Case Presentation: A 34-year-old man with decompensated cirrhosis secondary to chronic hepatitis C (MELD 21) presented with a chief complaint of severe abdominal pain. He routinely received outpatient paracentesis weekly, which was last performed 4days prior to symptom onset. He noted that his chronic large anterior abdominal wall hernia was usually reducible, but had not been easily reduced for 24hrs prior to presentation.
His physical exam was notable for a 1-cm umbilical hernia with overlying erythema and ascites with a fluid wave. General surgery was able to reduce the hernia at the bedside and applied a bolster and binder. He was admitted to the General Medicine service for management of ascites.
After creatinine rose (1.2 to 1.7) with an increase in diuretic dosing, the Hospital Medicine Bedside Procedure Service was consulted for 4L paracentesis. A 4-cm pocket of freely-flowing fluid was identified in the left lower quadrant, and the fluid was removed without immediate complication. The patient did not have any abdominal pain during or immediately after the procedure.
However, seven hours after paracentesis, the patient notified his nurse of recurrent abdominal pain similar to presentation. He was quickly assessed by the surgical team, who attempted unsuccessfully to reduce his umbilical hernia. He was taken for urgent herniorrhaphy. Intra-operatively, the patient was noted to have ecchymotic, but viable, bowel without devitalized areas. He tolerated surgery well and had no post-operative complications or recurrent hernia. The incarcerated hernia was disclosed to the patient as a likely complication of his most recent paracentesis.
Discussion: Umbilical hernias are commonly seen in patients with decompensated cirrhosis; the overall prevalence has been documented as approximately 20% in patients with ascites. Since umbilical herniorrhaphy in the setting of cirrhosis is associated with significant morbidity and mortality (up to 30% or higher depending on MELD), it is not often performed electively. Refractory ascites in the setting of decompensated cirrhosis is commonly managed by hospital medicine.
The commonly cited major complications of paracentesis include hemorrhage, infection, and bowel perforation, all with frequency of less than 1%. Data has not been published regarding rates of incarceration of umbilical hernia associated with large-volume paracentesis, though a pathophysiologic mechanism has been proposed: decompression during LVP reduces the diameter of the hernia ring, leading to trapping of hernia sac contents. Case report data suggests this complication occurs within 48hrs of the procedure. Umbilical hernia incarceration has also been reported after aggressive medical therapy of ascites, transjugular-intrahepatic portosystemic (TIPS) and peritoneovenous shunt placement.
Conclusions: Although incarceration of an umbilical hernia is a rare complication of bedside paracentesis, both the presence of umbilical hernias and the need for inpatient therapeutic paracentesis in this population are common. As such, hospitalists should be aware of this potential complication and assess for the presence of umbilical hernias before the procedure. If present, it has been suggested that an attempt should be made to reduce the hernia prior to fluid removal and to provide anticipatory guidance to the patient or primary providers to remain vigilant for signs and symptoms of incarceration including pain, distension or an irreducible, tender and erythematous hernia site.