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Year : 2019  |  Volume : 6  |  Issue : 3  |  Page : 181-183

Spontaneous expanding internal oblique hematoma induced by vigorous cough in an elderly patient under antiplatelet therapy: Case report and review of literature

Department of Radiology, Malabar Medical College, Kozhikode, Kerala, India

Date of Submission11-Jul-2018
Date of Decision26-Jul-2018
Date of Acceptance15-Aug-2018
Date of Web Publication13-Aug-2019

Correspondence Address:
Reddy Ravikanth
Department of Radiology, Malabar Medical College, Kozhikode - 673 315, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cjhr.cjhr_108_18

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Oblique muscle hematomas are an uncommon cause of acute abdominal pain and are more common in elderly individuals, particularly in those under anticoagulant therapy. They are often misdiagnosed from other causes of abdominal pain. We report a case of a cough-induced internal oblique hematoma in an elderly 62-year-old male patient under antiplatelet therapy. He had no history of trauma and presented with acute worsening pain in the left flank. Ultrasonography revealed a hypoechoic mass in the right lateral abdominal wall. Nonenhanced computed tomography of the abdomen showed a 6 cm × 4 cm × 7 cm hematoma in the left internal oblique muscle. The patient was managed conservatively without blood transfusion. Differential diagnosis of an acute-onset flank mass should include oblique muscle hematoma even in the absence of anticoagulant therapy or trauma.

Keywords: Anticoagulants, arteriography, computed tomography angiography, ecchymosis, internal oblique hematoma, transcatheter arterial embolization

How to cite this article:
Ravikanth R. Spontaneous expanding internal oblique hematoma induced by vigorous cough in an elderly patient under antiplatelet therapy: Case report and review of literature. CHRISMED J Health Res 2019;6:181-3

How to cite this URL:
Ravikanth R. Spontaneous expanding internal oblique hematoma induced by vigorous cough in an elderly patient under antiplatelet therapy: Case report and review of literature. CHRISMED J Health Res [serial online] 2019 [cited 2020 Aug 12];6:181-3. Available from: http://www.cjhr.org/text.asp?2019/6/3/181/264369

  Introduction Top

Oblique muscle hematomas are uncommon and present as acute abdominal pain with a palpable mass after muscular strain such as coughing and sneezing. The most common abdominal wall hematoma is a rectus sheath hematoma caused either by damage to the superior or inferior epigastric arteries or their branches or by direct damage to the rectus muscle.[1] In contrast, an internal oblique hematoma is extremely rare in the category of abdominal wall hematomas but is an important entity in the differential diagnosis of acute-onset abdominal pain. Oblique muscle hematoma can mimic other acute abdominal disorders and is more commonly seen in elderly, particularly if they are under anticoagulant therapy or have a chronic cough or cardiovascular disease.[2] Here, we present a case of an elderly 62-year-old male patient with left internal oblique hematoma induced by vigorous cough. Oblique muscle hematoma is often misdiagnosed due to lack of interdisciplinary awareness of the condition, leading to delay in the management and unnecessary surgical intervention.

  Case Report Top

An elderly 62-year-old male patient presented to the emergency department of our hospital with acute worsening pain, swelling in the left flank, and blackish discoloration of the overlying skin. There was no history of blunt trauma. The patient is a chronic smoker, had been coughing continuously for the past month, and had severe cough 1 day before the onset of pain. She had been receiving medications of inhaled beta-agonists, inhaled corticosteroids, inhaled anticholinergic, and oral theophylline, furosemide, acetylsalicylic acid, and diltiazem because of cor pulmonale and chronic obstructive pulmonary disease. Abdominal examination revealed a smooth, tender mass, with maximum diameter of 8 cm in the left lateral abdominal wall with ecchymosis of the overlying skin. Differential diagnoses included were incarcerated hernia and rupture of the abdominal aortic aneurysm. Laboratory findings included hematocrit 40%, hemoglobin 11.4 g/dl, platelets 150,000/mm 3, white blood cell count 10,500/mm 3, prothrombin time (PT) 28 s, activated partial thromboplastin time (aPTT) 34 s, and international normalization ratio 1.2. The patient's blood pressure was 150/90 mmHg, heart rate 95 bpm and nonarrhythmic, and respiratory rate 28 bpm. PT and aPTT were within the reference ranges. We performed ultrasound (US) and computed tomography (CT) of the abdomen. US revealed a hypoechoic mass in the left lateral abdominal wall. Unenhanced abdominal CT showed a 6 cm × 4 cm × 7 cm tissue mass in the left internal oblique muscle [Figure 1]. Acetylsalicylic acid treatment was stopped. Cold application and analgesic treatment were started.
Figure 1: Axial nonenhanced computed tomography image of the abdomen demonstrating hyperdensity suggesting hematoma in the left internal oblique muscle (arrow)

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  Discussion Top

Abdominal wall hematoma is an uncommon cause of acute abdominal pain. The incidence of spontaneous muscle hematoma (SMH) in patients on anticoagulants is 0.6%.[3] The prevalence of SMH is higher in women and elderly patients. Many risk factors have been reported for abdominal wall hematomas. These include aging, anticoagulant therapy, platelet disorders, trauma, recent surgery, injection procedures, and physical exercise as well as increased intraabdominal pressure from coughing, sneezing, vomiting, or straining during urination, defecation, or labor.[4] The most common presenting signs and symptoms of these hematomas are acute abdominal pain and firm, palpable abdominal wall masses. Because of their rarity, spontaneous lateral abdominal wall hematomas can be mistaken for several common acute abdominal conditions, such as appendicitis, sigmoid diverticulitis, perforated ulcers, ovarian cyst torsion, tumors, incarcerated inguinal hernias, mesenteric vascular disorder, dissecting abdominal aortic aneurysm, or necrotizing pancreatitis.[5] An abdominal wall mass with ecchymosis is the most important diagnostic finding for suspicion of a hematoma.[6]

The first-line imaging test for the radiological diagnosis of SMH is based on nonenhanced multidetector CT (MDCT).[7] MDCT provides a positive and topographic diagnosis. In 1996, Berná et al.[8] described a classification combining unenhanced CT results and the clinical presentation. This classification helps guide the patient management. Grade I SMH is small and associated with pain and no decrease in hemoglobin levels. Grade II SMH is more voluminous and often bilateral. They extend between and dissect the muscle fascia. CT angiography (CTA) plays an essential role in the management of severe SMH. The diagnostic sensitivity of CTA scan is better than arteriography for most locations, particularly the abdomen. Bleeding with a flow rate ≥0.3 mL/min can be detected.[2] Identifying the location of the vascular source of bleeding is good on CTA. Active leaking of contrast material or the enhancement of the hematoma in venous phase images identifies the source of bleeding of the SMH.[9]

The diagnosis of an oblique muscle hematoma is made by combining medical history, laboratory examination findings, and US and/or radiological findings.[10] US and CT scans can provide useful information for differential diagnosis to avoid unnecessary surgery. Conservative treatment is acceptable for most patients, and surgical treatment is limited to certain conditions, such as cases of hematoma progression, rupture into the peritoneal cavity, or infection. Surgical intervention or transcatheter arterial embolization is recommended when conservative management fails.[11] In our case, conservative treatment was administered because CT findings did not suggest active bleeding.

  Conclusion Top

The diagnosis of oblique muscle hematoma can be made clinically and via sonographic findings. CT of the abdomen should be performed for definitive diagnosis, and the principle therapy is conservative management. Conservative management remains the first therapeutic choice for the elderly. They should be considered in the differential diagnosis of painful abdominal masses in elderly patients, especially those suffering from severe cough attacks or receiving treatment with anticoagulants. The early diagnosis is the most important factor of low mortality in the elderly, preventing the unnecessary surgical intervention and determining the success of conservative treatment. Alternatively, transcatheter arterial embolization is an effective method for controlling the bleeding in rapidly expanding oblique muscle hematoma.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Linhares MM, Lopes Filho GJ, Bruna PC, Ricca AB, Sato NY, Sacalabrini M, et al. 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. 1
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. 2
Manckoundia P, Zarouala B, Lalu-Fraisse A, Besancenot JF, Lorcerie B, Pfitzenmeyer P, et al. Muscle hematoma in the very elderly receiving low-molecular-weight heparins. Presse Med 2000;29:702.  Back to cited text no. 3
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. 4
Klingler PJ, Wetscher G, Glaser K, Tschmelitsch J, Schmid T, Hinder RA, et al. The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders. Surg Endosc 1999;13:1129-34.  Back to cited text no. 5
Shimodaira M, Kitano T, Kibata M, Shirahata K. An oblique muscle hematoma as a rare cause of severe abdominal pain: A case report. BMC Res Notes 2013;6:18.  Back to cited text no. 6
Ernst O, Bulois P, Saint-Drenant S, Leroy C, Paris JC, Sergent G, et al. Helical CT in acute lower gastrointestinal bleeding. Eur Radiol 2003;13:114-7.  Back to cited text no. 7
Berná JD, Garcia-Medina V, Guirao J, Garcia-Medina J. Rectus sheath hematoma: Diagnostic classification by CT. Abdom Imaging 1996;21:62-4.  Back to cited text no. 8
Kodama K, Takase Y, Yamamoto H, Noda T. Cough-induced internal oblique hematoma. J Emerg Trauma Shock 2013;6:132-4.  Back to cited text no. 9
[PUBMED]  [Full text]  
Moreno Gallego A, Aguayo JL, Flores B, Soria T, Hernández Q, Ortiz S, et al. Ultrasonography and computed tomography reduce unnecessary surgery in abdominal rectus sheath haematoma. Br J Surg 1997;84:1295-7.  Back to cited text no. 10
Zissin R, Gayer G, Kots E, Ellis M, Bartal G, Griton I, et al. Transcatheter arterial embolisation in anticoagulant-related haematoma – A current therapeutic option: A report of four patients and review of the literature. Int J Clin Pract 2007;61:1321-7.  Back to cited text no. 11


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