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.