Quite a stretch : internal oblique muscle hematoma
A 76-year-old woman presented to the emergency department with a 1-week history of severe cough and a 2-day history of left abdominal pain. She had been healthy until the onset of symptoms. At a body mass index (BMI) of 28.1, she was obese according to the BMI standards for Asians and Asian Americans. She had not had any abdominal surgery or trauma and was not using anticoagulant drugs.

A physical examination identified a firm mass, measuring about 10 cm x10 cm, over the left abdomen and ecchymosis on the lower abdomen. Abdominal CT was performed. An enhanced image revealed a heterogeneous, high-attenuation mass, measuring 13 x 12 x 5.5 cm, in the internal oblique musculature. The finding indicated a hemorrhage with adjacent thickening of the contiguous abdominal wall musculature.

Key learnings:-
• The internal oblique muscle receives its blood supply mainly from the lower posterior intercostal arteries, lateral branches of the deep inferior epigastric artery, and ascending branches of the deep circumflex iliac artery. If, as in this patient, severe cough leads to overcontraction and overstretching of the internal oblique muscle, vessel rupture can occur.

• Risk factors for developing weakness in vessel walls include advanced age, arteriosclerosis, obesity, and pregnancy

• In addition, previous abdominal surgeries increase the probability of tears in vessels and muscles and subsequently, abdominal hematomas.

• Other risk factors for an abdominal hematoma are a tendency toward bleeding or the use of anticoagulant or antiplatelet drugs.

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