RSH is more common in women,1
probably owing to lean rectus muscle mass in comparison with men. This leads to a greater likelihood of bleeding in response to trivial abdominal wall trauma. Anticoagulation and trauma are the two most common predisposing factors in its development.1,2,3,4,5,6,7
None of the patients in the present report were receiving anticoagulants and their clotting profile was normal. However, both these patients were taking a small dose of aspirin, which might have aggravated bleeding because of platelet dysfunction.
Severe abdominal wall injury due to strenuous exercises is rare.8Pranayama
is a special exercise in yoga. It is done with continuous actions of inhaling and exhaling air, keeping the abdomen taut and relaxed alternately9
(fig 4). Laughter therapy sessions involve forced laughing for abdominal exercise and stress management. Forced laughing raises transdiaphragmatic pressure10
and as a result there is an increase in abdominal pressure. Thus the plausible explanation for RSH in the present report is vigorous abdominal contractions in Pranayama
and laughter therapy exercises.
Figure 4Pranayama technique of yoga.
What is already known on this topic
- It is an uncommon cause of abdominal pain which is often misdiagnosed
- It occurs because of bleeding into the rectus sheath from damage to the superior or inferior epigastric arteries or their branches or from rectus muscle tear.
- A number of risk factors have been identified and include anticoagulant treatment, vigorous coughing, contact sports, pregnancy, abdominal surgery, abdominal wall trauma, vigorous rectus muscle contractions, and certain medical conditions such as leukaemia and blood disorders.
- Ultrasound scan and CT are the two best imaging modalities for an accurate diagnosis.
- The patient's clinical condition determines the type of treatment. For a haemodynamically stable patient, treatment of the primary cause together with conservative management is appropriate. Emergency radiologically guided embolisation or surgery is reserved for those patients who are haemodynamically unstable and unresponsive to initial fluid resuscitation.
Abdominal pain and abdominal mass not only occur in RSH but also in numerous intra‐abdominal emergencies. RSH is therefore often misdiagnosed.1,2,3,4,5,6,7
The absence of any pathognomonic features renders imaging modalities as the sole non‐invasive alternative for the diagnosis of this condition. Although ultrasound, CT and magnetic resonance imaging of the abdomen have been used for diagnosis of RSH, a CT scan is the preferred radiological modality.1,4,5,7
Both our patients were correctly diagnosed with a CT scan. Stable patients should be managed conservatively, but unstable patients will require active resuscitation and surgical control of bleeding if further deterioration occurs.1,3
What this study adds
- Both of our cases occurred in patients taking part in non‐contact sports activities—yoga and laughter therapy—which has not been described previously.
- Aspirin treatment might have predisposed our patients to this uncommon condition.