2249 Rectus Sheath Hematoma Post Abdominal Paracentesis: A Rare Complication

Abstract

INTRODUCTION: Rectus sheath hematoma (RSH) is a very rare complication after abdominal paracentesis especially in patients who do not take antiplatelet or anticoagulants. We presented a case of rectus sheath hematoma post paracentesis in a patient without obvious risk factors. CASE DESCRIPTION/METHODS: A 56-year-old male with past medical histories of chronic diastolic congestive heart failure and end-stage renal disease (ESRD) on hemodialysis presented with abdominal pain after abdominal paracentesis for ascites. 4.3 L of yellow ascitic fluid was drained in the first attempt of ultrasound-guided paracentesis. Abdominal distension on the right flank was also noticed. Vital signs were stable. Abdominal exam showed moderate tenderness on right flank, no guarding, no rebound tenderness, no bruising. ESRD was believed to be the cause of ascites. He received hemodialysis one day prior to the procedure. He is not on any antiplatelet or anticoagulation therapy. Computed tomography scan of abdomen showed right rectus sheath hematoma 14 × 9 cm (Figure 1). Labs on admission showed Hemoglobin (Hb) of 9.2 g/dL (compared to baseline Hb of 10.8 g/dL), Platelet count 192000 /uL, PT 13.9 secs, PTT 34.6 secs, and INR 1.22, BUN 42 mg/dL, Creatinine (Cr) 5.6 mg/dL (similar to baseline Cr). Interventional radiologist was emergently consulted and performed embolization which found extravasation from the right iliolumbar artery (Figure 2). Coil embolization was done successfully. On post-embolization day 3, Hb continued to drop to 5.7 g/dL. He developed hypotension. Surgery team was notified and brought the patient to operation room for exploratory laparotomy. Intraoperative findings revealed that 2 L of hematoma was evacuated from the patient’s rectus sheath. No active bleeding was immediately noted. Upon the exploration of the anterior wall toward the medial side of the incision, a small bleeding vein was noted and ligated. Vital signs became stable after the operation. He was discharged without postoperative complications. DISCUSSION: Large RSH is a rare complication of paracentesis. It can also develop in a patient without obvious bleeding risk factors. Clinicians should watch for this potential complication when a patient presents with an abdominal mass or abdominal pain without other particular symptoms after paracentesis. RSH is a self-limited condition; however, our case suggests that RSH may take an unpredictable course and may not be successfully managed with a conservative approach.