How to Check for Abdominal Wall Hematoma After Paracentesis
If you suspect an abdominal wall hematoma after paracentesis, immediately perform bedside ultrasound to visualize the hematoma and assess for active bleeding, as this is the fastest and most practical diagnostic tool that can be repeated serially to monitor hematoma size. 1, 2
Clinical Recognition
Key Signs and Symptoms to Assess
- Severe abdominal pain localized to the puncture site, particularly in the lateral abdominal wall, which may develop immediately or within hours after the procedure 1, 3
- Visible or palpable abdominal wall mass that is painful and may be enlarging 2
- Hemodynamic instability including tachycardia, hypotension, or signs of ongoing blood loss requiring urgent intervention 4
- Drop in hemoglobin/hematocrit on serial blood draws if bleeding is significant 4
Diagnostic Imaging Approach
First-Line: Bedside Ultrasound
- Perform ultrasound immediately at the bedside to visualize the hematoma within the abdominal wall layers (subcutaneous tissue, oblique muscles, or rectus sheath) 1, 2
- Use serial ultrasound examinations to monitor hematoma size over time, as this is the most practical method for tracking progression or resolution 1
- Ultrasound can identify the location (lateral wall vs. rectus sheath) and approximate size of the collection 2
Second-Line: CT Abdomen and Pelvis with IV Contrast
- Order emergent CT with IV contrast if the patient shows signs of hemodynamic instability, ongoing pain, or if ultrasound suggests active bleeding 1, 3
- CT findings indicating active bleeding include contrast extravasation (active blush) within the hematoma, which suggests ongoing arterial injury requiring intervention 1, 3
- CT provides superior anatomic detail to identify the specific injured vessel (most commonly the inferior epigastric artery or deep circumflex iliac artery) 3, 4
- High-attenuation or mixed-attenuation hematoma on CT suggests acute or ongoing bleeding 5
Common Vascular Injuries to Identify
Most Frequently Injured Vessels
- Inferior epigastric artery (runs in the rectus sheath, midway between pubis and anterior superior iliac spine) is the most common source when puncture is too medial 5, 6, 4
- Deep circumflex iliac artery (lateral abdominal wall) can be injured with lateral puncture sites 1, 3
- Superficial inferior epigastric artery (subcutaneous layer) is a less common but recognized source 7
When to Escalate to Angiography
Indications for Emergent Angiography
- CT demonstrates active contrast extravasation indicating ongoing arterial bleeding 1, 3
- Hemodynamic instability despite resuscitation with fluids and blood products 4
- Rapidly expanding hematoma on serial ultrasound or clinical examination despite conservative management 1, 4
- Failure of conservative management with persistent pain, transfusion requirements, or hemoglobin drop 4
Angiography serves both diagnostic and therapeutic purposes, allowing immediate transcatheter arterial embolization with coils or gelfoam to control bleeding 1, 3, 4
Critical Pitfalls to Avoid
- Do not delay imaging if the patient complains of severe pain at the puncture site, even if vital signs are initially stable, as hematomas can expand rapidly 1, 4
- Do not assume coagulopathy caused the bleeding—most abdominal wall hematomas after paracentesis result from direct arterial injury, not coagulopathy, and occur in <1% of procedures 5
- Do not perform unnecessary surgery—angiographic embolization is the preferred intervention for arterial bleeding and avoids surgical morbidity 1, 4
- Recognize that bleeding can occur despite normal coagulation parameters, as the mechanism is mechanical vessel injury rather than coagulopathy 5