Incarcerated Umbilical Hernia as an Immediate Complication of Large Volume Paracentesis

Abstract

Purpose: Therapeutic paracentesis is a common procedure used in the management of refractory ascites in patients with cirrhosis. The procedure, while generally simple and safe, has known complications such as bleeding, viscus perforation and metabolic disturbances. We present a rare complication of therapeutic paracentesis: immediate post-procedure incarcerated umbilical hernia. A 57-year-old woman with alcoholic cirrhosis (Child's classification B) was admitted to ambulatory surgery unit for an elective paracentesis. She had massive ascites and a 6-cm umbilical hernia filled with fluid. Seven liters of clear, straw-colored fluid were removed with a 14-gauge needle, and this appeared to be a total paracentesis. She was given 50 grams of salt-poor albumin and prepped for discharge. After standing and dressing for discharge, the patient developed abdominal pain and distension. On examination, it was obvious that she had gas-filled bowel loops in a hernia that could not be reduced (figure). Abdomen was tympanic, consistent with bowel obstruction. Surgical consult was obtained and she underwent reduction and repair of the umbilical hernia, which she tolerated well. Elective repair of umbilical hernias in patients with cirrhosis is usually frowned upon, as hernia recurrence is common unless the ascites can be controlled with diuretics. In addition, this patient group is generally a poor surgical risk due to infection, bleeding and poor wound healing. However, there was not an option in this case, as the hernia presented acutely. Incarceration can occur due to a decrease in tension in the umbilical ring following large volume paracentesis. It may be reasonable to consider TIPS in patients with a significant umbilical hernia whose ascites cannot be controlled with diuretics and whose hernia size runs a risk of incarceration. At the very least, clinicians should be aware of this complication and evaluate patients complaining of pain and distention after paracentesis to rule out this life-threatening condition and be prepared to act quickly to avoid poor outcomes in this compromised group of patients.Figure