Hemorrhagic shock from bleeding pseudoaneurysm of deep circumflex iliac artery after abdominal paracentesis
CCCF ePoster library. Saoraya J. 11/12/19; 283435; EP61 Disclosure(s): This research was supported by Grants for Development of New Faculty Staff, Ratchadaphiseksomphot Endowment Fund, Chulalongkorn University
Dr. Jutamas Saoraya
Dr. Jutamas Saoraya
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Abstract
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ePoster
Topic: Clinical Case Report

Saoraya Jutamas1,2, Musikatavorn Khrongwong 1,3
 
1 Department of Emergency Medicine, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand; 
2 Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand;
3 Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.


Introduction

Abdominal paracentesis is a common diagnostic and therapeutic procedure in patients with ascites. However, a rare but lethal complication potentially affects the management. We reported a case of bleeding pseudoaneurysm after abdominal paracentesis. 

Case report

A 63-year-old female with past medical history of decompensated cirrhosis was brought to the emergency department due to altered mental status and abdominal pain. Three days ago, in a regular clinic visit, she underwent an abdominal paracentesis. The 1.5-liter, clear, yellowish ascites was released. She was discharged with normal vital signs. 

In this visit, her vitals were temperature of 37 degree Celsius, pulse rate of 94/min, respiratory rate of 20/min, and blood pressure of 80/50 mmHg. Her abdomen was markedly distended with generalized tenderness. The neurological exam revealed no focal deficits. Fluid resuscitation and empiric antibiotics was administered due to presumed sepsis. Laboratory testing revealed hemoglobin level of 7.2 g/dL, hematocrit of 21.6 % , WBC count of 25.2 x 103 per microliter,  platelet of 158 x 103  per microliter and the INR of 3.46. The hemoglobin was decreased from the level of  11.4 g/dl three days ago. Subsequently, a repeated physical examination uncovered a palpable mass at left side of the abdomen.

Computed tomography (CT) of the abdomen showed a 9.9 x 19.3 x 24.3-cm intramuscular hematoma with contrast extravasation at left lower abdominal wall (Figure 1 and 2). The angiogram revealed an extravasation from a pseudoaneurysm from a branch of left deep circumflex iliac artery (DCIA) (Figure 3). The glue embolization was performed successfully. Despite surviving this event, she developed hospital-acquired infection and septic shock and passed away. 

Discussion

Abdominal paracentesis is, though generally safe, not without significant complications.   The incidence of major hemorrhage or infection was 1.6 % of the patients who underwent this procedure (1). A common complication is bleeding and the inferior epigastric artery (IEA)  pseudoaneurysm formation. However, as in this case, bleeding pseudoaneurysm from DCIA can cause a potentially fatal complication. 

Previously, pseudoaneurysm of the DCIA was scarcely reported after abdominal wall procedures including paracentesis (2). Nevertheless, a small case series recently reported that DCIA was the most commonly injured artery necessitating endovascular treatment. Patients with DCIA injuries can manifest with abdominal wall hematoma or hemoperitoneum which can be a late presentation after the procedure. Although conservative treatment with blood product transfusion was successful in some cases, endovascular therapy is recommended (3).

Prevention of this complication is paramount. Traditionally, the landmark for paracentesis is to position laterally to the rectus sheath to avoid puncturing the IEA. As this technique can be at risk of puncturing DCIA because it ascends more laterally. The recommendation to prevent this complication is to perform ultrasound-assisted paracentesis with color Doppler to identify the vessel and avoidance of the needle trajectory (4). 

Conclusions 

 Bleeding DCIA pseudoaneurysm is a rare but significant complication of the abdominal paracentesis. Physicians should be aware of this condition as one of a cause of hemorrhagic shock in patient with cirrhosis.  Ultrasound-assisted paracentesis can minimize the risk of developing this complication. 

 


Image Image Image
  1. De Gottardi A, Thévenot T, Spahr L, et al. Risk of complications after abdominal paracentesis in cirrhotic patients: a prospective study. Clin Gastroenterol Hepatol. 2009 Aug 1;7(8):906-9.
  2. Satija B, Kumar S, Duggal RK, Kohli S. Deep circumflex iliac artery pseudoaneurysm as a complication of paracentesis. J Clin Imaging Sci. 2012;2:10. doi:10.4103/2156-7514.94022
  3. Kalantari J, Nashed MH, Smith JC. Post paracentesis deep circumflex iliac artery injury identified at angiography, an underreported complication. CVIR Endovascular. 2019 Dec 1;2(1):24.
  4. Millington SJ, Koenig S. Better with ultrasound: paracentesis. Chest. 2018 Jul 1;154(1):177-84.
ePoster
Topic: Clinical Case Report

Saoraya Jutamas1,2, Musikatavorn Khrongwong 1,3
 
1 Department of Emergency Medicine, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand; 
2 Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand;
3 Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.


Introduction

Abdominal paracentesis is a common diagnostic and therapeutic procedure in patients with ascites. However, a rare but lethal complication potentially affects the management. We reported a case of bleeding pseudoaneurysm after abdominal paracentesis. 

Case report

A 63-year-old female with past medical history of decompensated cirrhosis was brought to the emergency department due to altered mental status and abdominal pain. Three days ago, in a regular clinic visit, she underwent an abdominal paracentesis. The 1.5-liter, clear, yellowish ascites was released. She was discharged with normal vital signs. 

In this visit, her vitals were temperature of 37 degree Celsius, pulse rate of 94/min, respiratory rate of 20/min, and blood pressure of 80/50 mmHg. Her abdomen was markedly distended with generalized tenderness. The neurological exam revealed no focal deficits. Fluid resuscitation and empiric antibiotics was administered due to presumed sepsis. Laboratory testing revealed hemoglobin level of 7.2 g/dL, hematocrit of 21.6 % , WBC count of 25.2 x 103 per microliter,  platelet of 158 x 103  per microliter and the INR of 3.46. The hemoglobin was decreased from the level of  11.4 g/dl three days ago. Subsequently, a repeated physical examination uncovered a palpable mass at left side of the abdomen.

Computed tomography (CT) of the abdomen showed a 9.9 x 19.3 x 24.3-cm intramuscular hematoma with contrast extravasation at left lower abdominal wall (Figure 1 and 2). The angiogram revealed an extravasation from a pseudoaneurysm from a branch of left deep circumflex iliac artery (DCIA) (Figure 3). The glue embolization was performed successfully. Despite surviving this event, she developed hospital-acquired infection and septic shock and passed away. 

Discussion

Abdominal paracentesis is, though generally safe, not without significant complications.   The incidence of major hemorrhage or infection was 1.6 % of the patients who underwent this procedure (1). A common complication is bleeding and the inferior epigastric artery (IEA)  pseudoaneurysm formation. However, as in this case, bleeding pseudoaneurysm from DCIA can cause a potentially fatal complication. 

Previously, pseudoaneurysm of the DCIA was scarcely reported after abdominal wall procedures including paracentesis (2). Nevertheless, a small case series recently reported that DCIA was the most commonly injured artery necessitating endovascular treatment. Patients with DCIA injuries can manifest with abdominal wall hematoma or hemoperitoneum which can be a late presentation after the procedure. Although conservative treatment with blood product transfusion was successful in some cases, endovascular therapy is recommended (3).

Prevention of this complication is paramount. Traditionally, the landmark for paracentesis is to position laterally to the rectus sheath to avoid puncturing the IEA. As this technique can be at risk of puncturing DCIA because it ascends more laterally. The recommendation to prevent this complication is to perform ultrasound-assisted paracentesis with color Doppler to identify the vessel and avoidance of the needle trajectory (4). 

Conclusions 

 Bleeding DCIA pseudoaneurysm is a rare but significant complication of the abdominal paracentesis. Physicians should be aware of this condition as one of a cause of hemorrhagic shock in patient with cirrhosis.  Ultrasound-assisted paracentesis can minimize the risk of developing this complication. 

 


Image Image Image
  1. De Gottardi A, Thévenot T, Spahr L, et al. Risk of complications after abdominal paracentesis in cirrhotic patients: a prospective study. Clin Gastroenterol Hepatol. 2009 Aug 1;7(8):906-9.
  2. Satija B, Kumar S, Duggal RK, Kohli S. Deep circumflex iliac artery pseudoaneurysm as a complication of paracentesis. J Clin Imaging Sci. 2012;2:10. doi:10.4103/2156-7514.94022
  3. Kalantari J, Nashed MH, Smith JC. Post paracentesis deep circumflex iliac artery injury identified at angiography, an underreported complication. CVIR Endovascular. 2019 Dec 1;2(1):24.
  4. Millington SJ, Koenig S. Better with ultrasound: paracentesis. Chest. 2018 Jul 1;154(1):177-84.
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