Spontaneous abdominal wall hematoma

Specialty: Gastrointestinal.

• Hematoma of the rectus sheath
• anterior abdominal wall hemorrhage

Why it occurs

• Spontaneous or microtraumatic rupture of the superior or inferior epigastric arteries (or their perforating branches) within the sheath of the rectus abdominis muscle, favored by intense cough, persistent sneezing or vigorous physical exertion
• Active systemic anticoagulant treatment (warfarin, acenocoumarol, low molecular weight heparins or direct oral anticoagulants) with or without associated overdose
• Severe blood dyscrasias or end-stage liver failure with consumptive coagulopathy
• Minor blunt trauma to the abdominal wall unnoticed by the patient.

Initial workup

CT of the abdomen and pelvis with intravenous contrast and arterial phase (definitive study of diagnostic choice; allows identifying the hematoma of the rectus sheath, classifying its extension and detecting active bleeding due to extravasation of the contrast medium [arterial "blush"]) | Ultrasound of soft tissues of the abdominal wall (rapid, economical, useful to differentiate intra-abdominal solid/cystic mass from a blood collection in the wall) | Emergency analysis: complete blood count, clotting times (PT, aPTT, INR), kidney function and blood group typing with blood reserve | Fothergill physical maneuver (positive if the palpable abdominal mass remains palpable and immobile when asking the patient to lift the head and shoulders off the table, confirming extraponeurotic origin of the anterior wall).

Standard management

• Immediate reversal of active systemic anticoagulation — vitamin K 10 mg slow IV, concentrated prothrombin complex [PCC], or fresh frozen plasma if patient takes antivitamin K; protamine if you use heparin; or idarucizumab/andexanet alfa for new anticoagulants depending on availability
• Non-platelet analgesics of choice — paracetamol 1 g IV every 8 hours or metamizole 1-2 g IV; Strictly avoid NSAIDs such as ketorolac, ibuprofen or aspirin due to their antiplatelet effect that worsens bleeding.
• Supportive fluid therapy with isotonic crystalloids or plasma volume expansion to maintain hemodynamic stability.