Hemorrhagic Complications of Paracentesis: Aberrant Anatomy Versus Aberrant Technique - A Fatal Case of Abdominal Hemoperitoneum

Large-volume paracentesis carries roughly a 1% risk of overall complications. Hemorrhagic complications are classified as abdominal wall hematomas, pseudoaneurysms, and hemoperitoneum. Severe hemorrhage is rare (<0.2%), with death following this complication seen in <0.02% of cases. We present a fatal case of an ultrasound-guided paracentesis leading to subsequent hemoperitoneum from an aberrant intercostal artery, causing hemorrhagic shock and death. A 47-year-old black male with decompensated alcoholic cirrhosis, model for end-stage liver disease (MELD) score of 22, and Child-Pugh class C presented with a distended abdomen, international normalized ratio (INR) 1.9, and hemoglobin 9.6 g/dL. An ultrasound-guided therapeutic paracentesis was performed in the right lower quadrant with 50 mL intravenous albumin given after 4 L of uncomplicated ascitic fluid removal. The patient became hypotensive, tachycardic, and placed on pressor support medication within 12 hours after the procedure. After a complex hospital course, the patient passed away on hospital day 10 after multisystem organ failure. The patient was found to have an aberrant intercostal artery bleed secondary to the paracentesis procedure causing an abdominal hemoperitoneum.