P0788 - A Diagnostic Paracentesis Leading to Acute Hemoperitoneum and Small Bowel Obstruction (SBO)

Faisal Mehmood, MD¹, Tehseen Haider, MD², Clara Tow, MD^2
1Montefiore Medical Center, Yonkers, NY; ²Montefiore Medical Center, Bronx, NY

Introduction: Abdominal paracentesis is a commonly performed procedure on medical floors. It is rare to have serious complications after paracentesis. Risk of complications can be elevated in patients who are coagulopathic, taking antiplatelet or anticoagulant medications. We present a case of acute hemoperitoneum in a non-coagulopathic cirrhotic patient after a diagnostic paracentesis, and complicated by SBO.

Case Description/Methods: A 67-year-old man was admitted with altered mental status. His medical history was remarkable for cryptogenic decompensated cirrhosis (with ascites, hepatic encephalopathy, and prior variceal bleed), CKD-4 and CAD with recent stent placement. He underwent a diagnostic paracentesis, which was complicated by acute hemoperitoneum with a drop-in hemoglobin from 9.6g/dL to 4.9g/dL (Image 1A,1B). He remained hemodynamically stable, and was managed conservatively.




One week later after discharge, the patient returned with abdominal pain and multiple episodes of dark brown emesis. On exam, he had a distended, tympanic abdomen with mild diffuse tenderness. Labs were notable for hemoglobin of 8-9g/dL that was unchanged from his prior hospitalization, thrombocytopenia (110-130K/µL), creatinine of 3.2 mg/dl (at baseline) and serum lactate of 2.6. Liver tests, INR and serum electrolytes were normal. CT abdomen and pelvis showed a large unchanged hematoma measuring 16x9x16cm in the anterolateral left mid-abdomen compressing small bowel with multiple dilated fluid-filled small bowel loops (Image 2A,2B). NG tube was placed with caution given history of recent variceal banding and started intermittent low suction. Dual antiplatelet medications were continued given recent stent placement. His abdominal distension improved. Several days later, the NG tube was removed and diet was advanced. He was discharged with stable condition and has been without recurrent symptoms.

Discussion: Acute hemoperitoneum is a rare complication of paracentesis with the incidence being less than one percent. Management is conservative and rarely requires surgical intervention. However, it is important to monitor for secondary complications. To the best of our knowledge, this is the first reported case of SBO from hemoperitoneum after an abdominal paracentesis. Timely diagnosis is pivotal to prevent complications. Management can be challenging in these patients. Multidisciplinary teams should be involved in patient care to determine the best course of management whether it be conservative or interventional therapy.


Figure: Figure 1A and 1B: CT Abdomen and pelvis axial view and coronal view respectively demonstrates a large peritoneal hematoma (green arrows), normal small bowel loops (blue arrows), and large ascites (white arrows).
Figure 2A and 2B: CT Abdomen and pelvis axial view and coronal view respectively demonstrates a large peritoneal hematoma (green arrows), dilated small bowel loops (blue arrows), and large ascites (white arrows).


Disclosures:
Faisal Mehmood indicated no relevant financial relationships.
Tehseen Haider indicated no relevant financial relationships.
Clara Tow indicated no relevant financial relationships.


Faisal Mehmood, MD¹, Tehseen Haider, MD², Clara Tow, MD². P0788 - A Diagnostic Paracentesis Leading to Acute Hemoperitoneum and Small Bowel Obstruction (SBO), ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.