Cough-induced internal oblique hematoma
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/mm3; platelets, 162,000/mm3; 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 []. Unenhanced abdominal CT showed a 7 cm × 7 cm × 4 cm tissue mass in the right internal oblique muscle []. 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 []. 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 [].