Case Study: Post Paracentesis Syndrome

Summary

Many people with ascites secondary to liver disease have undergone paracentesis for symptomatic relief, for breathing difficulty due to their greatly increased abdominal girth preventing respiratory movements. A 43-year-old male, a known case of liver cirrhosis with intra-abdominal ascites, underwent paracentesis after confirming an empty bladder, and he returned the next day with bilateral scrotal fluctuant swelling. The swelling was brilliantly transilluminant. There was a definite positive cross-fluctuation sign. The swelling was not tense, nor was it organized to any one particular side. Testes were palpable separately. He was diagnosed to have Post Paracentesis Syndrome.

Background

Liver cirrhosis is a common and frequent problem throughout the world, with varying levels of morbidity affecting the patient. One of the major problems with cirrhosis is the development of refractory ascites, which causes further problems, especially with respiration if the quantity of fluid is great enough. Paracentesis is one of the commonly-used procedures to relieve the pressure on the chest and ease the effort of breathing. However, in rare instances, paracentesis can lead to complications and hamper the good that was meant to be done. Post paracentesis syndrome is one such complication which can occur, causing more distress than relief, even though it is not life threatening in any way.

Case Presentation

A 43-year-old male known to suffer from chronic liver cirrhosis presented to our centre with intra-abdominal ascites of long-standing duration. He was suffering from difficulty in breathing due to his greatly increased abdominal girth causing pressure on the chest wall, thereby leading to respiratory distress, bordering on respiratory acidosis.

Routine investigations were within normal limits with a normal level of haemoglobin and white cell count. His liver function tests revealed raised bilirubin and liver enzymes consistent with cirrhosis of the liver.

It was decided to intervene with the intention of improving his respiratory status. He underwent therapeutic paracentesis after confirming an empty bladder and under strict aseptic precautions. The abdomen was cleaned with Betadine and spirit, and a point located 5 cm above and medial to the anterior superior iliac spine was chosen for the site of puncture. An 18 gauge needle was inserted without local anaesthesia into the peritoneal cavity. A sample of 20 cc was aspirated and sent for microbiological examination. Following this, approximately one litre of fluid was removed from the abdominal cavity.

The patient tolerated the procedure well. He was discharged the same evening and was told to come for a repeat aspiration after 2 weeks, or on recurrence of respiratory distress.

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He returned the next day to the centre with complaints of bilateral scrotal fluctuant swellings. On physical examination, he was afebrile, breathing comfortably with an SpO2 of 98% on room air, with the only complaint being the scrotal swellings. The swelling was brilliantly transilluminant. There was a definite positive cross-fluctuation sign. The swelling was not tense, nor was it organized to any one particular side. Testes were palpable separately.

Scrotal OedemaBilateral Scrotal Oedema mimicking bilateral hydrocele

An ultrasound scan revealed a large anechoic communicating swelling, extending from the abdominal cavity to the scrotum. Both testes were visualized separately from the swelling, and there was no solid component.

Differential Diagnosis

Bilateral Hydrocele

Treatment

A decision was reached to treat the condition with conservative management. A tight scrotal support was applied, and the patient was asked to rest at home with minimal movement. Anti-inflammatory medication was given, to be taken in case of pain on an as-required basis. He was advised to follow up in the outpatient department for continued aspiration of his ascites periodically, on an interval schedule for two weeks.

Outcome and Follow Up

There was no oedema remaining on the 7th day after the procedure. There was no pain or inflammation, and the condition subsided completely. There was no need for surgical intervention or further aspiration of the scrotal swelling.

Discussion

An overview of Post Paracentesis Syndrome can be found in the paper, Sudden Scrotal Edema in Cirrhosis: A Postparacentesis Syndrome by Harold Conn. He explains that the cause of the syndrome in these cases, as well as the possibility of occurrence from other causes in non-cirrhotic patients. (4)

Other examples of similar instances include:

  • Downward tracking of pancreatic fluid into the scrotum, described in 1979 in USSR. (1)
  • A case of a fistulous tract created between the peritoneal cavity and subcutaneous tissue leading to massive vulvar oedema, 24 hours after lower abdominal paracentesis in a woman undergoing infertility treatment. (5)
  • A prospective study of 125 patients receiving paracentesis found very few major or minor complications. No patients in the study contracted bacterial peritonitis, and no patients died as a result of the complications. (3)

Such cases can be managed conservatively, since surgical exploration would add to the morbidity. (2)

Key Point

In conclusion, we would like to state that being aware of such a possibility can prevent misdiagnosis and unnecessary, expensive investigations and treatments.

Paracentesis is a safe procedure, carrying <1% risk of major complications and <1% risk of minor complications.

Fear of complications of the procedure should not preclude performing a paracentesis, provided certain precautions are taken.

Scrotal wall oedema following paracentesis can be treated conservatively if diagnosed correctly, and it does not require surgical intervention or aspiration of the swelling.

About The Author

Dheeraj MalchandaniDr. Dheeraj V. Mulchandani M.B.B.S., M.S., D.M.A.S. F.A.L.B.S. is currently an Associate Consultant in General and Laparoscopic Surgery and Hospital Administrator in South Mumbai.  He also has an M.B.A. in Corporate Management in Healthcare and Hospital Administration and is the Medical Director for Dr. Mulchandani’s Medical Services.

 

References (click to show/hide)

  1. Zimin AF, Satsukevich VN, Molchanov NP, Acute pancreatitis with hemorrhagic flow into the scrotum. Vestin Khir Im II Grek 1979, 122; 47-48
  2. Lee AD, Abraham DT, Agarwal S, Perakath B, The scrotum in Pancreatitis: JOI, J. Pancreas 2004, 5 (5), 357-359
  3. Runyon BA, ‘Paracentesis of Ascitic Fluid: A Safe Procedure’, Arch Internal Med. 1986, 146: 2259-61
  4. Harold O. Conn; Annals Internal Med. 1971 Vol. 74 No. 6 943-45. ‘Sudden scrotal oedema in cirrhosis: A Postparacentesis Syndrome’
  5. Dimitrios Vavilis, M.D., Stergios Tzitzimikas, Theodoros Agorastos, Aristotelis Loufopoules, Trifen Tsalikis, John N Bontis. Postparacentesis bilateral massive vulvar edema in a patient with severe ovarian hyperstimulation syndrome. Fertility and Sterility – April 2002 Vol. 77, Issue 4, Pg. 841-43


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2 Comments

  1. samir kapadia
    Posted May 2014 at 2:54 pm | Permalink

    Excellent article
    Very well presented

  2. DR Dheeraj V. Mulchandani
    Posted May 2014 at 4:55 am | Permalink

    Thank you!

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