Rectus Sheath Hematoma—A Rare and Dangerous Complication of Anticoagulation Therapy<br/>—A Case Report and Review of Current Literature

Rectus sheath hematoma (RSH) is a rare bleeding site which can be life-threatening. Our aim was to analyze clinical features, diagnosis, treatment and outcome of these cases in a general hospital. Results: During a period of 24 months, 8 cases of RSH were diagnosed (0.1% of all inpatients). Mean age was 79.4 years (y, SD +/- 14.1). 75% were female. 7 patients (pts) were on therapy with oral anticoagulants (OAC), 2 had a history of additional therapy with aspirin (ASA), 4 had low molecular weight heparin (LMWH) for bridging of OAC therapy. 4 pts had INR values between 3.1 - 4.4. One pt with liver cirrhosis (Child A), mild thrombocytopenia had ASA and LMWH prophylactically. Five pts (63%) were coughing. Main symptom was localized pain in 7 pts. One pt was incidentally diagnosed on a CT scan performed for different reason. 7 pts had a palpable mass of the abdominal wall. 5 RSH were diagnosed with CT, 2 with ultrasound, 1 clinically. All pts were treated conservatively. In 7 pts vitamine K and Beriplex® was substituted to reverse OAC. 4 pts received blood transfusions (1 - 4 units). The mean change of hemoglobin (Hb) was 37 g/l (SD +/- 22 g/l). The renal function was impaired in 7 pts (mean creatinine clearance 51 ml/min +/- 12.4) and declined further. 3 out of 8 pts died (38%, age 90 - 92 y, all female). In these patients, the observed change in Hb was 42 - 58 g/l. 2 pts had combination of VKA and LMWH. 1 pt had VKA only. Conclusion: Acute abdominal pain in pts with any form of OAC or therapy to inhibit platelet function should always raise suspicion about RSH. Extensive blood loss, shock and aggravation of renal failure can be fatal. In majority of cases, the hematoma is palpable and should prompt further examination of the abdominal wall. It is crucial to normalize coagulation parameters and to correct intravascular volume depletion to avoid shock and further decline of renal failure.