Spontaneous Retroperitoneal and Rectus Sheath Hemorrhage—Management, Risk Factors and Outcomes

Abstract

Background Spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH) is associated with high mortality in the literature, but studies on the subject are lacking. The objective of this study was to identify early predictors of the need for angiographic or surgical intervention (ASI) in patients with SRRSH and define risk factors for mortality. Methods We conducted a retrospective cohort study at a tertiary academic hospital. All patients with computed tomography-identified SRRSH between 2012 to 2017 were included. Exclusion criteria were age below 18 years, possible mechanical cause of SRRSH, aortic aneurysm rupture or dissection, and traumatic or iatrogenic sources of SRRSH. The primary outcome was the incidence of ASI and/or mortality. Results Of 100 patients included (median age 70 years, 52% males), 33% were transferred from another hospital, 82% patients were on therapeutic anticoagulation, and 90% had serious comorbidities. Overall mortality was 22%, but SRRSH-related mortality was only 6%. Sixteen patients underwent angiographic intervention (n = 10), surgical intervention (n = 5), or both (n = 1). Flank pain (OR 4.15,, p = 0.023) and intravenous contrast extravasation (OR 3.89, 95% CI 1.23-12.27, p = 0.020) were independent predictors of ASI. Transfer from another hospital (OR 3.72, 95% CI 1.30-10.70, p = 0.015), age above 70 years (OR 4.24, 95% CI 1.25-14.32, p = 0.020), and systolic blood pressure below 110 mmHg at the time of diagnosis (OR 4.59,, p = 0.027) were independent predictors of mortality. Conclusions SRRSH is associated with high mortality but is typically not the direct cause. Most SRRSHs are selflimited and require no intervention. Pattern identification of ASI is hard.

Rectus sheath and retroperitoneal haematomas in patients with Coronavirus 2019 infection

“…5 Cases of spontaneous rectus sheath (RSH), and retroperitoneal haematomas (RPH) have also been described, 6 both of which were rare pre-COVID-19. 7 Spontaneous RSH typically occurs in elderly patients and approximately two thirds of these bleeds are associated with therapeutic anticoagulation, whereas RPH characteristically occurs following trauma. 7 Recognised risk factors for RSH/ RPH include therapeutic anticoagulation, underlying coagulopathy, hypertension, abdominal wall injections, steroid therapy, cough and old age.…”

“…7 Spontaneous RSH typically occurs in elderly patients and approximately two thirds of these bleeds are associated with therapeutic anticoagulation, whereas RPH characteristically occurs following trauma. 7 Recognised risk factors for RSH/ RPH include therapeutic anticoagulation, underlying coagulopathy, hypertension, abdominal wall injections, steroid therapy, cough and old age. 7 As patients admitted with COVID-19 are typically prescribed steroid therapy and exhibit symptoms of severe cough, it is plausible that this could in part explain a higher risk of RPH/RSH in this population.…”

Spontaneous Pelvic Hemorrhage and Rectus Sheath Hematoma due to Anticoagulant Overdose: A Case Report

“…Conservative management that is based on adequate analgesia, rest, and reversal of anticoagulation is more frequently chosen treatment modality. Surgery is considered in hemodynamically unstable patients with expanding hematoma, and not responding to medical resuscitation with blood transfusion and IV fluids (9). In our case, conservative treatment was applied, and the patient was discharged without any complications.…”

“…The therapeutic options for both hematomas can be conservative or invasive (7)(8)(9). Conservative management that is based on adequate analgesia, rest, and reversal of anticoagulation is more frequently chosen treatment modality.…”

A Fatal Rectus Sheath Hematoma after a Myasthenia Crisis Case Report

“…Prior case reports highlighted that RSHs may be associated with abdominal injections and steroids or immunosuppressants. 1,[12][13][14] Systemic corticosteroids have been linked with spontaneous bruising and disrupted wound healing. 15 Future studies should investigate how corticosteroid dose may affect the development and outcomes of RSHs.…”