Rectus Sheath Hematoma Outcomes And Risk Factors In The Non-vitamin K Oral Anticoagulant (NOAC) Era
Anthony N. Grieff, MD, Calvin Qian, Charles Hamilton, Kristen Lee, William Beckerman, John Nosher.
Rutgers Robert Wood Johnson, New Brunswick, NJ, USA.
OBJECTIVES: Rectus sheath hematoma (RSH) is a relatively uncommon pathology characterized by injury to epigastric arteries and their tributaries resulting in a spectrum of asymptomatic to life-threatening hemorrhage. Risk factors are often multifactorial, but frequently related to anticoagulation. However the role of non-vitamin K oral anticoagulants (NOAC'S) remains uncertain.
METHODS: A retrospective review of all patients at a tertiary medical center diagnosed with RSH by computed tomography from 2010-2020 was performed. Patients were categorized by RSH at admission (<24hrs) or RSH during admission (>24hrs). Patients were divided into two 5-year cohorts from 2010-2015 (early cohort) and 2016-2020 (current cohort) in order to reflect the prevalence of NOAC’s
RESULTS: 129 patients met inclusion criteria during the study period; 56 patients in the early cohort (EC) and 73 patients in the current cohort (CC). There were no differences in age, gender, or medical comorbidities. Overall anticoagulation use did not vary between the EC and CC (38% vs 29%, p=.30) however, as expected warfarin was significantly greater in the EC (36 vs 7%, p<.01). No differences between cohorts were found for the severity of bleeding, the requirement for transfusion, hematoma size or embolization requirement. Notably, the EC was more likely to have RSH on admission (54% vs 36%, p=.04) and less likely to experience bleeding during admission; 46% vs 64%, p=.04). For all patients, risk factors for transfusion were advanced age (71.8 versus 63.0, p<.01), diabetes (45% versus 24%, p=.01), cirrhosis (9% versus 0%, p=.01) or an admission for a pulmonary-pathology (48% vs 27%, p=.01). Further, 51% of patients with in-hospital RSH were admitted for pulmonary issues compared to 21% with RSH on admission (p<.01). The only risk factor noted for embolization was a history of cirrhosis (20% versus 3%, p=.02) or active extravasation on CT (p=.01), Patients undergoing embolization received 6.8 units of packed blood cells compared to 1.5 for those who did not.
CONCLUSIONS: Patients on anticoagulation during the low-use NOAC period were more likely to present to the hospital with an RSH, suggesting that NOACS are associated with a lower risk of spontaneous RSH. Further, despite irreversibility, there was no evidence that NOACS were associated with worse bleeding, increasing transfusion requirements, or the need for interventional procedures in patients with RSH.
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