Why Am I Experiencing Stomach Pain When Coughing

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.

Cough-induced internal oblique hematoma

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PMCID: PMC3665063 PMID: 23723625

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

INTRODUCTION

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

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

Figure 2.

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

Figure 3.

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

Figure 4.

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

DISCUSSION

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

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.

Footnotes

Source of Support: Nil.

Conflict of Interest: None declared.

REFERENCES

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Why Am I Experiencing Stomach Pain When Coughing?

Experiencing stomach pain when coughing can be both uncomfortable and concerning. This type of discomfort can be a nuisance in your daily life, significantly affecting your quality of life and productivity. Understanding the various reasons behind this pain is important in identifying the appropriate treatments and potentially preventing more serious health issues.

Common Causes Of Stomach Pain When Coughing

Stomach pains when coughing often stem from the mechanical stress that coughing places on the abdominal muscles. Below are some of the most common triggers for this type of pain:

• Muscle Strain – Coughing intensely or coughing for prolonged periods can lead to muscle fatigue or strain in the abdominal region. This strain can cause sharp or aching pain that becomes more pronounced with subsequent coughs. Managing this requires general physical activities and avoiding actions that exacerbate the pain.
• Diaphragmatic Irritation – The diaphragm plays a crucial role in breathing and separates the chest from the abdomen. When you cough, this muscle contracts forcefully, irritating it and leading to referred pain in the stomach area. This pain typically feels like a sharp stitch on either side of the lower rib cage.
• Hernias – Hernias are characterized by an internal part of the body pushing through a weakness in a muscle or surrounding tissue wall. A common type includes abdominal hernias, where intestines or fatty tissues protrude through abdominal wall openings. Coughing can intensify the discomfort and pain associated with a hernia, making it more noticeable and occasionally severe.

More Serious Concerns

While often the stomach pain may be due to relatively benign causes, it can sometimes indicate more serious health issues:

• Gastrointestinal Problems – Various conditions such as gastritis, ulcers, or gastroesophageal reflux disease (GERD) can cause stomach pains. These conditions may lead to an inflammation of the stomach lining or the esophagus which becomes more painful during episodes of intense coughing.
• Infections – Both respiratory and abdominal infections can cause inflammation, which may be felt as abdominal pain. This type of pain typically worsens with the physical act of coughing because of the increased abdominal pressure and irritation caused by vigorous diaphragm movements.
• Organ Issues -Serious abdominal organ problems, such as liver, pancreas, or gallbladder complications, might also manifest as pain exacerbated by coughing. These conditions can be acute and require immediate medical attention to prevent further health deterioration.

Diagnosis and Treatment

Identifying the cause of stomach pain when coughing involves a comprehensive assessment by a healthcare provider, which usually includes a physical examination and possibly some diagnostic tests. You can learn more about the diagnostic process in emergency rooms by visiting our page on How Will the ER Diagnose The Cause of My Abdominal Pain?

Depending on the identified cause, treatment for stomach pain when coughing may vary:

• For Muscle Strain – Resting, avoiding strenuous activities, and applying heat or cold packs can help alleviate pain. Over-the-counter pain relief medications may also be recommended to manage discomfort.
• For Infections – Treatment could involve antibiotics or other specific medications to tackle the infection, along with supportive care to relieve symptoms.
• Serious Conditions – Various abdominal issues such as appendicitis, kidney stones, gallstones, cystitis, diverticular disease, hernias, ovarian cysts, and endometriosis typically require specific and sometimes immediate medical interventions.
• Chronic Conditions – For chronic conditions like ulcers or gastroesophageal reflux (GERD), management strategies usually include a mix of lifestyle changes, like dietary adjustments and altered eating habits, coupled with prescribed medications aimed at reducing stomach acid and facilitating healing.

Preventive Measures

Preventing excessive coughing and thus minimizing stomach pain can be achieved through several strategies.

• Treat the Cough Effectively – Managing the underlying cause of a persistent cough can prevent the strain and subsequent pain. Consulting a healthcare provider for the right cough suppressants or treatments is important.
• Strengthen Abdominal Muscles – Regular, gentle exercise can help strengthen the muscles around the stomach, making them less susceptible to strain from coughing.

When to Seek Emergency Care

Severe persistent stomach pain when coughing, particularly if accompanied by other concerning symptoms such as fever, vomiting, or inability to keep food down, requires immediate medical attention. In many cases, prompt diagnosis and treatment can prevent complications. You can visit Village Emergency Centers’ Locations to find the nearest emergency center for your needs.

Conclusion

While stomach pain when coughing is commonly due to the physical exertion placed on the abdominal muscles, it’s important to be aware of the potential for more serious conditions. By understanding the various causes and treatments, individuals can better manage their symptoms and seek medical advice when necessary. For more information about emergency care for abdominal pain, be sure to check out Emergency Room Services for Abdominal Pain.

At the Village Emergency Centers located in the Houston area, we are more than medical facilities. We are integral parts of our communities, staffed by board-certified doctors and registered nurses who are also your neighbors and friends. Our centers offer immediate compassion and emergency care 24/7 with wait times averaging less than 10 minutes. We are equipped to handle a range of emergencies from allergic reactions to broken bones, using state-of-the-art technologies like CT scans, X-rays, and ultrasounds. With facilities designed for comfort, including private exam rooms and a coffee bar, and accepting all private insurances, we do our best to make sure that every visit is as stress-free as possible. Whether it’s for minor issues or major emergencies, our doors are always open, providing top-tier, patient-centered care to the community. Find a location near you.