An Unusual Complication of Midline Abdominal Wall Paracentesis

Abstract

A 50 years old Caucasian female with history of Hepatitis C presented to the emergency room with complaints of fever, abdominal pain, abdominal distension and lower extremity swelling. On examination, patient had signs of chronic liver disease including chest wall spider angiomas, ascites, splenomegaly and lower extremity edema. Laboratory data showed leukocyte count of 12,500 cells per cubic millimeter, hemoglobin 11 grams per deciliter, platelets 47,000 cells per cubic millimeter, PT 37.8 seconds, INR 3.6, albumin 1.6 grams per deciliter, AST 47 units per liter, ALT 102 units per liter and alkaline phosphatase 195 units per liter. Patient underwent midline abdominal wall diagnostic paracentesis, for evaluation of spontaneous bacterial peritonitis (SBP), by emergency room physician. Peritoneal fluid analysis was not consistent with SBP. Patient underwent abdominal CT-Scan for further evaluation of abdominal pain. CT-Scan showed ascites, cirrhotic liver, splenomegaly and an incidental 8.7 × 8.5 × 8.3 cm pelvic mass. For further evaluation of the pelvic mass, patient had transvaginal abdominal ultrasound and duplex vascular study done, which showed an 8.1 × 8.2 cm ovarian cyst in open communication with a dilated varicose vein, with venous flow within the cyst. This was thought to be traumatic venous leak, by midline paracentesis, from the distended variceal vein into the ovarian cyst giving rise to pseudoaneurysm of the variceal vein. This ovarian cyst and venous communication was successfully obliterated with ultrasound guided thrombin injection into the cyst. To the best of our knowledge this type of complication from mid line paracentesis and than complete obliteration with thrombin injection has not been reported.