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Author: Mitchell Zekhtser, MS III
Western University of Health Sciences
AAEM/RSA Vice-Chair of Education Committee
Case
A 60-year-old female with a past medical history of alcoholic cirrhosis presented to the emergency department (ED) with abdominal pain and distension seven hours after undergoing a paracentesis. The patient noted that she routinely had the procedure done at her primary care office, but today she started feeling distended again at an accelerated rate. On exam, the patient was hypotensive with a pressure of 98/57, tachycardic with a heart rate of 110, and had diffuse abdominal tenderness worst in the left lower quadrant (LLQ). A computed tomography (CT) scan revealed blood between the abdominal wall and parietal peritoneum, and complete blood count (CBC) showed an acute drop in hemoglobin. Several hours after presentation, the patient underwent an emergent exploratory laparotomy, which revealed a lacerated left inferior epigastric artery (IEA), likely a result of her recent paracentesis. The patient lost four liters of blood throughout the operation. During her stay, she received a total of five units of packed red blood cells and three units of fresh frozen plasma. While the patient survived the surgery, unfortunately, she passed away two weeks later due to exacerbation of her chronic conditions.
Risks and Benefits
Therapeutic and diagnostic paracenteses are relatively common procedures but are not without risk. Patients may undergo a paracentesis in the ED due to severe dyspnea, infection, or, less commonly, abdominal discomfort, secondary to ascites. However, there are some risks involved, including hemorrhage, bowel or bladder puncture, infection, or a persistent leak.[1] In a retrospective study, 4,729 paracenteses were completed either blindly on the wards or via ultrasound (US) guidance in the radiology suite. Of those, nine patients (0.19%) had post-procedure hemorrhage, and one patient died within twenty-four hours of the procedure. Most of those patients presented with symptoms of pain, abdominal distension, nausea, and hemodynamic instability within an average of 11 ± 8 hours after their procedures.[2] This is not unlike the patient case above. Though the likelihood of risks is outweighed by the benefits of providing patients with therapeutic paracenteses, there are certain precautions that still need to be made to protect cirrhotic and coagulopathic patient population who require paracentesis for diagnosis.
Anatomical Considerations
Ascitic fluid can potentially collect anywhere within the abdominal cavity. In one study, aimed at assessing the safest location to perform a paracentesis, researchers compared the abdominal wall thickness and depth of ascites to determine the puncture site with the safest outcome. They assessed the infraumbilical midline area and the LLQ, which they defined as two finger breadths medial and two finger breadths cephalad of the left anterior superior iliac crest. The right lower quadrant (RLQ) was not assessed due to the increased frequency of adhesions. The researchers found that the abdominal wall is the thinnest and the depth of the ascitic fluid is the greatest in the LLQ; thus, they concluded it was the best puncture site for this procedure.[3] This data was even further corroborated in another retrospective study, in which no hemorrhagic complications were seen when paracenteses were performed in the LLQ.[4] In the case presented above, however, the paracentesis was performed in the LLQ and still resulted in hemorrhage, so it important to keep in mind that various patient factors may affect outcomes.
To assess why there may be complications with paracenteses in the LLQ despite its perceived safety, a study looked at the course of the IEA within fifty cadavers. The distance from the midline to the IEA ranged from 0.90-6.90 centimeters on the left side, and 1.30-7.40 centimeters on the right.[5] The study showed that there is a wide variance on where the IEA may arise. Therefore, it is not surprising that some patients may have unexpected IEA lacerations due to anatomical differences. Of note, there are several other arteries in that area that are at risk for laceration, such as the superficial circumflex artery in the outer quadrants of the abdomen.
Patient Safety and Ultrasound
To mitigate the variability and the potential to lacerate an abdominal wall artery, a study examined the role of ultrasound in preventing bleeding complications due to paracentesis. In the assessment of 69,859 patients, researchers found that there was a 68% risk-reduction for bleeding complications, as well as decreased length of hospital stay and mortality when ultrasound guidance was used.[6] Given the variability of the IEA, as well as the potential increased morbidity and mortality associated with non-ultrasound guided paracentesis, this study suggests that the utilization of ultrasound may improve overall patient outcomes.
Conclusion
Paracenteses are relatively safe procedures. However, there is still a small population of patients that may experience serious morbidity and mortality because of this procedure. Given the emergence of ultrasound, and studies that show risk-reduction in patients undergoing US-guided paracentesis, one should consider using ultrasound to improve patient outcomes and decrease mortality, especially in the setting of coagulopathy. This is especially important in the ED as these patients are in general, acutely sicker. Additionally, it is important to quickly recognize signs of patients with a potential hemorrhagic bleed status-post paracentesis, which can save patient’s life.
References:
1. Mcgibbon A, Chen GI, Peltekian KM, Van Zanten SV. An evidence-based manual for abdominal paracentesis. Dig Dis Sci. 2007;52(12):3307-15.
2. Pache I, Bilodeau M. Severe haemorrhage following abdominal paracentesis for ascites in patients with liver disease. Aliment Pharmacol Ther. 2005;21(5):525-9.
3. Sakai H, Sheer TA, Mendler MH, Runyon BA. Choosing the location for non-image guided abdominal paracentesis. Liver Int. 2005;25(5):984-6.
4. Grabau CM, Crago SF, Hoff LK, et al. Performance standards for therapeutic abdominal paracentesis. Hepatology. 2004;40(2):484-8.
5. Rao MP, Swamy V, Arole V, Mishra P. Study of the course of inferior epigastric artery with reference to laparoscopic portal. J Minim Access Surg. 2013;9(4):154-8.
6. Mercaldi CJ, Lanes SF. Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis. Chest. 2013;143(2):532-538.
7. Lubner M, Menias C, Rucker C, et al. Blood in the belly: CT findings of hemoperitoneum. Radiographics. 2007;27(1):109-25.
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