An oblique muscle hematoma as a rare cause of severe abdominal pain: a case report.

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by  Shimodaira, Masanori

Shimodairaetal.BMCResearchNotes2013,6:18
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CASE REPORT Open Access
An oblique muscle hematoma as a rare cause of
severe abdominal pain: a case report
Masanori Shimodaira1*, Tomohiro Kitano2, Minoru Kibata1 and Kumiko Shirahata1
Abstract
Background: Abdominal wall hematomas are an uncommon cause of acute abdominal pain and are often
misdiagnosed. They are more common in elderly individuals, particularly inthose under anticoagulant therapy.
Most abdominalwall hematomas occurin therectus sheath, and hematomas within the oblique muscle are very
rare and are poorly described in theliterature. Here we report the case ofan oblique muscle hematoma in a
middle-aged patient who was not under anticoagulant therapy.
Case presentation: A 42-year-old Japanese man presented witha painful, enlarging, lateral abdominal wall mass,
which appeared after playing baseball. Abdominal computed tomography and ultrasonography showed a large soft
tissue mass located inthe patient’sleft internal oblique muscle.A diagnosis of a lateral oblique muscle hematoma
was made and the patient was treated conservatively.
Conclusion: Physicians should consider an oblique muscle hematoma during the initial differential diagnosis of
pain inthe lateral abdominal wall even in the absence of anticoagulant therapy or trauma.
Keywords: Abdominal pain, Abdominal muscle, Oblique muscle, Hematoma
Background baseball. He gave no history of direct abdominal trauma
Abdominal wall hematomas are an uncommon cause of such as collision with another player. He had a history of
acute abdominal pain and are often misdiagnosed. They hyperuricemia;however,hehadnotundergoneanytherapy
resultfromruptureoftheepigastricvesselsorthedeepcir- for the same. There was no family history of bleeding dia-
cumflex iliac artery (rarely), or from tears of the fibers of thesis or hematological diseases. On physical examination,
the rectusabdominis or lateral obliquemuscles [1,2]. They his vital signs were as follows: temperature 36.8°C, blood
mayoccurbecauseoftrauma,physicalexercise,recentsur- pressure 108/69 mm Hg, pulse rate 58 beats/min, and re-
gery,orinjectionprocedures.Theymayalsooccurbecause spiratory rate 12 breaths/min. A firm mass was palpable
ofincreasedintraabdominalpressurefromcoughing,sneez- over the left lateral abdominal wall and it was tender. The
ing,vomiting,orstrainingduringurination,defecation,and skin color of the area was normal. Blood biochemistry on
labor [1,3-6]. Other predisposing factors include increased laboratory examination was within normal ranges and the
age, arterial hypertension, atherosclerosis, and systemic plateletcountwas174×103cells/μl,prothrombintimewas
anticoagulant therapy. Most abdominal wall hematomas 11.8 s, international normalized ratio was 0.99, and acti-
occur in the rectus sheath, and a hematoma within the vatedpartialthromboplastintimewas32.6s.
obliquemuscleisveryrare.Herewereportacaseofanob- Ultrasonography (US) showed a heteroechoic, well-
liquemusclehematomainamiddle-agedpatient. defined mass in the patient’s left lateral abdominal wall
(Figure 1). An emergency noncontrast computed tomog-
Case presentation raphy (CT) of the abdomen showed a hyperdense mass
in the left internaloblique muscle measuring10.5× 6.5 ×
A 42-year-old man presented with a painful, enlarging, lat-
5.5cm.Contrast-enhancedCTdidnotshowextravasation
eral abdominal wall mass, which appeared after playing
of the contrast material within the mass (Figure 2). The
*Correspondence:[email protected] diagnosis ofan oblique muscle hematoma was made. The
1DepartmentofGeneralMedicine,IidaMunicipalHospital,438Yawata-machi, patient was conservatively treated with analgesics. Four
Iida,Nagano-ken395-8502,Japan
daysafterthefirstvisit,thepatientrevisitedourdepartment
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Figure1Abdominalultrasonography(US).AnabdominalUS
Figure3Ecchymosisontheleftlateralabdomen.Ecchymosis
showedaheteroechoicmass(whitearrow)inthepatient’sleft presented4dayslateronthepatient’sleftlateralabdomen.
lateralabdominalwall.
for follow-up. His abdominal pain improved, but an ec- Misdiagnosis may lead to unnecessary negative laparoto-
chymosis was observed on the patient’s left lateral abdo- mies with increased morbidity and mortality [3]. There-
minalskin(Figure3). fore, these diseases should be considered as differential
diagnoses.
Discussion Manyriskfactorshavebeenreportedforabdominalwall
Abdominal wall hematomas are one of the causes of hematomas. These include aging, anticoagulant therapy,
acute abdominalpain.Arectus sheathhematoma caused plateletdisorders, trauma, recent surgery,injectionproce-
by the rupture of the epigastric artery is a rare, but well- dures, and physical exercise as well as increased intraab-
described, manifestation of abdominal hematoma. On dominal pressure from coughing, sneezing, vomiting, or
the other hand, an oblique muscle hematoma caused by straining during urination, defecation, or labor [6]. In the
a rupture of the deep circumflex iliac artery is very rare review of 126 cases of rectus sheath hematoma, it is
[1]. The most common presenting signs and symptoms reported that most patients (69%) wereon some forms of
of these hematomas are acute abdominal pain and firm, anticoagulation therapy and the mean age was 67.9 years
palpable abdominal wall masses. Because of their rarity, [5]. Our patient was not taking any medications affecting
abdominal wall hematomas can be mistaken for several blood coagulation and laboratory data regarding coagula-
common acute abdominal conditions such as appendi- tion function were within normal limits. Therefore, his
citis, sigmoid diverticulitis, perforated ulcers, ovarian internal obliquemuscle wasconsidered tobeinjuredbya
cyst torsion, tumors,orincarcerated inguinal hernias[7]. sudden or repetitive trunk movement, either rotation or
flexion/extension,whileplayingbaseball[8].
An abdominal wall mass with ecchymosis is the most
importantdiagnosticfindingforsuspicionofahematoma.
However,abdominalwallecchymosisisalatesignandthe
average time between its presentation and its onset takes
about 4 days, as reported in the literature [9]. Further-
more, ecchymosis is a rare presentation for an abdominal
wallhematoma.AstudybyCherryetal.showedthatonly
17% abdominal wall hematoma patients present with an
abdominalwallecchymosis[5].Inourpatient,ecchymosis
wasdetected4daysaftertheappearanceoftheabdominal
wall hematoma. To the best of our knowledge, this is the
first report of an oblique muscle hematoma that was
accompaniedbyecchymosis.
The diagnosis of an oblique muscle hematoma is made
Figure2Contrast-enhancedCT.Contrast-enhancedCTdidnot by combining medical history, laboratory examination
showextravasationofthecontrastmaterialwithinthemass
findings, and US and/or radiological findings. US and CT
(whitearrow).
scans can provide useful information for differential
Shimodairaetal.BMCResearchNotes2013,6:18 Page3of3
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diagnosistoavoidunnecessarysurgery[6].UScanbeuse- Competinginterests
fulasafirst-lineinvestigationbecauseitiswidelyavailable Theauthorsdeclarethattheyhavenocompetinginterests.
and portable [10]. In addition to US, contrast-enhanced Authors’contributions
CTcan detect and evaluate active bleeding from the rup- MSwrotethemanuscript.TKcontributedtothediagnosisandrevisedthe
ture site [4]. In the present case, contrast-enhanced CT manuscript.MKandKSreviewedtheliterature.Allauthorscontributed
intellectualcontent,havereadandapprovedthefinalmanuscript.
findingsdidnotshowactivebleeding.Therefore,wecould
not confirm which artery was ruptured by CT findings. Authordetails
Even in a patient without contrast extravasation at the 1DepartmentofGeneralMedicine,IidaMunicipalHospital,438Yawata-machi,
Iida,Nagano-ken395-8502,Japan.2Juniorresident,IidaMunicipalHospital,
bleeding site as observed on CT, selective digital subtrac-
438Yawata-machi,Iida,Nagano-ken395-8502,Japan.
tion angiography could be a useful imaging technique to
identifyanactivebleedingpoint[11]. Received:18September2012Accepted:15January2013
Published:18January2013
Although there is no grading for an oblique muscle
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Conclusion
21:62–64.
An oblique muscle hematoma is a very rare condition. In
the clinical setting, abdominal US and contrast-enhanced doi:10.1186/1756-0500-6-18
Citethisarticleas:Shimodairaetal.:Anobliquemusclehematomaasa
CTare useful for a diagnosis. A correct diagnosis is im-
rarecauseofsevereabdominalpain:acasereport.BMCResearchNotes
portant to avoid increasing morbidity or unnecessary 20136:18.
surgical intervention. Treatment is mainly conservative
and includes pain management. Physicians should con-
sider an oblique muscle hematoma in the initial differen-
tial diagnosis of abdominal pain even in the absence of
historyofanticoagulanttherapyorobvioustrauma.
Consent
Written informed consent wasobtained from thepatient
forpublicationofthiscasereportandanyaccompanying
images. A copy of the written consent is available for
review bytheEditor-in-Chief ofthis journal.