What is the approach to a patient with ascites and suspected internal hemorrhage?

Management of Ascites with Suspected Internal Hemorrhage

In patients with ascites and suspected internal hemorrhage, an immediate diagnostic paracentesis should be performed to confirm the diagnosis and guide treatment. 1

Diagnostic Approach

Initial Evaluation

• Perform an urgent diagnostic paracentesis to evaluate for hemorrhagic ascites 1
• Examine the gross appearance of ascitic fluid - hemorrhagic fluid appears bloody or dark red 1
• Send ascitic fluid for:
  • Cell count with differential 1
  • Albumin and total protein concentration for SAAG calculation 1
  • Bacterial culture (bedside inoculation into blood culture bottles) 1
  • Hematocrit of ascitic fluid if hemorrhagic 1

Additional Workup

• Obtain complete blood count, coagulation profile, and liver function tests 1
• Consider abdominal imaging (CT or ultrasound) to identify potential bleeding sources 2
• Evaluate hemodynamic status and monitor for signs of shock 1
• Consider diagnostic paracentesis even in patients with coagulopathy, as the risk of significant bleeding from the procedure is low (<1%) 1

Management Algorithm

Step 1: Resuscitation (if hemodynamically unstable)

• Establish large-bore IV access 1
• Administer crystalloids or colloids for volume expansion 1
• Consider blood product transfusion based on hemoglobin level and coagulation parameters 3
• Monitor vital signs closely 1

Step 2: Therapeutic Paracentesis

• Perform large-volume therapeutic paracentesis to remove hemorrhagic ascites 1
• Consider albumin replacement (8g per liter of fluid removed) for large-volume paracentesis 1
• The preferred site for paracentesis is the left lower quadrant, 3 cm cephalad and medial to the anterior superior iliac spine 1
• Avoid visible collaterals and the midline area 1

Step 3: Identify and Treat Underlying Cause

• For ruptured varices (common cause of hemorrhagic ascites):
  • Consider angiography with embolization 3, 2
  • Evaluate for TIPS (Transjugular Intrahepatic Portosystemic Shunt) if bleeding is from portal hypertension-related varices 1, 4
  • Note: TIPS should be used cautiously in patients with cardiac dysfunction 1
• For spontaneous bacterial peritonitis (which can trigger variceal bleeding):
  • Start empiric antibiotics (third-generation cephalosporins like cefotaxime) 1
  • Consider albumin administration (1.5 g/kg at diagnosis and 1 g/kg on day 3) 1

Step 4: Ongoing Management

• Monitor for rebleeding 3
• Manage underlying cirrhosis with sodium restriction (90 mmol/day) 1
• Initiate or adjust diuretic therapy once bleeding is controlled 1
• Consider liver transplantation evaluation for patients with decompensated cirrhosis 1, 4

Important Considerations and Pitfalls

• Do not delay paracentesis due to concerns about coagulopathy - studies show paracentesis is safe even with INR >2.0 and platelet counts <50,000/mm³ 1
• Avoid NSAIDs as they can worsen renal function and convert diuretic-sensitive ascites to refractory ascites 1
• Monitor electrolytes closely - hyponatremia may develop and requires careful management 1
• Be vigilant for hepatorenal syndrome - a common complication following hemorrhagic ascites 5
• Consider rare causes of hemorrhagic ascites such as ruptured splenic artery aneurysm in patients without clear evidence of cirrhosis 2

In patients with hemorrhagic ascites, the mortality risk is significant, and prompt diagnosis with immediate intervention is essential to improve outcomes 3, 4.