Hemorrhagic ascites from iatrogenic injury of the inferior epigastric artery

Case contributed by Dr Hoe Han Guan

Presentation

Hemorrhagic ascites from the paracentesis with sudden drop in hemoglobin level post procedure.

Patient Data

Age: 50 years
Gender: Male

On the non-contrast study, a few high-attenuating regions with attenuation number ranging from 60-70 HU were seen at the left external iliac region, left lumbar region (close to the anterolateral abdominal peritoneum) and left lower paracolic gutter, which are suggestive of acute clotted hemorrhage. These are likely to constitute "sentinel clot sign".

On arterial phase, vertical linear-like active contrast extravasation at the left lumbar region extends from the aforementioned acute clotted blood anteriorly to the left paracolic gutter posteriorly. Within the left lumbar anterolateral acute clotted hemorrhage, there is a spot of hyperdensity which has similar attenuation to the enhancement of artery, representing the "CT angiographic spot sign".

On portovenous and delay 5-minute phases, pooling of contrast noted at the left paracolic gutters.

Gross ascites. Multiple enhancing right pelvic and inguinal lymphadenopathy.

Viewing non-contrast, arterial, portovenous and delay phases in one view synchronously are very crucial for assessing the active contrast extravasation. Red arrow indicates active contrast extravasation on arterial phase. Green arrow indicates the pooling of contrast in portovenous phase.

CTA spot sign within the hematoma in the arterial phase is significant for urgent intervention.

Case Discussion

Intraoperatively, the culprit of the injured artery was identified to be one of the muscular branches from the left inferior epigastric artery, which was ligated and secured. Iatrogenic injury to the inferior epigastric artery and deep circumflex iliac artery are very common during abdominal paracentesis. 

This case highlights the importance of performing multi-phases for all patients presented with active bleeding to look for the source and evidence of acute bleeding.

Some of the useful signs to use while assessing the CT scan as demonstrated in this case are:

  • sentinel clot sign
  • assessing arterial phase for the active contrast extravasation and later looking for pooling of contrast in portovenous and delay phases
  • CTA spot sign has been well described for the cerebral hemorrhage, which is also well seen in this case.

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