Hemorrhagic Complications of Paracentesis: Aberrant Anatomy Versus Aberrant Technique - A Fatal Case of Abdominal Hemoperitoneum

Abstract

Large-volume paracentesis carries roughly a 1% risk of overall complications. Hemorrhagic complications are classified as abdominal wall hematomas, pseudoaneurysms, and hemoperitoneum. Severe hemorrhage is rare (<0.2%), with death following this complication seen in <0.02% of cases. We present a fatal case of an ultrasound-guided paracentesis leading to subsequent hemoperitoneum from an aberrant intercostal artery, causing hemorrhagic shock and death. A 47-year-old black male with decompensated alcoholic cirrhosis, model for endstage liver disease (MELD) score of 22, and Child-Pugh class C presented with a distended abdomen, international normalized ratio (INR) 1.9, and hemoglobin 9.6 g/dL. An ultrasoundguided therapeutic paracentesis was performed in the right lower quadrant with 50 mL intravenous albumin given after 4 L of uncomplicated ascitic fluid removal. The patient became hypotensive, tachycardic, and placed on pressor support medication within 12 hours after the procedure. After a complex hospital course, the patient passed away on hospital day 10 after multisystem organ failure. The patient was found to have an aberrant intercostal artery bleed secondary to the paracentesis procedure causing an abdominal hemoperitoneum.

Bedside ultrasonography prior to abdominal paracentesis is associated with low complication and high success rate: Experience in a National Health Service District General Hospital in the United Kingdom from 2013 to 2019

“…Case reports of complications, despite using ultrasound, are rare, and should not lead to the conclusion that all ultrasound guided procedures need to take place in the radiology department. 34,35 To the contrary, our data, similar to other articles, support the use of bedside ultrasound-assisted paracentesis leading to a high success rate for diagnostic aspirations and drain insertions. 12,14–17,19–23,35…”

“…We think this difference is likely due to the use of ultrasound prior to paracentesis in all our patients, compared to only 12% in the study of De Gottardi et al 9 Case reports of complications, despite using ultrasound, are rare, and should not lead to the conclusion that all ultrasound guided procedures need to take place in the radiology department. 34,35 To the contrary, our data, similar to other articles, support the use of bedside ultrasound-assisted paracentesis leading to a high success rate for diagnostic aspirations and drain insertions. 12,[14][15][16][17][19][20][21][22][23]35 Regarding the analysis of procedure activity, unfortunately coding data were not reliably reflecting the activity in 2019.…”