health and sport magazine. The last session was 3 days before
developing niggling pain over the left lower quadrant. She was
otherwise healthy and was taking prophylactic aspirin pre-
scribed by her family physician. At presentation, her blood
pressure was 128/76 mm Hg and her heart rate 86 beats/min.
Abdominal examination disclosed an ill-defined tender mass in
the left iliac fossa with localised peritonism. All her routine
blood tests were normal. A CT scan of the abdomen showed an
RSH of 106665 cm size (fig 3). Because the patient was stable,
she was treated with analgesia and was discharged home.
Subsequent review in the outpatient clinic showed complete
resolution of her left lower quadrant mass.
RSH is more common in women,
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.
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
Pranayama is a special exercise in yoga. It is done with
continuous actions of inhaling and exhaling air, keeping the
abdomen taut and relaxed alternately
(fig 4). Laughter therapy
sessions involve forced laughing for abdominal exercise and
stress management. Forced laughing raises transdiaphragmatic
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.
Abdominal pain and abdominal mass not only occur in RSH
but also in numerous intra-abdominal emergencies. RSH is
therefore often misdiagnosed.
The absence of any pathogno-
monic 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.
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
Strenuous abdominal exercises may lead to RSH. Clinicians
therefore need to be aware of this complication after
Figure 3 CT scan of abdomen in case 2 showing rectus sheath
Figure 4 Pranayama technique of yoga.
What is already known on this topic
It is an uncommon cause of abdominal pain which is
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.
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.
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