Giant rectus sheath hematoma after therapeutic paracentesis resulting in hemodynamic instability in the intensive care unit

Iatrogenic vascular complications of non-vascular percutaneous abdominal procedures

PURPOSE

The purpose of this paper is to compile and present all of the reported vascular complications that resulted from common non-vascular abdominal procedures in the literature. Non-vascular procedures include, though are not limited to, percutaneous abscess/fluid collection drainage (PAD), percutaneous nephrostomy (PN), paracentesis, percutaneous transhepatic cholangiography (PTC)/percutaneous biliary drainage (PBD), percutaneous biliary stone removal, and percutaneous radiologic gastrostomy (PG)/percutaneous radiologic gastrojejunostomy (PG-J). By gathering this information, radiologists performing these procedures can be aware of the associated vascular injuries, as well as take steps to minimize risks.

METHODS

A literature review was conducted using the PubMed database to catalog relevant articles, published in the year 2000 onward, in which an iatrogenic vascular complication occurred from the following non-vascular abdominal procedures: PAD, PN, paracentesis, PTC/PBD, percutaneous biliary stone removal, and PG/PG-J. Biopsy and tumor ablation were deferred from this article.

RESULTS

214 studies met criteria for analysis. 28 patients died as a result of vascular complications from the analyzed non-vascular abdominal procedures. Vascular complications from paracentesis were responsible for 19 patient deaths, followed by four deaths from PTC/PBD, three from biliary stone removal, and two from PG.

CONCLUSION

Despite non-vascular percutaneous abdominal procedures being minimally invasive, vascular complications still can arise and be quite serious, even resulting in death. Through the presentation of vascular complications associated with these procedures, interventionalists can improve patient care by understanding the steps that can be taken to minimize these risks and to reduce complication rates.

Hemodynamic Instability in Emergency Department: Giant Rectus Sheath Hematoma and Point-of-Care Ultrasonography

Iatrogenic rectus sheath hematoma (RSH) developed after paracentesis is a rare but life-threatening complication. Mortality rates of patients may increase due to delays in treatment and comorbid conditions. In this article, we present the case of a patient who was unstable in the emergency department and was diagnosed with RSH using point-of-care ultrasonography (POCUS). The importance of POCUS has increased as hematoma manifestations of patients with severe ascites tend to be obscured. POCUS has varied uses in the emergency department, and in this article we emphasize the use of POCUS in a life-threatening case of RSH.

Arterial anatomy of the anterior abdominal wall: Ultrasound evaluation as a real-time guide to percutaneous instrumentation

INTRODUCTION

Instrumenting the anterior abdominal wall carries a potential for vascular trauma. We previously assessed the presence, position, and size of the anterior abdominal wall superior and inferior (deep) epigastric arteries with computed tomography (CT). We now present a study using ultrasound (US) assessment of these arteries, to evaluate its use for real time guidance of percutaneous procedures involving the rectus sheath.

MATERIALS AND METHODS

Twenty-four participants (mean age 67.9 ± 9 years, 15 M:9 F [62:38%]) were assessed with US at three axial planes on the anterior abdominal wall: transpyloric plane (TPP), umbilicus, and anterior superior iliac spine (ASIS).

RESULTS

An artery was visible least frequently at the TPP (62.5 - 45.8%), compared with the umbilicus (95.8-100%) and ASIS (100%), on the left, χ² (2) = 20.571; p < .001, and right, χ² (2) = 27.842; p < .001, with a moderate strength association (Cramer's V = 0.535 [left] and 0.622 [right]). Arteries were most commonly observed within the rectus abdominis muscle at the level of the TPP and umbilicus, but posterior to the muscle at the level of the ASIS (95.8-100%). As with the CT study, the inferior epigastric artery was observed to be larger in diameter, start more laterally, and move medially as it coursed superiorly.

CONCLUSIONS

These data corroborate our previous results and suggest that the safest level to instrument the rectus sheath (with respect to vascular anatomy) is at the TPP. Such information may be particularly relevant to anesthetists performing rectus sheath block and surgeons during laparoscopic port insertion.

Arterial Anatomy of the Anterior Abdominal Wall: Evidence-Based Safe Sites for Instrumentation Based on Radiological Analysis of 100 Patients

Multiple medical interventions require percutaneous instrumentation of the anterior abdominal wall, all of which carry a potential for vascular trauma. We assessed the presence, position, and size of the anterior abdominal wall superior and inferior (deep) epigastric arteries to determine the safest site with respect to vascular anatomy of the rectus sheath. In a review of 100 arterial phase, contrast-enhanced abdominal computed tomography scans, anterior abdominal wall arteries were assessed bilaterally at three axial planes: transpyloric, umbilicus, and anterior superior iliac spine (ASIS). The mean age of patients was 69.2 years (SD ± 15), with 62 male and 38 female. An artery was visible least frequently at the transpyloric plane (5%), compared with the umbilicus (72-79%) and ASIS (93-96%), on the left (χ² (4) = 207.272; P < 0.001) and right (χ² (4) = 198.553; P < 0.001), with a moderate strength association (Cramer's V = 0.588 (left) and 0.575 (right)). The arteries were most commonly observed within the rectus abdominis muscle at the level of the umbilicus and ASIS on both sides (62-68%). The inferior epigastric artery was observed to be larger in diameter, start more laterally, and move medially as it travelled superiorly. These data suggest that the safest site to instrument the rectus sheath, with respect to vascular anatomy, is at the transpyloric plane. This information on anatomical variation of the anterior abdominal wall vasculature may be of particular interest to anesthetists performing rectus sheath block and surgeons during laparoscopic port insertion. Clin. Anat. 33:350-354, 2020. © 2019 Wiley Periodicals, Inc.

Spontaneous Rectus Sheath Hematoma: An Uncommon Cause of Acute Abdominal Pain

BACKGROUND A clinical condition that is often misdiagnosed, rectus sheath hematoma (RSH) is usually seen in the context of blunt abdominal trauma and/or anticoagulation therapy, rarely occurring spontaneously. We present a case of spontaneous rectus sheath hematoma (SRSH) without obvious risk factors and review the literature regarding diagnosis modalities and management. The aim of this case presentation is to highlight this rare clinical condition and emphasize the role of the physical exam in determining the appropriate treatment approach.   CASE REPORT A 50-year-old woman presented to the emergency room with right-sided pelvic pain for one day. Her medical history was specifically notable for recent coughing due to acute bronchitis, as well as the use of NSAIDs. Physical examination revealed marked tenderness in the hypogastric and right lower quadrant, with guarding and fullness in the same area. Laboratory investigation showed mild anemia and normal coagulation tests. Computed tomography demonstrated a right rectus muscle hematoma measuring 8.5×8.5 cm and extending into the lower abdomen and the extraperitoneal space, without active contrast extravasation. Close monitoring of vital signs and hemoglobin hematocrit levels along with supportive care with fluid resuscitation and pain control were initiated and the patient remained stable throughout her hospital stay. CONCLUSIONS Prompt recognition and management of SRSH are crucial. Physical examination is a key part of this process and imaging is the mainstay of diagnosis. Management remains for the most part supportive, although surgery or vascular embolization is required for uncontrolled hematomas with hemodynamic instability.

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.