US-Guided Paracentesis Complicated by Delayed Hemoperitoneum with Hemorrhagic Shock

Abstract

Delayed hemoperitoneum is a rare complication of paracentesis, a generally safe procedure with overall complications occurring in less than one percent of cases. Vascular injuries are often addressed during or immediately following paracentesis. Regardless, life-threatening hemorrhage may arise following this well-tolerated procedure, especially in the setting of coagulopathy. We present a case of delayed hemorrhagic shock due to bleeding from a branch of the right inferior epigastric artery after ultrasound-guided paracentesis. A 67-year-old female with history of primary biliary cirrhosis and recent tibia-fibula fracture complicated by deep vein thrombosis on full-dose anticoagulation presented with abdominal distention and pain secondary to new-onset ascites. With her anticoagulation held, platelet count of 63 thousand/mcl and INR of 1.4, she underwent an ultrasound-guided paracentesis with removal of 5L of clear, yellow ascitic fluid. Afterward, anticoagulation was resumed and diuretics were initiated. The next day, she developed asymptomatic hypotension. Labs were notable for a hemoglobin drop from 11.6 mg/dL to 10.8mg/dL; INR 1.5. Despite aggressive volume resuscitation, she was transferred to the intensive care unit with multi-organ system failure. Repeat hemoglobin was 4.8mg/dL. Noncontrast computed tomography was notable for a large amount of ascites with intraperitoneal blood (Figure 1a). Urgent coil embolization of a pseudoaneurysm of the right inferior epigastric artery was performed (Figure 1b, 1c). Her course was complicated by ischemic hepatitis, acute kidney injury, disseminated intravascular coagulopathy, arrhythmia, and acute encephalopathy necessitating intubation and eventual withdrawal of life-sustaining measures.Figure 1Most hemorrhagic complications following paracentesis are due to abdominal wall trauma. Often iatrogenic and perhaps underreported, damage to the inferior epigastric artery can be fatal. Currently, there are no known guidelines to correct coagulopathies prophylactically or use vascular-flow imaging during ultrasound-guided paracentesis to prevent and identify bleeds. Given the infrequent occurrence of delayed hemoperitoneum, ultrasound-guided paracentesis with Doppler may allow for better visualization of abdominal wall vessels, especially in high-risk patients on anticoagulation.