Just a Nick?: Mitigating and Identifying Paracentesis Complications

Image Credit: Wikimedia

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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.

Hepatic Encephalopathy Meets the ED

Image credit: Tareq Salahuddin

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Author: Alfred Morrobel, MS3
Medical Student
Universidad Iberoamericana

Introduction & Pathophysiology 
Hepatic encephalopathy (HE), also known as portosystemic encephalopathy, is a potentially deadly complication of chronic liver failure. HE is commonly caused by liver failure due to cirrhosis, but there are non-cirrhotic causes as well. Cirrhosis is commonly caused by alcohol abuse and hepatitis B & C, each of which contribute to chronic liver scarring.[1] Symptoms are similar regardless of the underlying etiology. The basis of hepatic encephalopathy is ammonia accumulation in the brain, which produces drastic motor and cognitive impairment.[3] HE results in a constellation of neurological problems that includes chronic fatigue, difficulty thinking, forgetfulness, asterixis, poor judgment, excessive confusion, disorientation, personality changes, and hyperactive deep tendon reflexes.[2] Patients with HE may also demonstrate stigmata of chronic liver disease: jaundice, ascites, peripheral edema, telangiectasias, caput medusae, and palmar erythema. In general, physicians use scoring systems, such as the West Haven Criteria, when diagnosing HE because of the variety of symptoms HE can cause in any individual patient. The criteria depend on the severity of the patients’ clinical symptoms, whether they are cognitive, motor, or both (see summary in table 1). [2,4]