Spontaneous Mesenteric Hematoma Following Severe Coughing in a Patient on Dual Antiplatelet Therapy: A Case Report.

Spontaneous mesenteric hematoma (SMH) is a rare cause of acute abdominal pain and may mimic more common intra-abdominal conditions, creating diagnostic challenges. A 67-year-old man with hypertension, hyperlipidemia, coronary artery disease status post four-vessel coronary artery bypass grafting, and chronic dual antiplatelet therapy with aspirin and clopidogrel presented with acute worsening lower abdominal pain. He reported a severe coughing episode during a recent bronchitis-like illness approximately two weeks before presentation, followed by lower abdominal pain in the same general region that persisted before acutely worsening on the day of admission. Initial computed tomography (CT) of the abdomen and pelvis demonstrated a large left lower abdominal collection adjacent to the sigmoid colon, raising concern for complicated diverticulitis with abscess formation or an infected hematoma. Repeat imaging favored a hematoma, and subsequent CT angiography demonstrated a stable collection without active contrast extravasation. Because the patient remained hemodynamically stable, with hemoglobin decreasing initially and subsequently stabilizing, and with no evidence of active bleeding, he was managed conservatively with close monitoring and supportive care. His abdominal pain improved, and he was discharged without surgical or interventional radiologic treatment. SMH should be considered in patients with atraumatic abdominal pain, particularly when imaging findings are atypical or mimic diverticulitis or other intra-abdominal pathology. In this case, the temporal relationship between severe coughing and subsequent localized abdominal pain raises the possibility that coughing-related increases in intra-abdominal pressure contributed to mesenteric vessel injury in the setting of dual antiplatelet therapy and underlying vascular risk factors. However, a direct causal relationship cannot be established. Early recognition and appropriate imaging can facilitate accurate diagnosis and support conservative management in hemodynamically stable patients without active bleeding.