Discussion
RSH was reported in modern literature by Richardson for the first time in 1857.12 Although it has been a well-defined disease since the very first report, it is often misdiagnosed. Although it makes up less than 2% of all patients who are admitted to the hospital due to acute abdominal pain alone, it is a pathology that should not be overlooked due to its mortality and complications.8,13
RSH is more common among women in their sixties.6,10This is attributed to women’s having a smaller amount of rectus abdominis muscles and reduction in the flexibility of epigastric veins with increasing age due to atheromatous changes in the epigastric vein walls. Another reason for increased incidence of SRSH in the old age is increased use of anticoagulant and antiaggregant drugs by the elderly.10 In line with the literature, majority of the patients in our series were female and predominantly in the 6th decade of their lives.
Possible risk factors for RSH are trauma, rapid and sudden changes in position, anticoagulant therapy, some hematologic diseases which disrupt blood clotting mechanisms, von Willebrand disease, hypertension, obesity, recent anterior abdominal wall surgery, cough attacks due to asthma and COPD exacerbations, injections, and pregnancy.6,7,9 Anticoagulant therapy has been identified as the most commonly reported risk factor for RSH.1,2,6,9,10 Patients with cardiovascular diseases and an ASA score of 3 made up the great majority of our series. Furthermore, the average body mass index of our patients was 28.3. Two thirds of our patients were on anticoagulant and/or antiplatelet therapy. Average INR value was 1.93.
RSH is diagnosed by means of such imaging techniques as Ultrasonography (USG), Computed Tomography (CT), and Magnetic Resonance (MR). Sensitivity of USG, which is the fastest and the easiest diagnosis tool for patients with suspected RSH, ranges between 80% and 90%.14,15 As it is difficult to distinguish between intraabdominal lesions and abdominal lesions by means of USG, Abdominal BT has become the gold standard imaging technique in the diagnosis of RSH. 10 Furthermore, Berná et al.11developed a classification system for RSH that pays attention to CT results. In our study, CT imaging was the standard method used. Average hematoma dimater was identified as 74 mm. Contrary to the series in the literature, the most common RSH in our series was Type 1 (75%).1,7,10
In the literature, surgical intervention is not recommended for Rectus Sheath Hematomas other than Type III Rectus Sheath Hematomas. Medical treaments such as bed rest, cessation of anticoagulants, hydration, transfusion based on decrease in hemoglobin, and Fresh Frozen Plasma for warfarin intoxication are recommended.7 In the literature, success rates ranging between 80% and 90% were reported for conservative treatment. 7,16 Surgical treatment is recommended in patients with Type III RSH whose hemodynamic stability cannot be insured via aggressive hydration and blood transfusion. Selective embolization of the epigastric arteries must be preferred over surgery even in this patient group as open surgical interventions intensify bleeding by eliminating the buffer capacity of the hematoma. Open surgery is recommended when bleeding cannot be controlled through embolization, when the hematoma is infected, and when compartment syndrome has developed.1,7 Limited number of studies are available in the literature relating to the comparison of treatment modalities used to treat rectus sheath hematomas. In their study comparing surgical treatment, percutaneous treatment, embolization therapy and conservative treatment; Gradauskas et al demonstrated that embolization of the epigastric artery is a useful method in stopping the bleeding in hemodynamically unstable patients. In the same study, similar results were obtained in terms of all parameters, including hematoma size, between percutaneous drainage and conservative treatment groups in patients who had Type I and Type II hematomas. Duration of hospital stay of patients who underwent percutaneous drainage was two times longer than those of the group that underwent conservative treatment. No serious complications associated with hematoma developed in both groups and readmission to the hospital was not required. Therefore, Gradauskas et al recommended that percutaneous drainage should be avoided as far as possible as it carries a potentially higher risk of infection.17 Smithson A et al suggested that most cases in their series responded to conservative treatment and that selective embolization of the epigastric artery could be the first treatment option in patients using low molecular weight heparin.1 The conservative approach was primarily adopted in all patients in our series and success was achieved in 90% of the patients with this treatment. One patient underwent percutaneous drainage and four patients underwent surgical treatment. Hemodynamic balance of the patients was determinative in determining the indication for surgical treatment.
Mortality rate of RSH varied between 12% and 20% in the studies carried out in the literature in the previous years.18,19 however, it has decreased to 4-5% in the recent studies. The principal reason for such decrease in mortality rate is the inclusion of selective embolization of epigastric arteries in treatment modalities.1 In the literature, mortality rate seems to be more related to significant comorbodities, anticoagulant therapies, large SRSHs, increased blood transfusion, and upper gastrointestinal system bleeding.10,20 In our series, incidence of mortality during hospital stay was 15% and this was not considered to be associated with rectus sheath hematoma alone. Mortality developed in many patients due to aggrevation of the comorbidities accompanying SRSH. Accompanying hemodynamic instability and/or comorbidities can account for increased mortality rate.
The significant limitations of our study is its retrospective design, along with the heterogeneity of the study population. Despite these limitations, our study provides the literature with detailed clinical data relating to this rare clinical condition.
In conclusion, SRSH is a cause of acute abdominal pain which is seen more often today due to an increase in the use of anticoagulant and/or antiaggregant drugs for various reasons. SRSH must be kept in mind in patients who have a comorbidity, use anticoagulant drugs in particular, have a palpable mass accompanied by newly developing abdominal pain, and have a low hemoglobin level. Such conditions as coughing, sneezing and compulsion that increase intraabdominal pressure must be investigated together with a detailed medical history of the patient. Suspecting of SRSH in such circumstances will render early and true diagnosis possible, and prevent morbidity and mortality with the help of an appropriate treatment method before hemodynamic instability occurs in these patients.
Acknowledgemen t
None
Sources of funding
We have no supportive funding.