Male With Abdominal Pain

Abstract

[Ann Emerg Med. 2012;60:392.] A 53-year-old man with a history of cirrhosis because of hepatitis C presented to the emergency department with abdominal pain for 1 week. He had a previous ventral hernia repair and recurrent ascites that had required paracentesis, the most recent being just before his onset of symptoms. The patient endorsed nausea and malaise but denied fevers, chills, or vomiting. He was in mild distress, was cachectic appearing, and had scleral icterus, jaundice, and a distended abdomen with dullness to percussion suggestive of ascites (Figure 1). Bedside ultrasonography performed in preparation for a paracentesis (Figure 2).Figure 2Abdominal ultrasonograph.Used with permission of Joshua Hong, MD, Department of Emergency Medicine, Loma Linda Medical Center, Loma Linda, CA.View Large Image Figure ViewerDownload Hi-res image Download (PPT) An abdominal wall pseudocyst is a large, walled collection of fluid recognized as a rare late complication of hernia repair.1Ielpo B. Cabeza J. Jimenez D. et al.Abdominal pseudocyst complicating incisional hernia repair: our experience and literature review.Hernia. 2011; 15: 233-237Crossref PubMed Scopus (11) Google Scholar The pathophysiology of pseudocyst formation remains unclear but is thought to be a result of seroma formation or previous hematoma formations.1Ielpo B. Cabeza J. Jimenez D. et al.Abdominal pseudocyst complicating incisional hernia repair: our experience and literature review.Hernia. 2011; 15: 233-237Crossref PubMed Scopus (11) Google Scholar Abdominal ultrasonography can confirm the presence of an abdominal cyst, often depicting the cyst wall and multiple loculations, whereas computed tomography of the abdomen may help delineate the full extension of the cyst and the lack of intraperitoneal communication.1Ielpo B. Cabeza J. Jimenez D. et al.Abdominal pseudocyst complicating incisional hernia repair: our experience and literature review.Hernia. 2011; 15: 233-237Crossref PubMed Scopus (11) Google Scholar There appears to be a strong association with pseudocyst formation and abdominal hernia repairs with synthetic mesh.2Ogunbiyi S.O. Morris-Stiff G. Sheridan W.G. Giant mature cyst formation following mesh repair of hernias: an underreported complication?.Hernia. 2004; 8: 166-168Crossref PubMed Scopus (17) Google Scholar Culture results of the fluid collection are usually negative, as was the case in our patient. Definitive treatment usually requires surgical excision of the pseudocyst because the fluid collection appears to quickly reaccumulate after aspiration.2Ogunbiyi S.O. Morris-Stiff G. Sheridan W.G. Giant mature cyst formation following mesh repair of hernias: an underreported complication?.Hernia. 2004; 8: 166-168Crossref PubMed Scopus (17) Google Scholar, 3Arya N. Batey N.R. Pseudocyst formation after mesh repair of incisional hernia.J R Soc Med. 1998; 91: 657-664Google Scholar