Sharp pain in lower abdomen when coughing

Pain is often a symptom of an underlying health problem and one area of the body that can experience great pain is the lower right abdomen. But when do you need to be concerned about an abdominal pain?

What is in the lower right abdomen?

Before anything else, it is important to review the body’s anatomy. What are the organs located in the abdomen, and what diseases are often seen in these areas?

The abdomen has four quadrants – upper right, lower right, upper left, and the lower left. In addition to these, there are three areas in the middle abdomen, namely, the epigastric, umbilical, and hypogastric area.

In each area, there are specific organs or parts of the gastrointestinal system. For instance, the right upper part of the abdomen is where the liver, gall bladder, right kidney, and pancreas are located. In the left upper quadrant, the stomach, left kidney, and spleen are situated. The lower left quadrant is where the small intestine, colon, ureter, and major veins or arteries to the veins are located. Lastly, the lower right abdominal area is the site of the appendix, ascending colon, and part of the female reproductive organs.

Right lower abdominal pain

There are many conditions that can cause lower right abdominal pain. But one of the most common causes is appendicitis. Other causes include:

These are differentiated by a careful history, looking for specific signs on physical examination, and diagnostic radiography, ultrasound, and/or CT scanning of the abdomen. Symptoms like fever, migration of pain from near the navel to lower down on the right side, and the presence of rigidity and rebound tenderness of the abdominal wall should alert the physician to the possibility of appendicitis.

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This must be confirmed by imaging studies as above. If the CT scan results are normal, the disease is likely to be localized in the female reproductive organs, the colon or the urinary tract, and specific examinations and tests must then be performed.

Pain in the lower right quadrant should be taken seriously if it is severe and accompanied by the following symptoms:

• Fever, chest pain, or a feeling of extreme faintness
• Severe vomiting immediately after eating
• Breathing problems
• Irregular pulse rate
• Dark or blackish stools
• Vomiting blood
• Mild pain persisting after two days
• Pain worsening, or accompanied by unexplained weight loss
• Pain with bloating over more than two days, or diarrhea for more than five days
• Pain with fever or associated urinary problems

It’s important to know about appendicitis as one of the most common causes of right lower quadrant abdominal pain.

What is appendicitis?

People who suffer from lower right abdominal pain may have a condition called appendicitis, or inflammation of the appendix. Appendicitis is a medical emergency and if it’s not treated immediately, it can be life-threatening. An inflamed appendix may burst or rupture, causing perforation and spilling of infective material into the abdominal cavity.

Causes of appendicitis

The appendix can be inflamed due to many causes, and more than one cause may be present in any given case. Some common reasons for inflammation of the appendix include:

• Blockage of the opening in the appendix
• Inflammatory bowel disease
• Hypertrophied (overgrown) tissue in the wall of the appendix (usually caused by an infection of the digestive tract)
• Trauma to the abdominal area
• the presence of hard stools, growths or parasites that can block the lumen of the appendix

The cause of appendicitis is unclear in many cases. It is true, nevertheless, that one of the most common causes is the obstruction of the appendix.

Appendicitis may be mild if treatment is initiated promptly. If pus builds up in the appendix due to inflammation, it may burst, flooding the abdominal area or cavity with the infected matter.

This usually happens after 36 hours from the onset of infection in the appendix. It may result in peritonitis (inflammation of the lining of the abdominal cavity) which is a potentially life-threatening complication, demanding prompt medical treatment.

Appendicitis is a medical emergency. The common symptoms include a dull pain near the umbilical area or navel that becomes sharp, loss of appetite, constipation or diarrhea with gas, inability to pass gas, nausea or vomiting, and fever.

Other symptoms may appear, such as painful urination and a feeling that having a bowel movement will relieve discomfort and pain. Appendicitis can be mistaken for other conditions, such as gassy pains.

However, appendicitis may be suggested if the pain begins near the navel and moves to the right lower quadrant, becomes worse upon moving, walking or sneezing, becomes more intense over a few hours, occurs abruptly and may even wake you up from sleep, if the pain is the first symptom to occur, and if it very severe, often described as a pain worse than you’ve never felt before.

If you feel any of these symptoms, you must seek medical attention immediately.

How is appendicitis treated?

The only treatment for appendicitis is the surgical removal of the inflamed appendix. Pain medications can help relieve pain, but not for long. As long as the appendix is inflamed, the pain will persist. Worse, the appendix can rupture and cause infection in the whole abdominal cavity.

Appendectomy is a procedure involving the removal of the appendix. The procedure can be done through two methods – laparoscopic surgery and laparotomy. In laparoscopic surgery, surgeons use small incisions and specialized tools to remove the appendix. Since it’s less invasive than the traditional surgery, it has fewer complications and a shorter hospital stay.

On the other hand, laparotomy involves the removal of the appendix through a single incision over the abdominal wall in the right lower right quadrant. This is more invasive and may require a longer time for the patient to recover.

Usually, antibiotics are intravenously given to reduce the risk of peritonitis. The typical length of stay is between three and five days. The removal of the appendix has not been shown to have any effect on the digestive system, whether in the short or long term.

Sources

Last updated Sep 20, 2021

Department of Urology, Toyama City Hospital, Toyama, Japan

Find articles by Koichi Kodama

Department of Urology, Toyama City Hospital, Toyama, Japan

Find articles by Yasukazu Takase

1Department of Internal Medicine, Toyama City Hospital, Toyama, Japan

Find articles by Hiroki Yamamoto

2Department of Emergency, Toyama City Hospital, Toyama, Japan

Find articles by Toru Noda

Received 2012 Aug 8; Accepted 2012 Sep 16.

Copyright : © Journal of Emergencies, Trauma, and Shock

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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

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.

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 [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].

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.

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.

Source of Support: Nil.

Conflict of Interest: None declared.

1. Cherry WB, Mueller PS. Rectus sheath hematoma: Review of 126 cases at a single institution. Medicine. 2006;85:105–10. [PubMed] [Google Scholar]

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. [PubMed] [Google Scholar]

3. Zainea GG, Jordan F. Rectus sheath hematomas: Their pathogenesis, diagnosis, and management. Am Surg. 1988;54:630–3. [PubMed] [Google Scholar]

4. Gocke JE, MacCarty RL, Foulk WT. Rectus sheath hematoma: Diagnosis by computed tomography scanning. Mayo Clin Proc. 1981;56:757–61. [PubMed] [Google Scholar]

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. [PMC free article] [PubMed] [Google Scholar]

6. Irwin RS. Complications of cough: ACCP evidence-based clinical practice guidelines. Chest. 2006;129:54S–8S. [PubMed] [Google Scholar]

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. [PubMed] [Google Scholar]

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. [PubMed] [Google Scholar]

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. [PubMed] [Google Scholar]

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. [PubMed] [Google Scholar]

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