Factors predicting need for intervention and mortality in patients with spontaneous rectus sheath hematoma

Spontaneous rectus sheath hematoma (RSH) is a potentially life-threatening cause of acute abdominal pain, particularly in elderly and anticoagulated patients. While most cases are managed conservatively, a significant proportion requires interventional procedures, and mortality remains substantial. The aim of the study was to identify the predictors of interventional procedure requirements and 90-day mortality in patients with spontaneous RSH.

This retrospective study included consecutive adult patients diagnosed with spontaneous RSH at a tertiary care center between January 2017 and December 2023. Clinical, laboratory, and imaging data were collected. Multivariate logistic regression was used to identify independent predictors of interventional radiology treatment and 90-day all-cause mortality.

The study consisted of 59 patients with a median age of 72 years, and 77.9% were females. Interventional radiology procedures were performed in 27.1% of cases, and 90-day mortality was 22.0%. Hematoma volume was independently associated with the need for intervention (odds ratio [OR]: 1.002; p=0.004). In a subgroup of patients undergoing computed tomography angiography (n=36), contrast extravasation was also a significant predictor (OR: 17.460; p=0.009). Independent predictors of 90-day mortality were advanced age (OR: 1.088; p=0.045) and greater hemoglobin decline (OR: 1.086; p=0.008).

Hematoma volume and contrast extravasation are significant predictors of the need for interventional treatment, while advanced age and hemoglobin decline predict 90-day mortality in spontaneous RSH. These findings support the use of objective radiologic and laboratory parameters for early risk stratification. Prospective multicenter validation is warranted to guide standardized management strategies in this high-risk population.