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

Background: The purpose of this study was to describe our experience in the conservative management of large rectus sheath hematoma (RSH) in patients undergoing anticoagulation therapy. Methods: This is a retrospective study of the medical histories of 12 cases of RSH (11 female, one male; mean age = 67.6 years). Seven patients were taking oral anticoagulants, three were taking intravenous unfractionated heparin, and two were taking subcutaneous low-molecular-weight heparin. Six patients had a history of coughing fits. Ultrasound examination and computed tomography (CT) was performed in all cases. Results: Clinically, the majority of patients presented acute abdominal pain, infraumbilical masses, and anemic syndrome. Ultrasonography demonstrated nine of the 12 cases of RSH, and CT showed the hematoma in all 12 cases. Type II (five cases) and type III (seven cases) indicate moderate and severe hematomas, respectively. Excessive anticoagulation was observed in eight cases, and coagulation within correct ranges was seen in the remaining four cases. In five patients the normalization of coagulation was achieved by administering vitamin K-1 and fresh frozen plasma. All cases of type III hematoma required blood transfusion, Conservative treatment was effective in all cases. Conclusions: 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.