Guzman Rojas Patricia, Sachdeva Reetika, Blonski Wojtek
Internal Medicine, University of Central Florida College of Medicine, Orlando, USA.
Gastroenterology, University of Central Florida College of Medicine, Orlando, USA.
Cureus. 2019 Mar 1;11(3):e4167. doi: 10.7759/cureus.4167.
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.
大量腹腔穿刺放液（LVP）是指抽取超过4升的腹水。该操作可能导致出血、感染、肠穿孔、循环衰竭或腹水渗漏等并发症。腹腔穿刺引起的出血主要表现为腹壁血肿。一名81岁男性，有肥胖和糖尿病病史，因意识模糊、新发黑便和尿臭入住我院。检查发现他仅对人物有定向力，腹部膨隆，液波震颤阳性，直肠指检有柏油样便。实验室检查结果显示全血细胞减少、低白蛋白血症、天冬氨酸转氨酶（AST）升高至43 U/L以及D-二聚体水平升高。尿液分析异常，白细胞（WBC）>180，白细胞酯酶和亚硝酸盐呈阳性。肝脏超声显示肝硬化。因上消化道（GI）出血和肝硬化开始使用奥曲肽静脉滴注、头孢曲松、乳果糖和泮托拉唑治疗。胸部计算机断层血管造影（CTA）显示双侧节段性肺栓塞呈阳性，因此，他也开始接受肝素静脉滴注。入院第5天，在超声引导下进行腹腔穿刺放液，抽取了6升腹水。入院第7天，患者出现急性左侧腰痛，并伴有低血压发作和血红蛋白下降。腹部CTA显示左腹膜后出血，但无活动性出血迹象。停用肝素静脉滴注，患者被转入重症监护病房（ICU）。患者入住ICU后的几天里血红蛋白稳定，不再需要输注浓缩红细胞。尽管因出血事件停用了肝素，但他的呼吸状况稳定。由于再次出血风险高，他未接受抗凝治疗而出院。导致静脉曲张出血的一种推测机制是由于腹压降低导致内脏循环迅速减压。由于出血来源是静脉，最初患者可能无症状。治疗可以是保守的、手术的或通过经导管干预。我们想强调，对于接受大量腹腔穿刺放液的患者，尤其是在抗凝治疗的情况下，需要密切监测，因为生存取决于早期诊断和治疗。需要提及的是，国际标准化比值（INR）既不是可靠的抗凝检测指标，也不是肝硬化患者出血的预测因素。
