Treatment of Rectus Sheath Hematomas: Eight Years of Single-Center Experience With a Review of Literature

Abstract

BACKGROUND: Rectus sheath hematoma is a rare and frequently misdiagnosed cause of acute abdominal pain. In the management of the patients with rectus sheath hematoma, which are mostly with advanced age and comorbid diseases, positive results can be obtained by avoiding unnecessary surgical procedures with correct diagnosis and treatment approaches. The presented study aims to contribute to the lack of algorithms and optimal treatment strategies in the management of rectus sheath hematoma patients with the description of our experience in their management. METHODS: Patients who underwent treatment with the diagnosis of rectus sheath hematoma between May 2010 and July 2018 were retrospectively analyzed. Demographic characteristics, medical histories, physical and laboratory findings and imaging methods, treatment processes, complications, morbidity, mortality, length of hospitalization and long-term follow-up results were searched. Data were analyzed from patient files, hospital computer registry system and radiology archives. Data analysis was performed using Microsoft Excel and IBM-SPSS-Statistics-24. RESULTS: The mean age of the 31 patients was 63.03 years (24-85 years). The female/male ratio (21/10) was 2.1. The most common presenting sign or symptom was abdominal pain (100%), followed by abdominal wall mass in 25 patients (80.6%). Twenty-five patients (80.6%) were receiving some form of anticoagulation and antiplatelet therapy. Diagnosis was confirmed by Computed Tomography in 11 (45.4%), Ultrasonography in five (16.1%) and Computed Tomography with Ultrasonography in 15 (33.3%). Eight patients (25.8%) were evaluated as Type-1, 10 (32.2%) as Type-2 and 13 (41.9%) as Type-3. Mean International Normalized Ratio (INR) value of patients was 2.59. Bleeding was controlled by surgery in three cases (9.6%). The conservative approach was preferred in 28 cases (90.3%). 29 (93.5%) patients were discharged after an average hospital stay of 7.48 days (4-21). One patient died on the postoperative 5th day and other on the 14th day of conservative treatment (6.45% mortality). The mortality rate of conservatively and surgically treated patients was 3.5% and 33.3%, respectively. CONCLUSION: Rectus sheath hematoma should be suspected in elderly patients using anticoagulants with acute abdominal pain, severe cough attacks and an umbilical palpable or radiologically supported mass. Computed Tomography and Ultrasonography should be performed in case of clinical suspicion. Early and correct diagnosis ensures successful conservative treatment and prevents unnecessary surgical procedures. In the management of cases where clinician experience is at the forefront, we are hopeful that a new effective algorithm system and guidelines for the diagnosis will be identified after increasing the presentations of case series and experiences.