In a decompensated cirrhotic patient who underwent large‑volume paracentesis yesterday and now has position‑dependent pain localized to the puncture side, what is the most likely cause?

Post-Paracentesis Pain: Likely Causes and Management

The most likely cause of position-dependent pain localized to the puncture site one day after large-volume paracentesis is an abdominal wall hematoma, which occurs in approximately 52% of hemorrhagic complications following this procedure. 1

Primary Differential Diagnosis

Abdominal Wall Hematoma (Most Common)

• Abdominal wall hematomas represent the most frequent hemorrhagic complication of paracentesis, accounting for 52% of all bleeding complications in a systematic review of 61 patients. 1
• These hematomas typically present with localized pain at the puncture site that worsens with movement or position changes, as the hematoma stretches the abdominal wall fascia and peritoneum. 1
• The pain is characteristically worse when the patient moves or changes position because this increases tension on the injured tissue and expanding hematoma. 1
• Most abdominal wall hematomas are self-limited and resolve with conservative management, though close monitoring is essential to detect expansion or hemodynamic instability. 1

Hemoperitoneum (Second Most Common)

• Hemoperitoneum accounts for 41% of hemorrhagic complications following paracentesis and can present with flank or abdominal pain. 1
• Delayed retroperitoneal hemorrhage can occur even 2-3 days post-procedure, initially presenting with localized flank pain before progressing to hypotension and hemoglobin drop. 2
• The mechanism involves injury to intercostal arteries, inferior epigastric vessels, or other abdominal wall vasculature during needle insertion. 2, 3
• Since the bleeding source is typically venous, patients can initially be asymptomatic or have only mild localized pain before developing hemodynamic instability. 2

Pseudoaneurysm (Rare but Serious)

• Pseudoaneurysms represent only 7% of hemorrhagic complications but require urgent intervention. 1
• These typically result from arterial injury, most commonly to aberrant intercostal or epigastric arteries. 3

Critical Assessment Steps

Immediate Clinical Evaluation

• Check vital signs for tachycardia or hypotension, which would indicate active bleeding requiring urgent intervention. 2, 3
• Obtain hemoglobin/hematocrit and compare to pre-procedure values to assess for significant blood loss. 2, 3
• Examine the puncture site for visible hematoma, ecchymosis, or ongoing bleeding. 1
• Assess for peritoneal signs (rebound tenderness, guarding) which would suggest hemoperitoneum rather than isolated wall hematoma. 1, 2

Imaging When Indicated

• If hemoglobin is dropping or patient becomes hemodynamically unstable, obtain CT angiography of the abdomen immediately to identify the bleeding source and determine if active extravasation is present. 2, 3
• Ultrasound can identify abdominal wall hematomas but may miss retroperitoneal bleeding. 2

Management Algorithm

For Stable Patients with Localized Pain (Likely Abdominal Wall Hematoma)

• Conservative management with close observation is appropriate for stable patients with isolated abdominal wall hematomas. 1
• Monitor hemoglobin every 6-12 hours for the first 24-48 hours to detect delayed bleeding. 2
• Provide adequate analgesia while avoiding NSAIDs due to bleeding risk. 1
• Hold any anticoagulation therapy if the patient was receiving it, as anticoagulation significantly increases risk of expansion and mortality. 2

For Unstable Patients or Expanding Hematomas

• Transcatheter coiling and embolization by interventional radiology is superior to surgical intervention, with significantly lower 30-day mortality rates (65% success with IR versus 35% with surgery). 1
• Surgical intervention should be reserved for cases where IR is unavailable or unsuccessful. 1
• Patients requiring intervention have higher mortality, emphasizing the importance of prevention through proper technique. 1

Prevention Considerations for Future Procedures

Optimal Technique to Minimize Bleeding Risk

• The left lower quadrant (2 finger breadths cephalad and medial to the anterior superior iliac spine) is the preferred site due to thinner abdominal wall and larger fluid pool. 4
• The puncture site must be at least 8 cm from midline and 5 cm above the symphysis pubis to avoid inferior and superior epigastric arteries. 4
• Use ultrasound guidance when available to reduce adverse events, particularly in obese patients or those with prior abdominal surgery. 4
• Avoid visible collateral vessels, which can be present even in non-midline locations. 4

Critical Pitfall to Avoid

• Coagulopathy (elevated INR or low platelets) is NOT a contraindication to paracentesis and does not predict bleeding risk. 4
• Bleeding complications occur in less than 1 in 1,000 procedures, with most occurring in patients with renal failure rather than coagulopathy. 4
• The fatal case of hemoperitoneum from an aberrant intercostal artery occurred despite ultrasound guidance, highlighting that anatomic variants can cause complications even with proper technique. 3

Bottom Line for This Patient

Begin with conservative management while monitoring for signs of expansion or hemodynamic compromise. Check hemoglobin now and repeat in 6-12 hours. If stable with isolated wall pain and stable hemoglobin, this represents a self-limited abdominal wall hematoma requiring only observation and analgesia. 1 If hemoglobin drops >2 g/dL or patient develops hypotension/tachycardia, obtain CT angiography immediately and consult interventional radiology for possible embolization. 1, 2