the rectus abdominis muscles.
      • If the mass remains palpable and does not cross the midline, a rectus abdominis hematoma is suspected.
  • Inspect for ecchymosis, which has been reported in some patients about 4 days after the onset of symptoms.(1)

Diagnosis

Making the Diagnosis

  • Suspect the diagnosis of rectus sheath hematoma in patients taking anticoagulants with a history of trauma or cough who present with severe, sharp, nonradiating abdominal pain and/or a tender abdominal wall mass.(1,2)
  • Confirm the diagnosis of a rectus sheath hematoma with imaging studies, such as ultrasound and/or computed tomography (CT).(1,2)
    • Appearance of a rectus sheath hematoma on an ultrasound:
      • There is usually a spindle shaped mass on longitudinal scans if the hematoma is above the arcuate line of Douglas.
      • There is typically an oval shaped mass on transverse and coronal scans if the hematoma is below the arcuate line of Douglas.
      • The mass typically appears homogeneous and sonolucent, but may appear heterogeneous in the presence of a clot.
      • No internal Doppler flow should be depicted with spectral, color, or power Doppler assessment.
    • Appearance of a rectus sheath hematoma on a CT scan:
      • An acute hematoma (present < 5 days) usually appears as a hyperdense mass behind an enlarged rectus abdominis muscle, and may have a “hematocrit effect” (visualized as 2 fluid levels formed due to a layering process, where heavier elements of the blood sink compared to lighter elements).
      • A chronic hematoma (present ≥ 5 days) usually appears isodense or hypodense compared to the surrounding muscle.

Differential Diagnosis

  • Consider the following conditions in the differential diagnosis of a rectus sheath hematoma:
    • Abdominal aortic aneurism(1)
    • Abdominal tumors(1,2)
    • Acute appendicitis(1,2)
    • Acute cholecystitis(1)
    • Diverticulitis(1)
    • Intestinal obstruction(1)
    • Ovarian torsion(1)
    • Rectus nerve entrapment(1)
    • Traumatic abdominal wall hernias including:(1,2)
      • Strangulated hernia
      • Spigelian hernia
      • Lumbar hernia
      • Transdiaphragmatic intercostal hernia
    • Morel-Lavallée lesion, which is a closed internal degloving of arteries, veins, and lymphatic vessels occurring from blunt or crush injury to abdomen(2)
    • Urinary obstruction(1)
    • Urinary tract infection(1)

Testing Overview

  • Perform routine blood tests, including a complete blood count and serial hemoglobin and hematocrit measurements in all patients, and coagulation studies for patients taking anticoagulants.
  • Perform imaging studies with ultrasonography and/or computed tomography (CT) to confirm the diagnosis.
    • Perform an ultrasound as the first-line imaging modality when CT is not available or for pediatric and pregnant patients, and in stable patients with a low-to-moderate clinical probability of a rectus sheath hematoma.
    • Perform a CT scan as the first-line imaging modality in patients with a high clinical probability of a rectus sheath hematoma, if not contraindicated.
    • Magnetic resonance imaging (MRI) is rarely used for the diagnosis of a rectus sheath hematoma but may be considered in patients with a chronic hematoma (≥ 5 days) if the CT imaging is inconclusive.
    • X-ray is not helpful in diagnosing a rectus sheath hematoma, but may be used to rule out other pathology in the differential diagnosis.

Blood Tests

  • Routine blood work should include a complete blood count and serial hemoglobin and hematocrit measurements in all patients, and coagulation studies for patients taking anticoagulants.(1,3)
    • The hematocrit is usually normal in small hematomas and low in large hematomas, although a normal hematocrit does not rule out a large hematoma.
    • Serial hemoglobin and hematocrit measurements are necessary for cases of hemorrhage to identify the blood volume loss and the need for transfusion or more aggressive therapeutic options.
    • Coagulation studies help determine the need for anticoagulation reversal and help to guide the process.
    • Leukocytosis may be found but has a low sensitivity and specificity for the diagnosis of a rectus sheath hematoma.

Imaging Studies

  • The diagnosis of a rectus sheath hematoma is typically confirmed with ultrasonography or computed tomography (CT), however, magnetic resonance imaging (MRI) may be useful in chronic cases (hematoma present ≥ 5 days) if the CT imaging is inconclusive.(1,2)
  • Ultrasound in the diagnosis of a rectus sheath hematoma:
    • Ultrasound can be used as the first-line imaging modality for any of following:(1)
      • When CT is not available
      • For pediatric and pregnant patients
      • In stable patients with low-to-moderate clinical probability of rectus sheath hematoma
    • While ultrasound is associated with a high sensitivity for rectus sheath hematoma, it may produce a small number of false-positives for detection of a mass which could lead to unnecessary laparotomies.(1,2)
    • The appearance of a rectus sheath hematoma on an ultrasound:(1,2)
      • There is usually a spindle shaped mass on longitudinal scans if the hematoma is above the arcuate line of Douglas.
      • There is typically an oval shaped mass on transverse and coronal scans if the hematoma is below the arcuate line of Douglas.
      • The mass typically appears homogeneous and sonolucent, but may appear heterogeneous in the presence of a clot.
      • No internal Doppler flow should be depicted with spectral, color, or power Doppler assessment.
  • CT scan in the diagnosis of a rectus sheath hematoma:
    • CT scan can be used as first-line imaging modality in patients with a high clinical probability of a rectus sheath hematoma, if not contraindicated.(1)
    • CT is accurate in determining the size, location, origin, extension, and nature of the hematoma.(1)
    • CT can be helpful in ruling out other abdominal pathology.(1)
    • The appearance of a rectus sheath hematoma on a CT scan:(1,2)
      • An acute hematoma (present < 5 days) usually appears as hyperdense mass behind an enlarged rectus abdominis muscle, and may have “hematocrit effect” (visualized as 2 fluid levels formed due to a layering process, where heavier elements of the blood sink compared to lighter elements).
      • A chronic hematoma (present ≥ 5 days) usually appears isodense or hypodense compared to surrounding muscle.
    • A rectus sheath hematoma can be classified according to CT findings, which has implications for clinical presentation and management.
      • Type 1:
        • A unilateral hematoma within the rectus abdominis muscle that does not dissect along fascial planes.
        • It does not typically cause a drop in hemoglobin level.
        • Management is usually conservative with an outpatient follow-up only.
      • Type 2:
        • A bilateral rectus abdominis muscle hematoma with expansion to the fascial plane between the rectus abdominis muscle and the transversalis fascia that does not extend into the prevesical space.
        • It is associated with a minor drop in hematocrit.
        • Management may involve observation and a short hospital stay, and may potentially require blood transfusion.
      • Type 3:
        • A large bilateral rectus abdominis muscle hematoma with expansion to the fascial plane between the rectus abdominis muscle and the transversalis fascia, prevesical space, and peritoneum.
        • It is associated with a severe drop in hemoglobin and hemodynamic instability.
        • Management involves blood transfusion, the reversal of anticoagulants, and embolization as needed.
      • Reference – West J Emerg Med 2010 Feb;11(1):76full-text
    • IV contrast is not needed for diagnosis of a rectus sheath hematoma, but active extravasation may be seen if a contrast agent is used.(2)
      • detection of IV contrast extravasation on computed tomography scan associated with slightly lower hemoglobin and greater likelihood of having surgery or embolization but does not appear to be associated with hemodynamic instability or hematoma expansion in patients with anticoagulant-related spontaneous rectus sheath or iliopsoas hematomas (level 2 [mid-level] evidence)
        • based on retrospective cohort study
        • 68 adults (median age 75 years) with anticoagulant-related spontaneous rectus sheath hematoma (35% of patients) or iliopsoas hematoma (65% of patients) were evaluated
        • 35% of patients were hemodynamically unstable
        • comparing patients with detection of IV contrast extravasation on CT (36 patients) vs. no contrast extravasation on CT (32 patients)
          • hemodynamic instability in 44% vs. 30% (not significant)
          • mean hemoglobin 8.38 g/dL vs. 9.52 g/dL (p = 0.04)
          • surgery and/or embolization in 63.9% vs. 18.8% (p < 0.05)
        • among the 15 patients who had a follow-up CT, detection of extravasation of contrast material on CT was not significantly associated with the hematoma’s volume at follow-up
        • Reference – Abdom Radiol (NY) 2016 Nov;41(11):2241
  • MRI in the diagnosis of a rectus sheath hematoma:(1,2)
    • MRI is rarely used for the diagnosis of a rectus sheath hematoma but can be considered if CT imaging is inconclusive in a patient with a chronic hematoma.
    • A high signal intensity on T1 and T2 weighted sequences only occurs in chronic hematoma cases (present > 5 days).
  • X-ray in the diagnosis of rectus sheath hematoma:(1)
    • X-ray is not helpful in diagnosing rectus sheath hematoma.
    • Anterior to posterior and lateral decubitus x-ray views may help rule out other pathology in the differential diagnosis.

Management

Management Overview

  • The management of a rectus sheath hematoma is based on the patient’s clinical status and the size of the hematoma.(1,3)
  • In most patients, a rectus sheath hematoma is self-limiting and can be managed effectively with conservative measures.
  • Consider invasive hemorrhage control with arterial embolization or surgical ligation of bleeding vessels for patients with any of the following:
    • Hemodynamic instability and enlarging hematomas unresponsive to conservative management and anticoagulation reversal
    • Signs and symptoms of severe peritoneal irritation
    • Signs of abdominal compartment syndrome
  • Follow-up should include a physical exam, blood tests, and serial ultrasound imaging.

Conservative Management

  • In most patients, a rectus sheath hematoma is self-limiting and can be managed effectively with conservative measures.(1,2,3)
  • Infrequently, patients fail conservative management and require angiography and embolization or surgical ligation of the bleeding vessels.(1,2)
  • conservative management (bed rest, blood products, and vitamin K) reported to be effective in patients with spontaneous rectus sheath hematoma taking anticoagulants or antiplatelet medications (level 3 [lacking direct] evidence)
    •  based on case series
    • 14 adults (mean age 66 years, 71% female) with spontaneous rectus sheath hematoma treated conservatively with bed rest, blood products, and vitamin K, were followed for 3 months to 2 years
    • 93% of patients were taking anticoagulants or antiplatelet medications prior to rectus sheath hematoma
    • 79% of patients received blood or blood products, and 35% were given vitamin K
    • classification of rectus sheath hematoma per computed tomography (CT) findings
      • type 1 rectus sheath hematoma in 3 patients (21.4%) (mean 22.3 mm)
      • type 2 rectus sheath hematoma in 9 patients (64.3%) (mean 40.6 mm)
      • type 3 rectus sheath hematoma in 2 patients (4.2%) (mean 93.5 mm)
    • all patients recovered from rectus sheath hematoma and had reintroduction of anticoagulants/antiplatelets at mean of 7.6 days
    • no recurrences reported at follow-up
    • Reference – Emerg Med Int 2019;2019:2406873full-text

Fluid and Electrolytes

Blood Transfusion

  • Red blood cell transfusion should be given for hemodynamic instability or a significant drop in hemoglobin (West J Emerg Med 2010 Feb;11(1):76full-text).
  • Blood transfusion was reported to be required in about 80% of 99 patients (88.9% of patients were taking anticoagulants) with spontaneous rectus sheath or retroperitoneal hematomas in case series (Am J Surg 2020 Apr;219(4):707).

Anticoagulation Reversal

  • Anticoagulant reversal is indicated in patients taking anticoagulants who are over-anticoagulated, have major or life-threatening bleeding, or require urgent surgery/procedure. (Br J Haematol 2013 Jan;160(1):35full-text, editorial can be found in Br J Haematol 2013 Jan;160(1):1).
  • Specific guidance on the application of anticoagulation reversal strategies depends on the type of anticoagulant and the clinical setting; see Anticoagulation Reversal for guidance according to clinical setting for:
    • Vitamin K antagonists
    • Direct oral factor Xa inhibitors
    • Direct oral thrombin inhibitor
    • Unfractionated heparin
    • Low-molecular-weight heparin
    • Heparinoid
    • Fondaparinux
    • Parenteral direct thrombin inhibitors
  • The decision to restart anticoagulation in patients with a rectus sheath hematoma while on oral anticoagulants is determined by the need for continued treatment.
    • If continued anticoagulation is indicated, the risk of bleeding should be weighed against the benefits of anticoagulation therapy, and the risk factors that contributed to the bleeding event should be addressed if possible.
    • Consider temporary or long-term parenteral anticoagulation in patients with contraindications to oral medications, patients with cancer-associated venous thromboembolism, pregnant patients, patients requiring urgent surgery, patients at high risk of bleeding, and patients requiring bridging to restart vitamin K antagonists.
    • Reference – J Am Coll Cardiol 2017 Dec 19;70(24):3042
    • restarting anticoagulants at median 4 days reported to be safe in most patients with spontaneous rectus sheath hematoma; thrombotic complications reported to be more common than bleeding complications in these patients (level 3 [lacking direct] evidence)
      •  based on case series
      • 156 adults (mean age 73 years, 63% female) diagnosed with spontaneous rectus sheath hematoma and taking anticoagulants were evaluated after discontinuing anticoagulants (median follow-up 25.8 months)
      • anticoagulants used included
        • coumadin in 64%
        • heparin IV in 21%
        • aspirin in 8%
        • other anticoagulants (anagrelide, ardeparin, integrilin, and low-molecular-weight heparin) in 7%
      • 19% of patients had procedural interventions with majority having embolization of inferior epigastric artery, and 61% of patients required blood product transfusion
      • 62% of patients had anticoagulants restarted during hospitalization at median of 4 days (range 2-8 days) with therapeutic levels (INR ≥ 2) reached at 9 days (range 6-14 days)
        • 100% of patients taking aspirin alone were restarted at median 2 days (range 1-4 days)
        • 67% of patients taking coumadin were restarted at median 4 days (range 2-7 days)
        • 50% of patients taking antiplatelets (other than aspirin) were restarted at median 6 days (range 2-13 days)
      • 5% overall mortality (8 patients)
      • 15% of patients (23 patients) developed complications, including
        • acute kidney failure in 8 patients
        • thrombotic events in 5 patients
        • bleeding events (enlargement of rectus sheath hematoma 2 days after resumption of anticoagulants) in 2 patients
        • other complications in 8 patients
      • Reference – World J Surg 2013 Nov;37(11):2555

Surgery and Procedures

  • Consider invasive hemorrhage control such as arterial embolization or surgical ligation of bleeding vessels in patients with any of the following:(1)
    • Hemodynamic instability and enlarging hematomas that are unresponsive to conservative management and anticoagulation reversal
    • Signs and symptoms associated with severe peritoneal irritation
    • Signs of abdominal compartment syndrome
  • About 8% of patients with a rectus sheath hematoma are reported to require surgical or endovascular management.(2)
  • For arterial embolization, the preferred approach includes digital subtraction angiography and selective embolization of the culprit vessel. This approach is reported to achieve a high degree of success and has a low risk of rebleeding (Ultrasound J 2019 Jun 18;11(1):13full-text).
    • The most common embolization technique is selective catheterization of the vascular pedicle causing the hemorrhage, and can involve:
      • The use of combined gelfoam torpedoes and coils for embolization materials
      • Embolization of anastomotic arteries which may be helpful in preventing recurrence
      • Reference – Diagn Interv Imaging 2015 Jul;96(7-8):789
    • transcatheter arterial embolization with modified n-butyl-cyanoacrylate glue reported to be effective in anticoagulated patients with spontaneous rectus sheath hematoma (level 3 [lacking direct] evidence)
      •  based on case series
      • 50 anticoagulated adults (mean age 71 years, 50% female) with spontaneous rectus sheath hematomas (11 patients), or iliopsoas hematomas (38 patients), or both (1 patient) were treated emergently with transcatheter arterial embolization with modified n-butyl-cyanoacrylate glue
      • in patients with rectus sheath hematoma
        • 75% of patients showed active bleeding of rectus sheath hematoma on arteriography
        • 100% had no persistent or recurrent bleeding of rectus sheath hematoma within 30 days of embolization (defined as clinical success)
        • 0% of patients died within 30 days
      • Reference – J Vasc Interv Radiol 2018 Feb;29(2):210
  • Surgical ligation of the culprit vessel:
    • Indications for surgical ligation:
      • When embolization is not available.
      • When the patient progresses to abdominal compartment syndrome.
      • If the hematoma is infected; surgery allows for the removal of the hematoma, which lowers the intra-abdominal pressure.
      • Reference – Ultrasound J 2019 Jun 18;11(1):13full-text
    • Suggested surgical ligation technique:
      • Make a 2-cm longitudinal skin incision below the inferior margin of the hematoma.
      • Dissect the rectus abdominis muscle.
      • Identify the inferior epigastric artery and perform the ligation.
      • Evacuate the hematoma as follows:
        • Make a 4-cm longitudinal incision at the site of the hematoma.
        • Dissect the anterior fascia of the rectus abdominis muscle.
        • Evacuate the hematoma.
        • Pack with absorbable hemostat and thrombin gauze.
      • Reference – Int Surg 2015 Jan;100(1):190full-text
  • Ultrasound-guided drainage of the hematoma:
    • Ultrasound-guided drainage is not recommended routinely, as it may prolong the patient’s length of hospital stay and increase the risk of hematoma infection.
    • Ultrasound-guided drainage may be useful in patients treated conservatively, when infection is suspected.
    • Reference – Ultrasound J 2019 Jun 18;11(1):13full-text

Follow-Up

  • Conservative treatment, embolization, and surgical ligation should all be followed-up with a physical exam, blood tests, and serial ultrasound imaging.
    • For conservative treatment, serial ultrasound is performed to measure the size of the hematoma.
    • For embolization and surgical ligation, serial ultrasound is performed to:
      • Identify early rebleeding within the rectus sheath
      • Determine if infection is present for which ultrasound-guided diagnostic aspiration may be helpful
    • Reference – Ultrasound J 2019 Jun 18;11(1):13full-text

Complications

  • Bleeding from rectus sheath hematoma can result in:
    • Hypovolemic shock, which is reported in up to 37.5% of patients (Surg Clin North Am 2014 Feb;94(1):71)
    • Abdominal compartment syndrome, which is reported in up to 35% of trauma patients with intraperitoneal injury:
      •  This may cause end-organ dysfunction that progresses to multisystem organ failure within several hours to days.
      • Clinical signs of abdominal compartment syndrome include:
        • Oliguria
        • Decreased cardiac output
        • Changes in minute ventilation
        • Intracranial hypertension
        • Changes in splanchnic blood flow
      • Diagnosis of abdominal compartment syndrome is confirmed by indwelling catheter manometry of the bladder.
      • Reference – Vasc Med 2008 Nov;13(4):275
    • Myonecrosis(2,3)
    • Anemia(2)
    • Myocardial infarction, which is caused by hypovolemia and is more common with higher rectus sheath hematoma grades (Vasc Med 2008 Nov;13(4):275)
    • Cardiac arrhythmias, which are caused by hypovolemia and are more common with higher rectus sheath hematoma grades (Vasc Med 2008 Nov;13(4):275)
    • Acute kidney failure, which may be due to prerenal (hypovolemia), intrarenal, or postrenal causes (Case Rep Emerg Med 2014;2014:164245full-text)
    • Small bowel infarction (likely caused by hypotension) (Med Sci Monit 2005 Oct;11(10):CS57)
  • Other complications of rectus sheath hematoma reported in case reports:

Prognosis

  • Rectus sheath hematoma is typically a self-limited condition that resolves in 2-3 months with nonoperative management.(1,3)
  • About 8% of patients are reported to require surgical or endovascular management for a more severe hematoma.(2)
  • A rectus sheath hematoma can be fatal in severe cases if not diagnosed and managed appropriately.
    • Mortality is reported in:(1,3)
      • 1.6%-4% overall
      • Up to 25% of patients taking anticoagulants
      • 13% of pregnant patients (mortality 50% in developing fetus)
    • An overall 6.4% mortality (3.6% mortality after conservative treatment and 33.3% mortality after surgical treatment) was reported in a retrospective cohort of 31 adults (mean age 63 years, range 24-85 years, 68% female) with a rectus sheath hematoma in Turkey between May 2010 and Jul 2018 (Ulus Travma Acil Cerrahi Derg 2021 Mar;27(2):222PDF).
    • An overall 7% mortality (2 patients) was reported in a retrospective cohort of 29 adults (mean age 67 years, 79% female) with a rectus sheath hematoma (80.6% were receiving anticoagulant or antiplatelet therapy) taking anticoagulants in Lithuania between 2007 and 2017; both patients who died had severe (type 3) rectus sheath hematomas (Medicina (Kaunas) 2018 May 30;54(3):doi:10.3390/medicina54030038full-text).

Prevention and Screening

  • Not applicable.

Guidelines and Resources

Guidelines

  • No relevant guidelines for “Rectus Sheath Hematoma” found 2024 Apr 23 on MEDLINE search using guidelines limiter.

Review Articles

  • To search MEDLINE for (Rectus Sheath Hematoma) with targeted search (Clinical Queries), click therapy, diagnosis, or prognosis.

Patient Information

  • DynaMed Editors have not identified patient education materials that meet our criteria for inclusion (freely accessible, nonpromotional, topic-specific). We will continue to search for acceptable materials and welcome your suggestions.

References

General References Used

The references listed below are used in this DynaMed topic primarily to support background information and for guidance where evidence summaries are not felt to be necessary. Most references are incorporated within the text along with the evidence summaries.

  1. Hatjipetrou A, Anyfantakis D, Kastanakis M. Rectus sheath hematoma: a review of the literature. Int J Surg. 2015 Jan;13:267-271.
  2. Matalon SA, Askari R, Gates JD, Patel K, Sodickson AD, Khurana B. Don’t Forget the Abdominal Wall: Imaging Spectrum of Abdominal Wall Injuries after Nonpenetrating Trauma. Radiographics. 2017 Jul;37(4):1218-1235.
  3. Buffone A, Basile G, Costanzo M, et al. Management of patients with rectus sheath hematoma: Personal experience. J Formos Med Assoc. 2015 Jul;114(7):647-51.

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