What is the appropriate evaluation and management of vulvar swelling and bruising on the side of the needle insertion after large‑volume paracentesis for ascites?

Vulvar Swelling After Paracentesis: Evaluation and Management

Immediate Assessment

This is almost certainly post-paracentesis vulvar edema caused by ascitic fluid tracking through the needle tract into the subcutaneous tissues of the vulva, a rare but well-documented complication when the puncture site is in the lower abdomen. 1

Key Clinical Features to Confirm the Diagnosis

• Unilateral vulvar swelling developing within 12-24 hours after paracentesis when the lower abdomen was used as the puncture site 1
• The swelling occurs on the same side as the needle insertion 1
• Associated bruising or ecchymosis at the puncture site extending toward the vulva 1
• The mechanism involves a fistulous tract created by the puncturing needle through which ascitic fluid is forced by increased intra-abdominal pressure into subcutaneous tissues, presenting as unilateral vulvar edema 1, 2

Critical Differential Diagnoses to Rule Out

Before attributing this solely to fluid tracking, you must exclude:

• Abdominal wall hematoma (the most common hemorrhagic complication, occurring in 52% of bleeding cases after paracentesis) 3
• Hemoperitoneum (41% of hemorrhagic complications) 3
• Inferior epigastric artery injury with bleeding tracking to the vulva 4
• Retroperitoneal hemorrhage (can present with delayed symptoms and hypotension) 5

Immediate Evaluation Steps

Clinical Assessment

• Check vital signs immediately for hypotension or tachycardia suggesting active bleeding 5
• Examine the puncture site for expanding hematoma, active bleeding, or persistent fluid leak 4, 6
• Assess hemoglobin/hematocrit and compare to pre-procedure values to detect occult bleeding 5
• Palpate the vulvar swelling to distinguish between fluid (soft, fluctuant) versus hematoma (firm, tender) 1, 2

Imaging if Bleeding is Suspected

• Obtain CT angiography of the abdomen and pelvis if there is hemodynamic instability, significant drop in hemoglobin, or expanding hematoma to identify active bleeding source 5
• Ultrasound can help differentiate fluid collection from hematoma if CT is not immediately available 3

Management Algorithm

If This is Simple Fluid Tracking (No Active Bleeding)

Conservative management is the treatment of choice, as this complication is self-limited and resolves spontaneously within 7-10 days without late sequelae. 1, 2

• Scrotal/vulvar elevation to promote fluid drainage 2
• Continue diuretic therapy (spironolactone and furosemide at current doses) to prevent re-accumulation of ascites and reduce intra-abdominal pressure 2
• Reassure the patient that this will resolve within 10 days 1
• Monitor for signs of infection at the puncture site 6
• No surgical intervention is needed 1

If There is Active Bleeding or Hematoma

• Stop any anticoagulation immediately if the patient is receiving heparin or other anticoagulants 5
• Transfuse packed red blood cells if hemoglobin drops significantly or patient becomes hemodynamically unstable 5
• For expanding abdominal wall hematoma or hemoperitoneum with active bleeding on CT:
  • Interventional radiology with transcatheter coiling/embolization is superior to surgery and should be the first-line intervention 3
  • Surgical intervention (open or laparoscopic) has significantly higher 30-day mortality compared to IR-guided intervention 3
• Transfer to ICU for close monitoring if bleeding is confirmed 5

Management of Persistent Fluid Leak at Puncture Site

If there is ongoing ascitic fluid leakage from the puncture site:

• Position the patient on the opposite side (away from the puncture site) for 2 hours 4, 6
• Place a purse-string suture around the drainage site, which is one of the most effective methods to stop persistent leakage 4, 6

Prevention for Future Procedures

To prevent this complication in future paracenteses, use the upper abdomen (left upper quadrant) or ensure the puncture site is at least 8 cm from the midline and 5 cm above the symphysis pubis. 4, 1

• Avoid the lower abdomen as the puncture site, as this phenomenon was not observed when paracentesis was performed through the upper abdomen 1
• Use ultrasound guidance to reduce adverse events by 68% 4
• Employ the Z-track technique to ensure puncture sites on skin and peritoneum don't directly overlie each other 6

Common Pitfalls to Avoid

• Do not assume coagulopathy caused the problem – bleeding complications occur in <1/1000 procedures and are more common in renal failure than coagulopathy 4
• Do not delay imaging if bleeding is suspected – retroperitoneal hemorrhage can present with delayed symptoms hours after the procedure 5
• Do not perform surgical exploration as first-line treatment for hemorrhagic complications – IR-guided intervention has superior outcomes 3
• Do not discontinue diuretics unless there is hemodynamic instability, as they are needed to prevent ascites re-accumulation 4, 2