Abdominal Wall Hematoma Following Paracentesis

Abstract

Purpose: Paracentesis is typically a very benign procedure, even in the presence of coagulopathy. We present the case of a 67-year old woman with cirrhosis who underwent a paracentesis and subsequently developed an abdominal wall hematoma. A 67 year old women with ascites secondary to cirrhosis, an INR of 1.38 and platelets of 37, underwent an ultrasound guided paracentesis in the right lower quadrant. No immediate complications were reported but the patient was noted to have a swelling at the paracentesis site few hours after the procedure. This swelling progressively enlarged and by the next morning, the patient had developed a 24 cm x 12 cm tense abdominal wall hematoma extending from the rib cage to the inguinal ligament. The patient was transfused eight units of packed red blood cells and multiple units of platelets and fresh frozen plasma because of the enlarging hematoma, hypotension, tachycardia, pallor and anemia. A diagnosis of abdominal wall hematoma was made on a CT scan of the abdomen (Figure 1) and a surgical consultation was requested for draining the hematoma. Intra-operatively the hematoma was seen extending anterior to and into the rectus sheath all the way from the subcostal margin to the inguinal ligament. Arterial bleeding was not seen and some venous oozing was controlled with electrocautery. The patient tolerated the surgery well but eventually succumbed to a nosocomial pneumonia. Paracentesis is considered a safe procedure even in patients with a coagulopathy. Hemorrhagic complications occur in less than 1% of cases and major hemorrhagic complications requiring transfusions are even rarer. Post procedure bleeding can take the form of intraperitoneal bleeding, inferior epigastric artery pseudo-aneurysm and abdominal wall hematoma, as was the case in our patient. Bleeding during the procedure can result from puncture of superficial epigastric vessels, intra abdominal collaterals or paraumbilical veins. Performing the procedure in the avascular midline under ultrasound guidance can potentially decrease these hemorrhagic complications. Coagulopathy, if present, must be corrected in addition to definitive treatment, which includes surgical drainage of abdominal wall hematomas and embolization of inferior epigastric pseudoaneurysms.Figure