Management of Rectus Sheath Hematoma

Diagnostic Evaluation

• The American College of Radiology states that CT scan is the preferred diagnostic modality for rectus sheath hematoma, with ultrasound having significant limitations for evaluating retroperitoneal and abdominal wall structures 1, 2
• Ultrasound cannot reliably determine if bleeding is currently active or has resolved, which is the key clinical question in a patient with ongoing symptoms 1, 2
• Anatomical evaluation of deep structures is difficult with ultrasound due to patient positioning limitations and lack of sufficient acoustic windows 1, 2

Appropriate Use of Imaging

• The American College of Radiology Appropriateness Criteria suggest that repeat CT with IV contrast is only necessary if there are clinical signs suggesting active rebleeding, such as new hypotension, significant hemoglobin drop, acute expansion of the mass, or hemodynamic instability 1
• CT can detect contrast extravasation indicating active arterial bleeding that might require interventional radiology embolization 1

Follow-up Imaging After Retroperitoneal Bleed

Imaging Modalities and Characteristics

• The American College of Radiology recommends CT as the optimal modality for monitoring clinically suspected rebleeding because it can detect contrast extravasation indicating active arterial bleeding that might require interventional radiology embolization 3
• The attenuation pattern on CT helps determine the acuity and need for intervention, with high attenuation or mixed attenuation indicating acute bleeding or rebleeding, and low attenuation suggesting subacute to chronic blood products 3