Abdominal Pain When Coughing

Abdominal pain while coughing is a very common symptom and is caused by a wide range of illnesses. Abdominal pain may or may not be associated with coughing. Abdominal pain while coughing is caused by abdominal muscle injuries or diseases of internal abdominal organs. Most internal abdominal pain while coughing is acute in nature unless the pain is caused by chronic diseases or abdominal cancer.¹ The abdominal pain caused by the diseases of abdominal skin, subcutaneous tissue, and muscles may or may not be aggravated while coughing.

The abdominal pain caused by inflammatory diseases of abdominal organs resulting in peritonitis, appendicitis, and gastroenteritis often increases in intensity following coughing. Exclusive back pain caused by facet joint or paravertebral muscle spasm does not be caused by abdominal pain when coughing. But a spinal nerve pinch or irritation of the spinal nerve in the back can cause severe pain that is spread over the anterior or lateral abdominal wall. Such pain is caused by lower thoracic or upper lumbar sensory nerves pinch, and lower spinal cord compression.² Most abdominal pain when coughing is felt on the front and lateral side of the belly. The abdominal pain caused by skin diseases is much simple to diagnose since skin lesions are seen by individuals or physicians during the examination.

The cause of generalized abdominal pain is often difficult to diagnose as compared to regional and dermatomal pain. In such cases, the physician will request an ultrasound examination or CT scan of the abdomen to confirm the cause of abdominal pain while coughing. The intensity of abdominal pain increases during coughing for the following reasons-

1. Coughing Triggers Pain From Inflamed Or Injured Abdominal Muscle³– The pain caused by diseases of abdominal muscles increases in intensity during cough. The coughing causes vigorous abdominal muscle contraction that increases pain if the muscle is inflamed, injured, or torn. Muscle inflammation is observed following blunt or penetrating abdominal injuries. Similarly, diseases of abdominal muscles like myofascial syndrome or fibromyalgia often cause an increased intensity of pain following coughing. Repeated coughing causes abdominal muscle fatigued and fatigued muscle goes into severe spasm during coughing that causes intense pain. Severe repeated coughing also causes intra-muscular bleeding and hematoma (blood clot) formation within the abdominal muscle that causes persistent abdominal pain.⁴
2. Coughing Increases Intra-Abdominal Pressure- Increased frequency of coughing causes increased intra-abdominal pressure.⁵ The pain becomes severe if one is suffering from the inflammatory disease of the appendix, fallopian tube, peritoneum, and abdominal viscera. The increased abdominal pressure during coughing irritates the inflamed peritoneum which results in sudden gasping pain. Similarly, increased abdominal pressure during coughing squeezes the inflamed abdominal organ which results in severe pain. Such an increase in pain is observed in individuals suffering from appendicitis, torsion of the fallopian tube, and mesentery embolism⁶. The published data suggest coughing causes volvulus⁷, a hernia that involves abdominal viscera, and also causes perforation of viscera. The herniated small or large intestine may get strangulated during a severe attack of coughing.
3. Coughing Causes Intra-Abdominal Bowel Volvulus And Torsion- Intense coughing causes intestinal volvulus and torsion⁷. Bowel volvulus and torsion cause bowel obstruction and strangulation which results in severe pain. If the such complication is not treated soon then the bowel becomes ischemic as the blood supply is restricted and may result in conditions like gangrene of the small or large intestines.
4. Coughing Causes Abdominal Hernia And Bowel Obstruction- Persistent intense cough sometimes causes inguinal or umbilical hernia.⁸ The sudden popping of viscera through the umbilicus or inguinal canal causes an umbilical or inguinal hernia. The such condition causes severe abdominal pain during coughing. Occasionally bowel within the hernia may get obstructed and cause severe continuous intense pain. If the bowel within the hernia is strangulated, then the bowel will go into a stage of gangrene unless strangulation is relieved by surgery⁹. The condition is considered an emergency.
5. Coughing Increases Epidural Pressure That Results In Irritation Or Pinch Of Spinal Nerve- Abdominal wall receives pain fibers from lower thoracic spinal nerves.10 Coughing increases pressure in the epidural space. If the nerve is pinched because of a disc bulge or herniation, then coughing causes an increased intensity of pain. Pain is felt in the abdominal wall. Such pain may be associated with tingling, numbness, and weakness of abdominal muscles.¹⁰ The intensity of pain caused by diabetes, post-herpetic neuralgia, or shingles increases in intensity during and following coughing.

1. Causes of Skin Diseases That Causes Abdominal Pain-

   Skin diseases like furuncle, carbuncle, and cellulitis cause abdominal wall pain. The contraction of underlying abdominal muscles during coughing increases the intensity of pain.

   Following skin diseases causes abdominal pain-

   • Carbuncle
   • Furuncle or boil
   • Cellulitis
   • Hematoma

2. Causes of Generalized Abdominal Pain.

   Generalized abdominal pain during coughing is felt in the entire abdomen. Such pain is caused by disease of the peritoneum, small intestine, and large bowel. The pain is spread over the entire abdomen when the inflammatory disease is widely spread in the peritoneum and viscera. Peritoneum is the serous membrane lining the abdominal cavity and also covers the abdominal organs. Infection of the peritoneum is known as peritonitis. Peritonitis is an inflammatory disease of the parietal and visceral peritoneum, Parietal peritoneum covers the inside of the abdominal wall, and the visceral peritoneum covers the abdominal organs. Symptoms like severe pain during and after coughing are caused by peritonitis and such pain is always widely spread over the abdomen. Similarly, widespread bowel infection such as enterocolitis and bacterial dysentery causes generalized abdominal pain while coughing and the pain continues for a long time. Chronic non-infectious inflammatory bowel diseases like ulcerative colitis or Crohn’s disease also cause wide spread abdominal pain while coughing. Rarely constipation also causes widespread abdominal pain.

   Causes of generalized abdominal pain-

   • Peritonitis,
   • Bacterial dysentery,
   • Ulcerative colitis,
   • Chron’s disease and
   • Constipation

3. Causes of Upper Abdominal Pain

   The upper abdominal is divided into 3 quadrants right, middle, and left quadrants. Upper abdominal pain when coughing is spread in all 3 quadrants or one of the 3 quadrants. The bilateral pain is spread over the right and left sides of the upper abdomen. The right upper abdominal pain during coughing is caused by diseases of the transverse colon, liver, and gall bladder. Left-side abdominal pain is caused by a peptic ulcer. A peptic ulcer is caused by an ulcer of the mucosal membrane of the stomach and duodenum. The middle upper abdominal pain triggered by coughing is often caused by diseases of the lower esophagus, gall bladder, and pancreas. Causes of Upper Abdominal Pain-

   • Gastric ulcer,
   • Duodenal ulcer.
   • Acid reflux
   • Esophagitis
   • Pancreatitis
   • Pancreatic cancer
   • Gallbladder disease
   • Liver diseases

4. Causes of Middle Abdominal Pain

   Middle abdominal pain while coughing is felt on the right and left side of the umbilicus as well as around the umbilicus. The right side middle abdominal pain during coughing is caused by inflammatory disease of ascending colon and small intestine. Left-side middle abdominal pain during coughing is caused by disease of the spleen, duodenum, small intestine, and descending colon. The pain that spreads around the umbilicus following a cough is caused by an umbilical hernia and diseases of the pancreas.

   • Rupture aorta
   • Umbilical hernia
   • Intestinal Obstruction
   • Mesentery embolism
   • Rupture spleen
   • Splenic ischemia

5. Causes of Lower Abdominal Pain

   Lower abdominal pain while coughing is caused by diseases of pelvic organs as well as organs underlying the lower abdomen. Diseases of pelvic organs that causes lower abdominal pain during coughing are urinary bladder infection (cystitis) or cancer of the urinary bladder in male and female. The disease of the fallopian tube, like infection, tubal pregnancy, and torsion of the fallopian tube causes lower abdominal pain during cough. Ovarian cancer or torsion of the ovary on the left or right side causes either left or right lower abdominal pain following cough. Appendicitis causes continuous right lower abdominal pain that often, becomes severe following coughing.

• Appendicitis
• Fallopian tube torsion
• Ovarian disease
• Cystitis– Urinary bladder infection
• Fibroid- Uterus
• Endometriosis

Nevertheless, abdominal pain that is induced or increased by coughing should be evaluated by detail history taking and clinical assessment. This is all the more important when the patient complains of a cough triggering abdominal pain or coughing increases the severity of abdominal pain. Detail history of the pain helps to understand the cause and intensity of pain that is aggravated by coughing. History should include the duration of pain and how long the increased intensity of abdominal pain has lasted following coughing. History should include if abdominal pain becomes severe following the consumption of a heavy meal. Understanding other details like types of pain, associated symptoms, and worsening of abdominal pain following activities is also important to differentiate the cause and disease related to abdominal viscera.

1. Pain Intensity- The symptoms like the increased intensity of abdominal pain following coughing should be thoroughly evaluated by clinical examination, lab studies, ultrasound examination, and CT scan. Most such pains are caused by inflammation, infection, and cancer of the abdominal organs and peritoneum. Most abdominal pain often begins as mild pain and then becomes severe as the illness advances. The torsion, obstruction, and strangulation of the bowel, fallopian tube, and ovary cause the sudden occurrence of severe pain.

   Embolism, tissue infarction, and rupture of abdominal aneurysm also cause intense severe abdominal pain. Abdominal pain intensity following coughing is measured as mild, moderate, severe, and very severe or counted as a visual analog score (VAS) from number 0 to 10.

   • Pain Intensity-
   • Mild- VAS 0 to 3
   • Moderate- 4 to 5
   • Severe- 6 to 8
   • Very severe- 9 to 10

2. Type of Abdominal Pain Observed After Coughing-

   1. 1. Abdominal Cramp- The intestinal or bile duct contraction causes abdominal cramps. Abdominal cramp is also caused by bowel obstruction and volvulus.

   Causes Of Abdominal Cramp After Cough-

   1. 1. • Indigestion
         • Gallstone blocking bile duct
         • Chron’s disease
         • Ulcerative colitis
         • Dysentery
         • Volvulus
         • Intestinal obstruction

      2. Stabbing Pain- The sudden intense abdominal pain is frequently felt like stabbing pain following coughing when it is caused by a perforated stomach or duodenal ulcer, ruptured aortic aneurysm and obstructed hernia. Peritonitis also causes stabbing pain in the abdomen.

   Causes of Stabbing Abdominal Pain After Cough-

   1. 1. • Rupture abdominal aneurysm
         • Mesentery infarction
         • Mesentery artery embolism
         • Perforated ulcer
         • Strangulated inguinal or abdominal hernia
         • Peritonitis
         • Appendicitis

      2. Squeezing Pain- Squeezing-type abdominal pain during cough is also described as a feeling of tightness. Most individual describes such pain following a cough as if someone is squeezing organs inside the abdomen.

   Causes of Squeezing Abdominal Pain Or Tightness Of Abdomen-

   1. • Diarrhea and frequent bowel movement caused by food indigestion, food poisoning or dysentery.
      • Inflammatory bowel diseases like Crohn’s bowel disease and ulcerative colitis
      • Gastritis
      • Menstruation or premenstrual pain
      • Gall bladder inflammation
      • Pancreatitis and
      • Pancreatic cancer
      • Endometriosis
      • Uterus fibroid
      • Menstrual pain

   2. Twisting Pain- Twisting abdominal pain following cough feels as if the abdominal viscera is twisted, and the pain is localized in one area. The twisting type of abdominal pain after coughing is also felt as a squeezing and stabbing type of pain but more localized in one area. The individual is often unable to move since pain intensity increases with movements.

   The Causes Of Twisting Type Of Abdominal Pain Following Cough-

   • Bowel obstruction
   • Volvulus
   • Fallopian tube obstruction
   • Fallopian tube torsion
   • Strangulated abdominal hernia
   • Hiatus hernia
   • Appendicitis
   • Menstrual pain
   • Endometriosis

   Piercing Pain- Piercing abdominal pain following cough is felt as if something is piercing through the viscera. It is difficult to differentiate between stabbing and piercing pain that is increased in intensity following a cough. Occasionally stabbing pain following coughing is felt in one segment while piercing pain is felt in the wider area. Pain following coughing migrates from one segment to another segment like upper abdominal piercing pain may be felt in the lower abdomen.

   Causes Of Piercing Abdominal Pain Following Cough-

   • Perforated ulcer
   • Peritonitis
   • Strangulated hernia
   • Appendicitis

3. Associates Symptoms With Abdominal Pain When Coughing-

   1. Nausea- Almost all diseases causing abdominal pain following coughing are also associated with nausea.
   2. Vomiting- Vomiting following coughing in patients suffering from abdominal pain is caused by gastritis, enteritis, dysentery, peritonitis, appendicitis, mesentery infarction, fallopian tube torsion, and gall bladder diseases.

   Diarrhea is observed in the following conditions when an individual is suffering with increase bowel pain following coughing-

   • Bile duct obstruction,
   • Cholecystitis,
   • Enteritis,
   • Dysentery,
   • Peritonitis,
   • Appendicitis,
   • Mesentery infarction,
   • Fallopian tube torsion

References:

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