Acute hemoperitoneum after large-volume paracentesis

Successful Transcatheter Arterial Embolization of Abdominal Wall Hematoma from the Left Deep Circumflex Iliac Artery after Abdominal Paracentesis in a Patient with Liver Cirrhosis: Case Report and Literature Review

The occurrence of an abdominal wall hematoma caused by abdominal paracentesis in patients with liver cirrhosis is rare. This paper presents a case of an abdominal wall hematoma caused by abdominal paracentesis in a 67-year-old woman with liver cirrhosis with a review of the relevant literature. Two days prior, the patient underwent abdominal paracentesis for symptom relief for refractory ascites at a local clinic. Upon admission, a physical examination revealed purpuric patches with swelling and mild tenderness in the left lower quadrant of the abdominal wall. Abdominal computed tomography revealed advanced liver cirrhosis with splenomegaly, tortuous dilatation of the para-umbilical vein, a large volume of ascites, and a large acute hematoma at the left lower quadrant of the abdominal wall. An external iliac artery angiogram showed the extravasation of contrast media from the left deep circumflex iliac artery. Embolization of the target arterial branches using N-butyl-2-cyanoacrylate was then performed, and the bleeding was stopped. The final diagnosis was an abdominal wall hematoma from the left deep circumflex iliac artery after abdominal paracentesis in a patient with liver cirrhosis.

Massive Hemoperitoneum after Paracentesis in a Patient with Budd-Chiari Syndrome: Treated with a TIPS after Negative Arteriogram

Paracenteses are considered safe procedures; however, in patients with portal hypertension, the rapid shifts in intraabdominal pressure can prompt hemorrhage from an ectopic varix. Little literature exists on the appropriate management in this clinical setting. Here, we describe a patient with portal hypertension secondary to Budd-Chiari syndrome, presenting with massive hemoperitoneum following paracentesis. Angiography was performed, without revealing an arterial source of bleeding. Subsequently, transjugular intrahepatic portosystemic shunt placement was performed via a recanalized middle hepatic vein, reducing the patient's portosystemic gradient from 15 to 6 mm Hg. This patient developed no further signs or symptoms of bleeding and remained hemodynamically stable until discharge. Follow-up imaging confirmed patency of her shunt and resolution of her ascites, without the need for future paracentesis. This case highlights that in the absence of arterial extravasation, the possibility of ectopic variceal hemorrhage should be considered, which can be successfully treated with portosystemic shunt creation.

Lights and Shadows of Paracentesis: Is an Ultrasound Guided Approach Enough to Prevent Bleeding Complications?

Paracentesis is a validated procedure for diagnosing and managing ascites. Although paracentesis is a safe procedure with a 1–2% risk of complications such as bleeding, it is necessary to inform the patient about the possible adverse events. We would like to share our experience with two cases of bleeding after paracentesis. In our unit, two major hemorrhagic complications occurred in 162 procedures performed over the year 2020 (frequency of bleeding complications: 1.2%). We report two clinical cases of post-paracentesis abdominal wall hematomas. Despite a similar clinical presentation, the management approach was different: in the first case, embolization of the epigastric artery supplying the hematoma was performed. In the second case, conservative treatment was adopted. Our report aims to provide food for thought about a potentially challenging hemorrhagic complication, even with the risk of adverse outcomes.

Post paracentesis deep circumflex iliac artery injury identified at angiography, an underreported complication

BACKGROUND

Though injury to the inferior epigastric artery (IEA) is reported to be the most common source of hemorrhagic complications from paracentesis, we wish to present our experience involving deep circumflex iliac artery (DCIA) injuries that in our experience is the artery most frequently injured during paracentesis.

METHODS

Sixteen patients with clinically significant hemorrhage following paracentesis were referred to our Interventional Radiology service for trans-catheter embolization. Patterns of hemorrhage from diagnostic cross-sectional imaging and subsequent angiographic findings and management were investigated.

RESULTS

8/16 patients (50%) had angiographic evidence of injury to the DCIA and 4/16 patients (25%) had evidence of injury to the IEA, with two of these patients demonstrating hemorrhage from both the DCIA and IEA; 3/16 patients had injuries to subcostal and/or intercostal arteries; while 3/16 patients had negative angiograms. All patients underwent embolization of the identified injured arteries, and empiric embolization was performed of the DCIA and/or IEA in the three patients with negative angiograms. Fourteen of sixteen patients stabilized post embolization, while two patients required a second embolization procedure to achieve hemostasis; all patients were subsequently discharged home in stable condition.

CONCLUSION

Both the IEA and the lesser known DCIA need to be considered when performing paracentesis and at subsequent angiography for post paracentesis iatrogenic hemorrhage. Knowledge of both of these at-risk abdominal wall arteries may help minimize hemorrhagic complications from paracentesis.

Delayed Retroperitoneal Hemorrhage as a Complication of Large-volume Paracentesis

Large-volume paracentesis (LVP) consists of the removal of more than four liters of ascitic fluid. This procedure can cause complications such as hemorrhage, infection, bowel perforation, circulatory failure, or ascitic fluid leakage. The main presentation of paracentesis-induced hemorrhage is abdominal wall hematoma. An 81-year-old male with a past medical history of obesity and diabetes mellitus presented to our hospital with confusion, new onset black tarry stools, and foul-smelling urine. He was found to be oriented only to person and had abdominal distention with positive fluid wave sign and melanotic stools on rectal exam. Laboratory results elucidated pancytopenia, hypoalbuminemia, elevated aspartate aminotransferase (AST) of 43 U/L, and elevated D-dimer levels. Urinalysis was abnormal, showing >180 white blood cells (WBC) with positive leukocyte esterase and nitrites. Liver ultrasound evidenced cirrhosis. Octreotide drip, ceftriaxone, lactulose, and pantoprazole were initiated for upper gastrointestinal (GI) hemorrhage and cirrhosis. A computed tomography angiogram (CTA) of the chest was positive for bilateral segmental pulmonary embolism, therefore, he also started receiving heparin drip. On the fifth day of admission, an ultrasound-guided paracentesis was done, with six liters of ascitic fluid removed. On the seventh day of admission, the patient presented acute left flank pain with an associated episode of hypotension and drop in hemoglobin. A CTA of the abdomen showed left retroperitoneal hemorrhage but no signs of active bleeding. Heparin drip was discontinued, and the patient was transferred to the intensive care unit (ICU). The patient's hemoglobin was stable throughout the days after ICU admission, and he did not require any more transfusions of packed red blood cells. His respiratory status was steady although heparin was discontinued due to a bleeding episode. He was discharged without anticoagulation therapy due to his high risk for rebleeding. One of the proposed mechanisms leading to variceal bleeding is the rapid decompression of splanchnic circulation due to decreased abdominal pressure. Since the source of bleeding is venous, initially, the patients can be asymptomatic. Treatment can be conservative, surgical or by means of transcatheter interventions. We would like to emphasize the need for the close monitoring of patients undergoing large-volume paracentesis, especially in the setting of anticoagulation therapy, as survival depends upon early diagnosis and treatment. It is important to mention that international normalized ratio (INR) is neither a reliable anticoagulation test nor a predictive factor of bleeding in cirrhotic patients.

Acute kidney injury, but not sepsis, is associated with higher procedure-related bleeding in patients with decompensated cirrhosis

BACKGROUND

Bleeding after low-risk invasive procedures can be life-threatening or can lead to further complications in decompensated cirrhosis patients. In unstratified cohorts of hospitalized patients with cirrhosis, the rate of procedure-related bleeding is low despite abnormal coagulation parameters. Our objective was to identify patients with decompensated cirrhosis at a high risk of developing procedure-related bleeding in whom the value of pre-procedure transfusions could be assessed.

METHODS

Hospitalized patients with cirrhosis who developed post-paracentesis hemoperitoneum confirmed by CT scan, from the period of January 2012 to August 2016, constituted the study group. They were compared to patients hospitalized in the same period in whom post-paracentesis hemoperitoneum was suspected but ruled out by CT scan. A retrospective chart review was conducted to determine specifics of the adverse event, patient characteristics and risk factors for bleeding.

RESULTS

On multivariate analysis, acute kidney injury prior to paracentesis was the only independent predictor of post-paracentesis hemoperitoneum (OR 4.3, 95% CI 1.3-13.5, P = .01), independent of MELD score, large volume paracentesis, sepsis, platelets, INR and haemoglobin levels.

CONCLUSIONS

Infection/sepsis is generally considered predictive of bleeding in cirrhosis. Our study suggests that acute kidney injury, and not sepsis, is the most important predictor of post-procedure bleeding in patients with decompensated cirrhosis. Although end-stage renal disease is a known cause of bleeding in non-cirrhotic patients, there are no studies establishing acute kidney injury as a risk factor for post-procedure bleeding in cirrhosis. Future studies investigating blood product transfusion needs in cirrhosis prior to procedures should carefully look at patients with acute kidney injury.

Severe Intraperitoneal Hemorrhage from Pseudoaneurysm after a Large-volume Paracentesis, Successfully Treated with Microcoil Embolization

Large-volume paracentesis-induced intraperitoneal hemorrhage due to pseudoaneurysm formation is rarely reported. Here, we present a 56-year-old man with alcoholic liver cirrhosis admitted for massive ascites. Large-volume paracentesis was performed. Three days later, he became pale and complained of dyspnea and abdominal distention with hypotension. Percutaneous iliac angiography revealed contrast media leakage from a branch of the left circumflex iliac artery with pseudoaneurysm. He was successfully treated with microcoil embolization. Several days later, ascitic fluid increased and large-volume paracentesis was performed again. Two days later, his hemoglobin level suddenly decreased. An abdominal computed tomography scan showed new active bleeding at the left lower lateral peritoneal cavity, just anterior to the metalic coils. Percutaneous iliac angiography revealed contrast media extravasation from a branch of the left inferior epigastric artery with formation of collateral vessel. Percutaneous embolization was successfully performed again. After coil embolization, there were no further bleeding episodes.

Cirrhosis-related musculoskeletal disease: radiological review

Musculoskeletal problems in patients with liver disease are common; however, they are not so well described in the literature. Therefore, there is a need to collate information on these disorders, as their incidence is on a constant rise and some of these pathologies can severely debilitate the patient's quality of life. These disorders are parietal wall varices with or without bleeding, spontaneous intramuscular haematoma (e.g. rectus sheath), abdominal wall hernia, anasarca, hepatic osteodystrophy, septic arthritis, osteomyelitis, necrotizing fasciitis, osseous metastases from hepatocellular carcinoma etc. While portal hypertension plays a key role in disorders, in others, dysregulation of the coagulation system or a compromised immune system are responsible. Imaging plays an essential role in the assessment of these complications and awareness of these musculoskeletal manifestations is vital for establishing a timely diagnosis and planning of appropriate therapy, as these disorders can significantly impact the morbidity and mortality and also influence candidacy for liver transplantation. We herein comprehensively appraise various musculoskeletal complications associated with chronic liver disease/liver cirrhosis especially from an imaging perspective which, to the best of our knowledge, have not been collectively described in English literature.

Management of ascites in children

Ascites is the pathologic accumulation of fluid within the peritoneal cavity. There are many causes of fetal, neonatal and pediatric ascites; however, chronic liver disease and subsequent cirrhosis remain the most common. The medical and surgical management of ascites in children is dependent on targeting the underlying etiology. Broad categories of management strategies include: sodium restriction, diuresis, paracentesis, intravenous albumin, prevention and treatment of infection, surgical and endovascular shunts and liver transplantation. This review updates and expands the discussion of the unique considerations regarding the management of cirrhotic and non-cirrhotic ascites in the pediatric patient.

Hemorrhagic Complications Following Abdominal Paracentesis in Acute on Chronic Liver Failure: A Propensity Score Analysis

ABSTARCT

Patients with acute on chronic liver failure (ACLF) usually present with severe coagulopathy. Abdominal paracentesis is often performed in these patients. The aim of this study was to analyze the prevalence of hemorrhagic events after paracentesis and the predictive factors of this condition in ACLF populations.ACLF patients who underwent paracentesis were retrospectively enrolled within a 5-year period. A propensity score (PS) matching analysis was used to select matched cases from the overall nonhemorrhagic group to be used as the control group. Hemorrhagic complications and risk factors were examined using logistic regression analysis.A total of 602 abdominal paracenteses were carried out on 218 ACLF patients and 18 (2.99%) hemorrhagic complications were identified. The MELD scores were higher in hemorrhagic patients than overall patients before PS matching (25.77±6.65 vs 21.04 ± 7.93, P = 0.013). We matched 18 cases with bleeding events to 72 unique cases without. The hemorrhagic group had significantly lower fibrinogen levels and higher PT levels than nonhemorrhagic cases. Logistic regression analysis revealed that lower fibrinogen levels could independently predict hemorrhagic complications (OR: 0.128, 95% CI: 0.023-0.697, P = 0.017). The best cut-off value for reliable measurement of fibrinogen levels was 0.70 g/L, with a sensitivity of 76.4% and a specificity of 80.0%. The area under curve was 0.733 (95% CI 0.604-0.862, P value 0.002).Severe hemorrhagic complications occur more commonly in ALCF patients than previously thought. A low fibrinogen level is an independent predictor of bleeding events in patients with MELD >25.

Bleeding Rate for Ultrasound-Guided Paracentesis in Thrombocytopenic Patients

OBJECTIVES

The purpose of this study was to determine the rate of major bleeding complications for ultrasound-guided paracentesis performed in thrombocytopenic patients.

METHODS

We retrospectively reviewed the electronic medical records of patients with platelet counts of less than 50,000/μL who had ultrasound-guided paracenteses performed in the Department of Radiology without correcting preprocedural platelet transfusions between 2005 and 2011. Medical records were evaluated for evidence of major bleeding complications (grade 3 or higher as defined by the National Institutes of Health's Common Terminology Criteria for Adverse Events, version 4.03) and their clinical sequelae. Platelet count and bleeding complications were evaluated for an association, and a sensitivity analysis was performed to determine whether analysis of a control group of patients without thrombocytopenia would yield added confidence in this assessment.

RESULTS

Among 304 procedures in 205 thrombocytopenic patients (69% male; mean age ± SD, 56.6 ± 11.9 years), the mean platelet count was 38,400 ± 9300/μL (range, 9000-49,000/μL). Three major bleeding complications requiring red blood cell transfusion were observed in patients with platelet counts of 41,000 to 46,000/μL, for a complication rate of 0.99% (95% confidence interval, 0.3%-2.9%). No patient required an additional procedure or died because of the bleeding complication. There was no association of platelet count with bleeding complications. The sensitivity analysis showed that further evaluation of patients with normal platelet counts would not add to the conclusion.

CONCLUSIONS

The risk of major bleeding after ultrasound-guided paracentesis in thrombocytopenic patients is very low. In most patients, routine assessment of the preprocedural serum platelet concentration is not necessary, and correction of such an abnormal laboratory value is not indicated.

Hemorrhagic complications of paracentesis: a systematic review of the literature

Introduction. Large volume paracentesis is considered a safe procedure carrying minimal risk of complications and rarely causing morbidity or mortality. The most common complications of the procedure are ascitic fluid leakage, hemorrhage, infection, and perforation. The purpose of this study was to evaluate all hemorrhagic complications and their outcomes and to identify any common variables. Methods. A literature search for all reported hemorrhagic complications following paracentesis was conducted. A total of 61 patients were identified. Data of interest were extracted and analyzed. The primary outcome of the study was 30-day mortality, with secondary endpoints being achievement of hemostasis after intervention and mortality based on type of intervention. Results. 90% of the patients undergoing paracentesis had underlying cirrhosis. Three types of hemorrhagic complications were identified: abdominal wall hematomas (52%), hemoperitoneum (41%), and pseudoaneurysm (7%). Forty percent of the patients underwent either a surgical (35%) or an IR guided intervention (65%). Patients undergoing a surgical intervention had a significantly higher rate of mortality at day 30 compared to those undergoing IR intervention. Conclusion. Abdominal wall hematomas and hemoperitoneum are the most common hemorrhagic complications of paracentesis. Transcatheter coiling and embolization appear to be superior to both open and laparoscopic surgery in treatment of these complications.

Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis

Ultrasound guidance enables visualization of the needle insertion site for thoracentesis and paracentesis. The improved accuracy of needle placement using ultrasound may reduce risk of complications and their costs associated with these procedures. Using claims data from the Premier Perspective hospital database from January 1, 2007, through December 31, 2008, we conducted an observational cohort study examining the effect of ultrasound guidance on risk of pneumothorax among patients undergoing thoracentesis and on risk of bleeding complications after paracentesis. Patients at elevated risk of these outcomes for reasons beyond the procedure of interest were excluded. Adjusted risk of events was assessed using multivariate logistic regression controlling for patient and hospitalization characteristics. Hospitalization cost and length of stay (LOS) were estimated using multivariate ordinary least squares regression of log-transformed values. We analyzed 61,261 thoracentesis and 69,859 paracentesis patient records. Approximately 45% of these procedures were ultrasound guided. Pneumothorax occurred in 2.7% (n = 1,670) of patients undergoing thoracentesis. Of patients undergoing paracentesis, 0.8% (n = 565) experienced bleeding complications. After adjustment, ultrasound guidance reduced the risk of pneumothorax after thoracentesis by 19% (OR, 0.81; 95% CI, 0.74-0.90) and by 68% for bleeding complications after paracentesis (OR, 0.32; 95% CI, 0.25-0.41). Pneumothorax increased the total cost of hospitalization by $2,801 (P < .001) and LOS by 1.5 days (P < .001). Bleeding complications increased cost by $19,066 (P < .0001) and LOS by 4.3 days (P < .0001). The data indicate that ultrasound guidance is associated with decreased risk of pneumothorax with thoracentesis and of bleeding complications with paracentesis. These complications resulted in measurable increases in hospitalization costs and LOS.

Diagnosis and management of delayed hemoperitoneum following therapeutic paracentesis

Abdominal paracentesis is a frequently employed diagnostic and therapeutic procedure for patients with refractory ascites, typically in patients with cirrhosis. It is generally regarded as a safe procedure with significant complications occurring in <1% of cases. Most hemorrhagic complications are due to abdominal wall trauma, during which clear evidence of active bleeding is usually visualized during the procedure. Delayed hemoperitoneum is a rare complication of large-volume paracentesis in which clinical evidence of active bleeding is typically absent until substantial blood loss has taken place (often several days to a week later), leading to an exceedingly high mortality rate. Herein we describe a case of delayed hemoperitoneum in a 55-year-old man with heart failure. This case emphasizes the importance of identifying patients who are at high risk for delayed hemoperitoneum as well as the need to closely monitor complete blood counts in the days following a large-volume paracentesis.

Hemoperitoneum in cirrhotic patients without abdominal trauma or tumor

BACKGROUND

Hemoperitoneum is associated with several emergency conditions and is especially evident when it occurs in patients with liver cirrhosis. This study aimed to assess the clinical characteristics of cirrhotic patients who did not have abdominal trauma or tumor but who developed hemoperitoneum.

METHODS

We reviewed the clinical records of 1276 consecutive cirrhotic patients with hemoperitoneum at our center between January 2007 and December 2009. Hemoperitoneum was confirmed by abdominal paracentesis.

RESULTS

Of the 1276 cirrhotic patients, 19 were found to have hemoperitoneum, but only 6 did not have abdominal trauma or tumor. The occurrence of spontaneous hemoperitoneum in the cirrhotic patients was therefore 0.5%. Hemoperitoneum can occur spontaneously in severely decompensated cirrhotic patients with intra-abdominal collateral vessels and high scores on the model for end-stage liver disease and Child-Pugh-Turcotte test. Most patients presented with abdominal distension, abdominal pain, increased abdominal girth and hemodynamic instability with a significant drop in the hemoglobin level. Three patients died of hemorrhagic shock within 24 hours, and the other 3 died of hepatic encephalopathy or spontaneous bacterial peritonitis after 5 to 10 days because of further decompensation of the liver.

CONCLUSIONS

Hemoperitoneum can occur in cirrhotic patients who do not have abdominal trauma or tumor. It mainly occurs in severely decompensated end-stage cirrhotic patients. Cirrhotic patients with hemoperitoneum have a poor prognosis.

Surgical repair of umbilical hernias in cirrhosis with ascites

The most common complications of umbilical hernias in patients with cirrhosis and ascites include leakage, ulceration, rupture and incarceration. If such a complication is present, there is a high mortality rate after surgical repair. Elective repair is the most effective choice, as it prevents complications with a lower mortality. However, the control of ascites before and/or after repair is mandatory but may not always be possible with diuretics and paracentesis. Portal decompression by transjugular intrahepatic portosystemic shunt (TIPS) with better control of ascites may allow these patients to undergo surgery. Patients with cirrhosis and umbilical hernias should be referred for consideration of an elective surgical repair with mesh, preferably after optimal management of ascites. There should be a low threshold for placement of a TIPS to facilitate surgery and reduce the chance of severe recurrence of ascites. If surgery is contraindicated, a TIPS must be considered for control of ascites.

Risk of complications after abdominal paracentesis in cirrhotic patients: a prospective study

BACKGROUND & AIMS

Complications and technical problems of paracentesis in cirrhotic patients are infrequent. However, the severity and the incidence of these events and their risk factors have not been assessed prospectively.

METHODS

Cirrhotic patients (n = 171) undergoing paracentesis were included. Of the 515 paracenteses, 8.8% were diagnostic, and 91.2% were therapeutic. Technical features, demographic data, and adverse events during a period of 72 hours after the procedure were examined.

RESULTS

Major complications occurred in 1.6% of procedures and included 5 bleedings and 3 infections, resulting in death in 2 cases. Major complications were associated with therapeutic but not diagnostic procedures and tended to be more prevalent in patients with low platelet count (<50 10(9)/L), Child-Pugh stage C, and in alcoholic cirrhosis patients. Technical problems occurred in 5.6%. The most frequent complication was a leak of ascites at the puncture site (5.0%), and in 89.5% there were no complications.

CONCLUSIONS

The safety of paracentesis in cirrhotic patients might be decreased if risk factors, which depend on the characteristics of the patient and of the procedure itself, are present.

An evidence-based manual for abdominal paracentesis

The purpose of this study was to provide evidence-based approaches to detect ascites, perform paracentesis, order tests, and interpret the results. A Medline search was performed to identify relevant articles. Of 731 identified articles, 50 articles were used. The most sensitive findings for ascites detection are ankle edema (93%), increased abdominal girth (87%), flank dullness (84%), and bulging flanks (81%). Paracentesis is safe, with bleeding rates and leakage of <1%. An ascitic fluid polymorphonuclear cell count >or=250 cells/mm(3) is the most sensitive test (86%-100%) to diagnose spontaneous bacterial peritonitis. The serum-ascites albumin gradient is the most useful test in identifying portal hypertension-related ascites. Large-volume paracentesis is effective in the treatment of refractory ascites. We conclude that paracentesis is a safe and vital procedure in patients with new-onset ascites. Once detected, an algorithmic approach to ordering tests and their interpretation is useful to determine etiology and direct further management.

Should bleeding tendency deter abdominal paracentesis?

BACKGROUND AND AIMS

This study was conducted to evaluate the complications and bleeding associated with either thrombocytopoenia or prolongation of prothrombin time for ultrasound-guided abdominal paracentesis in the emergency department.

STUDY DESIGN AND PATIENTS

In an emergency department of a tertiary centre, patients receiving ultrasound-guided abdominal paracentesis by the emergency physicians were prospectively enrolled. Patient characteristics, the preprocedure international normalised ratio for prothrombin time and the platelet count, and the procedure-related complications were collected and analysed.

RESULTS

For a 2-year study period, a total of 410 abdominal paracenteses in 163 patients were investigated. The preprocedure international normalised ratio for prothrombin time was more than 1.5 in 142 paracenteses; the preprocedure platelet count was less than 50 x 10(3) microL(-1) in 55 paracenteses. Only two out of 410 procedures (0.5%, 95% confidence interval=0.1-1.8%) were associated with minor complications of cutaneous bleeding in the same patient (0.6%, 95% confidence interval=0.1-3.4%) at different visits. There was no significant procedure-related bleeding or complications even in patients with marked thrombocytopoenia or prolongation in international normalised ratio.

CONCLUSIONS

Bleeding complication of ultrasound-guided abdominal paracentesis is uncommon and appears to be very mild, regardless of preprocedure international normalised ratio or platelet count. Routine correction of prolonged international normalised ratio or thrombocytopoenia before abdominal paracentesis may not be necessary.

Choosing the location for non-image guided abdominal paracentesis

OBJECTIVES

The optimal location for paracentesis has not been studied scientifically. The evolving obesity epidemic has changed the physique of many patients with cirrhosis and ascites such that needles inserted into the abdominal wall may not reach fluid. We aimed to determine the location for paracentesis that would have the thinnest abdominal wall and the deepest amount of fluid.

METHODS

Ultrasound measurements of abdominal wall thickness and depth of ascites were recorded in two locations, the infraumbilical midline (ML) and the left lower quadrant (LLQ), in 52 patients with cirrhosis and ascites admitted to a single inpatient liver unit.

RESULTS

The abdominal wall was significantly thinner (1.8 vs. 2.4 cm; P<0.001) and the depth of ascites greater (2.86 vs. 2.29 cm; P=0.017) in the LLQ as compared with the infraumbilical ML position. In the left lateral oblique position, the difference in the depth of ascites was more pronounced when comparing the LLQ with the infraumbilical ML (4.57 vs. 2.78 cm; P<0.0001).

CONCLUSIONS

The LLQ is preferable to the ML infraumbilical location for performing paracentesis.

Severe haemorrhage following abdominal paracentesis for ascites in patients with liver disease

BACKGROUND

Bleeding is a recognized complication of abdominal paracentesis. Special concern has been raised when it is performed in patients with liver failure because of coagulation disorders and collaterals in the abdominal wall.

AIM

To assess the clinical characteristics of patients who developed haemorrhagic complications after paracentesis.

METHODS

We reviewed all cases of severe haemorrhage occurring after paracentesis in patients admitted to the Liver Unit of our institution between 1994 and 2004.

RESULTS

Nine cases were identified among 4729 procedures. The occurrence of severe haemorrhage represented 0.19% of all procedures with a death rate of 0.016%. Bleeding was not related to operator experience, elevated international normalized ratio or low platelets. It occurred in patients with high model for end-stage liver disease and Child-Pugh scores. Furthermore, some degree of renal failure was present in all but one patient.

CONCLUSION

Severe haemorrhage after abdominal paracentesis in patients with liver disease occurs in 0.2% of cases. It occurs in patients with severe liver failure and is often associated with significant pre-existing renal dysfunction.

Bleeding ectopic varices--treatment with transjugular intrahepatic porto-systemic shunt (TIPS) and embolisation

BACKGROUND/AIMS

Bleeding ectopic varices due to cirrhosis can be difficult to manage. We report our experience of uncontrolled bleeding from ectopic varices treated with transjugular intrahepatic porto-systemic shunt (TIPS).

METHODS

We selected the 21 cirrhotics who underwent TIPS for bleeding ectopic varices from our database: Child-Pugh grade A (2), B (11) and C (8). Site of bleeding was rectal (11), colonic (2), ileal 1, jejunal 1, duodenal 1, and stomal (5).

RESULTS

TIPS was performed successfully in 19/21 (90%) patients. All except 1 had either a reduction in portosystemic pressure gradient < or = 12 mmHg (n=12) or reduction by 25-50% of baseline (n=6). TIPS alone was used in 12/19: 7 of these 12 had no further bleeding; 5 (42%) rebled within 48 h, and had embolisation, 4 without further bleeding. In 7 of 19, TIPS and embolisation were performed together: 2 patients (28%) rebled; further embolisation stopped the bleeding.

CONCLUSIONS

Ectopic varices do rebleed despite a reduction of porto-systemic pressure gradient < or = 12 mmHg or by 25-50% of baseline, following TIPS. Embolisation stopped bleeding in all but 1 patient. We recommend performing embolisation at the time of the initial TIPS to control bleeding from ectopic varices.

Emergent ultrasound interventions

The interventionist can perform many emergent procedures with ultrasound guidance, because of its real-time, multiplanar imaging capability and portability. With the use of color Doppler, additional important information, such as aberrant vessels, can be ascertained to help plan needle trajectory. Ultrasound is also useful for nonemergent procedures, such as biopsies. All interventionists are encouraged to be facile with the use of ultrasound.

TIPS: an update

During the last 15 years the transjugular intrahepatic portosystemic shunt (TIPS) procedure has become a safe and effective treatment of portal hypertension. Its major obstacle, the high rate of shunt insufficiency, is going to be solved by the availability of covered stents showing a patency rate of up to 90%. The treatment of acute oesophageal and gastric variceal bleeding is an unsolved problem because variceal bleeding remains the major cause of death in patients with cirrhosis. TIPS has become the rescue treatment of choice because it combines high efficacy with low invasiveness. In this context, the timing of the rescue TIPS is of major importance for achieving definitive haemostasis before multi-organ failure develops. In the prevention of re-bleeding, TIPS is accepted as a second-line treatment, required in about 10-20% of patients. TIPS may be indicated when more than two significant re-bleedings occurred within a time frame of 12 months in spite of adequate first-line measures i.e. drugs or ligation. Refractory ascites is the third main indication for TIPS. Five randomized studies comparing TIPS with paracentesis show good response and comparable survival. Interpretations of authors and comments of reviewers are, however, controversial and do not permit a definitive recommendation.

When endoscopic therapy or pharmacotherapy fails to control variceal bleeding: what should be done? Immediate control of bleeding by TIPS?

BACKGROUND

Acute variceal bleeding is the major cause of death in patients with chronic liver disease. This justifies the search for a more effective therapy to achieve rapid and definitive hemostasis in every patient. At present, the recommended standard treatment for acute variceal bleeding consists of immediate drug treatment with terlipressin or octreotide together with early endoscopic band ligation or sclerotherapy. In the case of ectopic varices terlipressin and cyanoacrylate embolization (if varices can be reached by endoscope) are in use.

FOCUS

The treatment is considered to have failed when bleeding continues or significant bleeding recurs within 48 h. This indicates the need for emergency transjugular intrahepatic portosystemic shunting (TIPS) which has been regarded as rescue treatment of choice when standard treatment fails. Although randomized studies against supportive treatment are lacking, the high efficacy and relatively low mortality after TIPS implantation are convincing. It is reasonable that smaller shunts should be preferred (probably 8 mm in diameter) since most patients have an increased risk of liver failure. To increase the effect of the shunt with respect to acute hemostasis it should be combined with transjugular embolization of the varices.

CONCLUSION

Only strict adherence to the definition of failure of standard treatment and a generous indication to the TIPS implantation before multiorgan failure occurs may decrease the high mortality of acute variceal bleeding.

Large-volume paracentesis in the management of ascites in children

BACKGROUND

Large-volume paracentesis has been evaluated for both therapeutic and diagnostic purposes in the management of ascites in cirrhotic adults. There are no published data relating to the safety, efficacy, or methods of this procedure in children. The objective of this study was to characterize the authors' initial experience with large-volume paracentesis (> 50 ml/kg of ascites) for removal of tense abdominal ascites in the pediatric population.

METHODS

Retrospective chart review was performed of 21 large-volume paracentesis sessions in seven children (ages 6 months-18 years) with tense ascites that did not respond to other measures.

RESULTS

Mean volume removed was 3,129 +/- 2,966 ml (mean +/- standard deviation) or 118 +/- 56 ml/kg over 2.9 +/- 3.7 hours by a 16-gauge intravascular catheter in 6 sessions, by an 18-gauge intravascular catheter in three sessions, and by a 15-gauge fenestrated, stainless-steel paracentesis needle in 12 sessions. Large-volume paracenteses performed with the paracentesis needle had significantly shorter duration of drainage and faster flow rates than those performed with the intravascular catheter. The only complication encountered was decreased urine output in one session.

CONCLUSIONS

Large-volume paracentesis is a safe and effective therapeutic method for managing tense abdominal ascites in children. The use of the paracentesis needle significantly improved the speed and efficiency of large-volume paracentesis compared with the intravascular catheter.

Clinical management of ascites and its complications

Development of ascites is a poor prognostic sign with a 1 year mortality rate of up to 50%. Cirrhotic patients who develop ascites should therefore be evaluated for liver transplantation. Even though current therapies of ascites are not associated with a survival benefit, the elimination of ascites will improve quality of life and prevent the development of lethal complications such as SBP and HRS. Therapy of ascites should be directed at correcting the pathophysiologic abnormalities that lead to ascites formation, namely sodium retention, reduced effective arterial blood volume, and sinusoidal hypertension.

Inferior epigastric artery pseudoaneurysm: a complication of paracentesis

Two patients had inferior epigastric artery pseudoaneurysms after therapeutic paracentesis for ascites caused by portal hypertension. The first patient, a 62-year-old man, had a two-week history of left lower quadrant pain, tenderness, and nonpulsatile mass after a paracentesis for ascites. A left inferior epigastric artery pseudoaneurysm measuring 10 cm in diameter and 20 cm in length was diagnosed by means of Duplex ultrasound and arteriography. The patient was treated with percutaneous embolization, with successful thrombosis of the pseudoaneurysm. The second patient, a 33-year-old woman, had a six-week history of left lower quadrant pain, tenderness, and nonpulsatile mass after a paracentesis for ascites. Computerized tomography and arteriography showed a left inferior epigastric artery pseudoaneurysm, measuring 7 cm in diameter and 9 cm in length. The patient was treated with percutaneous embolization with successful thrombosis of the pseudoaneurysm. Both patients were discharged in good condition 2 days after embolization. Inferior epigastric artery pseudoaneurysm is a complication of paracentesis, and percutaneous embolization may be preferable to surgical repair in patients with chronic liver failure and portal hypertension.

The first decade of the transjugular intrahepatic portosystemic shunt (TIPS): state of the art

The transjugular intrahepatic portosystemic shunt (TIPS) is an interventional treatment resulting in decompression of the portal system by creation of a side-to-side portosystemic anastomosis. Since its introduction 10 years ago, more than 500 publications have appeared demonstrating rapid acceptance and increasing clinical use. This review summarizes the present knowledge of technical aspects and complications, follow-up of patients, and indications. With respect to the technique, the TIPS procedure is probably one of the most difficult interventions and, therefore, technical success and complications clearly depend on the skills of the operator. Thus, the number and kind of complications reported in this review do not necessarily relate to the procedural complications of an experienced center. The follow-up of the TIPS patient has to assess shunt patency, liver function and hepatic encephalopathy. Shunt patency can best be monitored by duplex-sonography. Routine radiological revision seems not to be helpful and does not improve results, i.e., rebleeding and survival. Short term patency may be improved by anticoagulation, while such a treatment does not influence long-term patency. With respect to the indications of TIPS, much is known about treatment of variceal bleeding. The nine randomized studies that are available to date show that survival is comparable between patients receiving TIPS or endoscopic treatment. The second group of patients is the group with refractory ascites and related complications, such as hepatorenal syndrome and hepatic hydrothorax. It has been demonstrated that TIPS improves these complications, but randomized studies are still lacking. In addition, TIPS has been applied successfully to patients with Budd-Chiari syndrome, portal vein thrombosis, before liver transplantation, and for the treatment of ectopic portal hypertensive bleeding.