Journal of Emergencies, Trauma, and Shock
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 Table of Contents    
CASE REPORT  
Year : 2013  |  Volume : 6  |  Issue : 2  |  Page : 132-134
Cough-induced internal oblique hematoma


1 Department of Urology, Toyama City Hospital, Toyama, Japan
2 Department of Internal Medicine, Toyama City Hospital, Toyama, Japan
3 Department of Emergency, Toyama City Hospital, Toyama, Japan

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Date of Submission08-Aug-2012
Date of Acceptance16-Sep-2012
Date of Web Publication19-Apr-2013
 

   Abstract 

Violent or sustained cough can be associated with serious musculoskeletal complications. We report a case of a cough-induced internal oblique hematoma in an obese 73-year-old woman who was not receiving antithrombotic therapy. She had no history of trauma and presented with acute worsening pain in the right flank. She had been coughing continuously for the past month and had severe cough 2 days before the onset of pain. Ultrasonography revealed a hypoechoic mass in the right lateral abdominal wall. Unenhanced computed tomography of the abdomen showed a 7 cm × 7 cm × 4 cm hematoma in the right internal oblique muscle. The patient was managed conservatively without blood transfusion. Acute abdominal pain together with an abdominal painful mass, particularly in patients with cough, should alert physicians to the possibility of an abdominal wall hematoma.

Keywords: Abdominal wall hematoma, computed tomography, cough, internal oblique muscle, ultrasonography

How to cite this article:
Kodama K, Takase Y, Yamamoto H, Noda T. Cough-induced internal oblique hematoma. J Emerg Trauma Shock 2013;6:132-4

How to cite this URL:
Kodama K, Takase Y, Yamamoto H, Noda T. Cough-induced internal oblique hematoma. J Emerg Trauma Shock [serial online] 2013 [cited 2019 Jul 23];6:132-4. Available from: http://www.onlinejets.org/text.asp?2013/6/2/132/110789



   Introduction Top


An abdominal wall hematoma is a rare cause of an acute abdominal disorder and a known complication of abdominal trauma, surgery, and excessive strain on the abdominal musculature. The most common abdominal wall hematoma is a rectus sheath hematoma caused by damage to the superior or inferior epigastric arteries or their branches or by direct damage to the rectal muscle. Patients present with varying symptoms, but the most common features are abdominal pain and a mass in the lower abdomen, most frequently on the right side. [1],[2] An abdominal wall hematoma has multiple possible etiologies, including antithrombotic therapy. The increasing use of antithrombotic therapies has led to an increase in patients without obvious precipitating events. Ultrasonography (US) is a first-line diagnostic tool with a sensitivity of only 80-90%, whereas computed tomography (CT) is an excellent method for diagnosis with nearly 100% sensitivity and specificity, providing precise information on the nature, size, and complications. [3],[4] This condition encompasses a wide spectrum of severity (self-limiting to fatal), depending on the development of complications.

In contrast, an internal oblique hematoma is extremely rare in the category of abdominal wall hematomas but an important entity in the differential diagnosis of abdominal pain. Herein, we present a case of a cough-induced internal oblique hematoma in an obese patient who was not receiving antithrombotic therapy. Interdisciplinary awareness of this condition is essential as it is frequently difficult to diagnose, leading to delay in treatment or unnecessary surgery.


   Case Report Top


A 73-year-old woman with no history of trauma presented with acute worsening pain of 6 h duration in the right flank. She had been coughing continuously for the past month and had severe cough 2 days before the onset of pain. She was obese (body mass index, 29.6) and a non-smoker. She had been treated for hypertension and cerebral infarction but was receiving no antiplatelet or anticoagulant therapies. She had undergone several abdominal surgeries (transabdominal hysterectomy for myoma uteri, transabdominal sacrocolpopexy for vault prolapse, and open appendectomy for appendicitis) more than 2 years before her presentation. On arrival, a hard, smooth, and painful mass (diameter, approximately 5 cm) was palpable on her right flank during physical examination. Her vital signs were as follows: Blood pressure, 139/73 mmHg; pulse, 96 beats/min; body temperature, 37.2°C; and respiratory rate, 12 breaths/min. The laboratory findings were as follows: Hematocrit, 38.0%; hemoglobin, 13.0 g/dL; white blood cells, 8700/mm 3 ; platelets, 162,000/mm 3 ; creatine phosphokinase, 123 IU/L; lactate dehydrogenase, 165 IU/L; and C-reactive protein, 0.92 mg/dL. Prothrombin time and activated partial thromboplastin time were within the reference ranges. We performed US and CT of the abdomen. US revealed a hypoechoic mass in the right lateral abdominal wall [Figure 1]. Unenhanced abdominal CT showed a 7 cm × 7 cm × 4 cm tissue mass in the right internal oblique muscle [Figure 2]. We speculated that repeated damage during the cough attacks probably led to the abdominal wall hematoma. She was treated conservatively with bed rest and analgesics. The leukocyte count was normal and the hemoglobin level had decreased to 10.7 g/dL the next day. However, the anemia did not worsen and she did not require a blood transfusion. On the third day of hospitalization, an ecchymosis appeared in the right flank and lower abdominal area [Figure 3]. Because she had typical symptoms such as heartburn and regurgitation, and an endoscopy showed reflux esophagitis, we diagnosed gastroesophageal reflux-related chronic cough. Empirical treatment with a proton pump inhibitor relieved the cough. On US, it was observed that the size of the hematoma reduced and the patient's abdominal pain decreased gradually. The patient was discharged 13 days later. A follow-up CT 3 months later showed that the hematoma was resolving [Figure 4].
Figure 1: Ultrasonography showing a hypoechoic mass in the right lateral abdominal wall

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Figure 2: Computed tomography of the abdomen showing a 7 cm × 7 cm × 4 cm hematoma in the right internal oblique muscle

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Figure 3: An ecchymosis in the right flank and lower abdominal area on the third day of hospitalization

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Figure 4: Follow-up computed tomography 3 months later showing that the hematoma was resolving

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   Discussion Top


Violent or sustained cough can be associated with serious musculoskeletal complications. Cough is a vital reflex to protect the airways from foreign material and clear excessive secretions. Involuntary coughing involves a coordinated quick contraction of the thoracic, abdominal, and pelvic muscles, which increases intrathoracic and intra-abdominal pressure. The most frequent and best documented cough-related complications are rib fractures, which are caused by opposing muscular forces in the middle of the ribs at the axillary line from the serratus anterior and external oblique muscles. [5] Other complications including diaphragm rupture, abdominal wall herniation, and abdominal wall hematoma have been reported. [6] One-third of the patients with a rectus sheath hematoma have coughing episodes as the major triggering factor. [1]

Understanding the factors associated with an abdominal wall hematoma is important to facilitate this diagnosis early in its presentation. In the presence of predisposing factors, an abdominal wall hematoma can occur as a result of non-traumatic injury. These factors include overcontraction or overstretching of the abdominal muscles by coughing, sneezing, twisting, or vomiting. Moreover, weakness of the vessel wall or a decrease in muscular resistance as a result of hypertension, arteriosclerosis, advanced age, obesity, pregnancy, previous surgery, bleeding tendency, or use of anticoagulants may be associated with the occurrence of a hematoma. The most frequent cause of a non-traumatic rectus sheath hematoma is antithrombotic therapy. Approximately 70% patients with a rectus sheath hematoma have had some form of anticoagulation therapy at the time of diagnosis. [1],[2]

An internal oblique hematoma is extremely rare and only a few cases have been reported. [7],[8] This type of hematoma is usually caused by damage to the lower intercostal or lumbar arteries or ascending branches of the deep circumflex iliac artery. In the present case, the hematoma was thought to have been caused by rupture of the lumbar artery, which was based on the location of the hematoma, and was probably induced by overcontraction and overstretching of the internal oblique muscle at the time of coughing. Moreover, weakness of the arterial wall resulting from advanced age, obesity, or previous abdominal surgeries may be associated with the occurrence of a hematoma.

Conservative treatment is acceptable for most patients with an abdominal wall hematoma, and surgical treatment is limited to conditions such as progression of the hematoma, a rupture into the peritoneal cavity, or infection. Several reports have demonstrated that angiography with embolization can control bleeding and avoid surgical intervention. [7],[9] There are reported cases of a repeat rectus sheath hematoma after restarting anticoagulation therapy. [1] In the present case, long hospitalization was required for treatment of the gastroesophageal reflux-related cough because we were concerned about repeat bleeding caused by her persistent cough. Some specific risk factors for progression of a hematoma seem to coexist in elderly subjects: Atrophy of cutaneous and subcutaneous tissues reducing trauma neutralization and vascular fragility or fat involution limiting external compression during vascular leakage. [10] An ecchymosis often appears after the onset of bleeding and may not depend on the status of active bleeding. Repeated blood tests and US are necessary to evaluate whether the active bleeding has persisted.


   Conclusion Top


An abdominal wall hematoma is a rare cause of an acute abdominal disorder, and may be misdiagnosed from other causes of abdominal pain. Acute abdominal pain together with an abdominal painful mass, particularly in patients with cough, should alert physicians to the possibility of an abdominal wall hematoma.

 
   References Top

1.Cherry WB, Mueller PS. Rectus sheath hematoma: Review of 126 cases at a single institution. Medicine 2006;85:105-10.  Back to cited text no. 1
    
2.Linhares MM, Lopes Filho GJ, Bruna PC, Ricca AB, Sato NY, Sacalabrini M. Spontaneous hematoma of the rectus abdominis sheath: A review of 177 cases with report of 7 personal cases. Int Surg 1999;84:251-7.  Back to cited text no. 2
    
3.Zainea GG, Jordan F. Rectus sheath hematomas: Their pathogenesis, diagnosis, and management. Am Surg 1988;54:630-3.  Back to cited text no. 3
    
4.Gocke JE, MacCarty RL, Foulk WT. Rectus sheath hematoma: Diagnosis by computed tomography scanning. Mayo Clin Proc 1981;56:757-61.  Back to cited text no. 4
    
5.Kawahara H, Baba H, Wada M, Azuchi M, Ando M, Imura S. Multiple rib fractures associated with severe coughing-a case report. Int Orthop 1997;21:279-81.  Back to cited text no. 5
    
6.Irwin RS. Complications of cough: ACCP evidence-based clinical practice guidelines. Chest 2006;129:54S-8S.  Back to cited text no. 6
    
7.Nakayama T, Ishibashi T, Eguchi D, Yamada K, Tsurumaru D, Sakamoto K, et al. Spontaneous internal oblique hematoma successfully treated by transcatheter arterial embolization. Radiat Med 2008;26:446-9.  Back to cited text no. 7
    
8.Tai CM, Liu KL, Chen CC, Lin JT, Wang HP. Lateral abdominal wall hematoma due to tear of internal abdominal oblique muscle in a patient under warfarin therapy. Am J Emerg Med 2005;23:911-2.  Back to cited text no. 8
    
9.Shimizu T, Hanasawa K, Yoshioka T, Mori T, Kajinami T, Yokoyama K, et al. Spontaneous hematoma of the lateral abdominal wall caused by a rupture of a deep circumflex iliac artery: Report of two cases. Surg Today 2003;33:475-8.  Back to cited text no. 9
    
10.Manckoundia P, Zarouala B, Lalu-Fraisse A, Besancenot JF, Lorcerie B, Pfitzenmeyer P. Muscle hematoma in the very elderly receiving low-molecular-weight heparins. Presse Med 2000;29:702.  Back to cited text no. 10
    

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Correspondence Address:
Koichi Kodama
Department of Urology, Toyama City Hospital, Toyama
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.110789

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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