Conservative treatment of large rectus sheath hematoma in patients undergoing anticoagulant therapy

Abstract

RSH must be suspected in women of advanced age undergoing treatment with anticoagulants who present the clinical triad of acute abdominal pain, infraumbilical mass, and anemic syndrome. CT is the examination of choice for the diagnosis of RSH. Early diagnosis of RSH permits conservative management, even in the case of large hematomas with hemodynamic repercussions and avoids unnecessary surgical intervention.

Spontaneous rectus sheath hematoma in patients on anticoagulation therapy

“…[4,5,9] Concordant with the previous reports, the male to female ratio was in favor of females in our series. One possible reason for the sex difference is the disparity in the size, shape and tone of the rectus muscle.…”

“…[1][2][3] The causes of RSH described in the literature include anticoagulant therapy, hematological disorders, trauma, physical exercise, coughing, sneezing, pregnancy, and hypertension. [3][4][5] The most common predisposing factor is anticoagulant therapy, and coughing has been implicated as the most important precipitating risk factor. [6] Anticoagulant therapy is indicated for the prophylaxis of cardiac valve prosthesis, left ventricular dysfunction, and atrial fibrillation, and for the treatment of acute coronary syndrome, pulmonary embolism, deep vein thrombosis, and acute ischemic cerebrovascular disease.…”

“…US has sensitivity ranging from 70% to 90% in published reviews, while CT has 100% sensitivity and specificity for RSH in many series. [5,[12][13][14] Both methods are useful for differentiating intra-abdominal pathologies and reducing unnecessary laparotomy. On the other hand, CT is the gold standard diagnostic modality, because most of these patients are elderly cardiac patients, and several acute abdominal conditions including mesenteric ischemia, rupture of an abdominal aneurysm, peptic ulcer disease, and perforation secondary to aspirin must be excluded.…”

“…When active bleeding is identified, patients can be managed with catheter-based arterial embolization, by radiologically guided drainage or by laparotomy with vessel ligation and evacuation of the hematoma. [2,3,5,15] Although the surgical treatment of patients with larger RSH due to anticoagulation therapy is associated with shorter hospital stay and less need for analgesics, patients may also develop abdominal hypertension that may progress to ACS and an increased risk of significant morbidity or death. [16] With early diagnosis and conservative management, surgical intervention can be avoided even with large hematomas.…”

Retroperitoneal Hematoma in a Patient with Advanced Chronic Kidney Disease Receiving Warfarin Therapy

“…However, some authors have suspected that unrecognized trauma, such as minor trauma in sports and vomiting or coughing, may initiate blood loss which continues unabated when clotting factors are absent or depleted. Although such minor trauma is a recognized inciting factor in hemophilia-related spontaneous retroperitoneal bleeds (20,21), it could not be specifically identified in our patient. Based on the present autopsy findings, the following pathogenesis of our patient was considered.…”