{"id":2380,"date":"2021-10-06T13:54:23","date_gmt":"2021-10-06T11:54:23","guid":{"rendered":"https:\/\/angh.net\/abstracts\/complications-hemorragiques-severes-apres-ponctions-dascite-therapeutiques\/"},"modified":"2021-10-06T13:54:23","modified_gmt":"2021-10-06T11:54:23","slug":"complications-hemorragiques-severes-apres-ponctions-dascite-therapeutiques","status":"publish","type":"post","link":"https:\/\/angh.net\/abstracts\/complications-hemorragiques-severes-apres-ponctions-dascite-therapeutiques\/","title":{"rendered":"Complications h\u00e9morragiques s\u00e9v\u00e8res apr\u00e8s ponctions d\u2019ascite th\u00e9rapeutiques."},"content":{"rendered":"

2021<\/strong><\/p>\n

Charlotte Vanveuren (1), Ambroise Lalieu (1), Xavier Pauwels (2), Benjamin Le Coq (3), Elodie Warmoes (1), Faustine Wartel (1), Arnaud Boruchowicz (1).<\/p>\n

Services des Maladies de L\u2019Appareil Digestif (1), de Radiologie Interventionnelle (2) et de Chirurgie Visc\u00e9rale (3). Centre Hospitalier de Valenciennes.<\/em><\/p>\n

Gastroent\u00e9rologie <\/strong>– \u00a02021-05-20 –\u00a0CO –<\/p>\n

________________________________<\/p>\n

La ponction d\u2019ascite (diagnostique et th\u00e9rapeutique) est un acte r\u00e9alis\u00e9 r\u00e9guli\u00e8rement dans les services d\u2019h\u00e9patogastroent\u00e9rologie en hospitalisation conventionnelle et de jour. Les complications majeures sont constitu\u00e9es par les h\u00e9morragies et les infections (2). Les complications h\u00e9morragiques de la ponction d\u2019ascite sont consid\u00e9r\u00e9es comme rares mais peuvent engager le pronostic vital (1). Nous rapportons 3 observations de complication h\u00e9morragique suite \u00e0 une ponction d\u2019ascite.
\nLe premier cas est celui d\u2019une patiente de 65 ans pr\u00e9sentant une cirrhose compliqu\u00e9e d\u2019une ascite r\u00e9fractaire et des ponctions d\u2019ascite hebdomadaires \u00e9taient r\u00e9alis\u00e9es sans complication. Elle pr\u00e9sentait une thrombop\u00e9nie \u00e0 67000\/mm3 et une insuffisance r\u00e9nale chronique (DFG 28ml\/min) Le score de CHILD \u00e9tait \u00e0 B9 et le MELD \u00e0 21.
\nEn janvier 2016 une nouvelle ponction est r\u00e9alis\u00e9e de 10 litres d\u2019un liquide citrin sans complication imm\u00e9diate. Au retrait du cath\u00e9ter une h\u00e9morragie \u00e9tait mise en \u00e9vidence avec un saignement actif en regard du point de ponction.
\nUn bilan biologique r\u00e9alis\u00e9 en urgence mettait en \u00e9vidence une perte de 2 points du taux d\u2019h\u00e9moglobine en 3 heures. Un scanner avec injection permettait de mettre en \u00e9vidence un h\u00e9matome de 25 cm et une h\u00e9morragie active art\u00e9rielle au d\u00e9pend d\u2019une branche de l\u2019art\u00e8re iliaque externe gauche. Une embolisation \u00e9tait r\u00e9alis\u00e9e permettant l\u2019h\u00e9mostase. L\u2019\u00e9volution \u00e9tait favorable. De nouvelles ponctions d\u2019ascite, sous rep\u00e9rage \u00e9chographique, \u00e9taient r\u00e9alis\u00e9es en h\u00f4pital de jour sans complication avec un recul de 2 ans. La patiente est d\u00e9c\u00e9d\u00e9e deux ans apr\u00e8s d\u2019une insuffisance r\u00e9nale aigue dans un contexte de syndrome h\u00e9pato r\u00e9nal.<\/p>\n

La deuxi\u00e8me observation est celle d\u2019un homme de 57 ans pr\u00e9sentant une r\u00e9cidive de cirrhose alcoolique apr\u00e8s une transplantation h\u00e9patique effectu\u00e9e en Avril 2012 pour h\u00e9patite aigue alcoolique s\u00e9v\u00e8re.
\nDes ponctions d\u2019ascites \u00e9taient n\u00e9cessaires \u00e0 partir de f\u00e9vrier 2020 pour ascite r\u00e9fractaire. Il existait une insuffisance r\u00e9nale chronique avec un DFG \u00e0 61 ml\/min. Le score de CHILD \u00e9tait \u00e0 C13 avec un MELD \u00e0 27. Les plaquettes \u00e9taient \u00e0 63000\/mm3.
\nLe 6 juillet 2020 il b\u00e9n\u00e9ficie d\u2019une ponction d\u2019ascite \u00e9vacuatrice. A la fin de la ponction, le patient pr\u00e9sente une douleur abdominale, une hypotension art\u00e9rielle avec un \u00e9tat de choc r\u00e9fractaire au remplissage. Le bilan biologique r\u00e9alis\u00e9 en urgence mettait en \u00e9vidence une an\u00e9mie avec un taux d\u2019h\u00e9moglobine \u00e0 5.7 g\/dl. Un scanner avec injection mettait en \u00e9vidence un h\u00e9mop\u00e9ritoine avec un saignement actif au temps veineux en regard de la goutti\u00e8re parieto-colique gauche.
\nDevant l\u2019absence de possibilit\u00e9 d\u2019embolisation et l\u2019instabilit\u00e9 h\u00e9modynamique une prise en charge chirurgicale \u00e9tait d\u00e9cid\u00e9e et une transfusion de 6 concentr\u00e9s \u00e9rythrocytaires \u00e9tait r\u00e9alis\u00e9e.
\nUne laparotomie \u00e9tait r\u00e9alis\u00e9e. Un saignement intrap\u00e9riton\u00e9al \u00e9tait confirm\u00e9. L\u2019\u00e9volution \u00e9tait d\u00e9favorable conduisant au d\u00e9c\u00e8s du patient.
\nLe dernier cas est celui d\u2019un homme de 31 ans, suivi pour une cirrhose alcoolique, sevr\u00e9e compliqu\u00e9e d\u2019ascite r\u00e9fractaire, avec un projet de TIPS en cours.
\nLa cirrhose \u00e9tait class\u00e9e CHILD B7 avec un MELD \u00e0 12. Le taux de plaquettes \u00e9tait \u00e0 166000\/mm3, la fonction r\u00e9nale \u00e9tait normale.
\nUne ponction d\u2019ascite est r\u00e9alis\u00e9e en h\u00f4pital de jour le 18 avril 2018 (\u00e9vacuation de 8 L). Le patient se pr\u00e9sente le 25 avril dans notre service pour douleur abdominale. L\u2019examen clinique met en \u00e9vidence une voussure abdominale. Le patient ne pr\u00e9sente pas de signes de choc. Sur le plan biologique il existe une an\u00e9mie (h\u00e9moglobine \u00e0 10.2 g\/dl contre 11.8 g\/dl le 18 avril). Il b\u00e9n\u00e9ficie d\u2019un scanner abdomino-pelvien qui r\u00e9v\u00e8le un h\u00e9matome avec un pseudoan\u00e9vrysme de l’art\u00e8re \u00e9pigastrique inf\u00e9rieure gauche d\u00e9velopp\u00e9e dans le muscle grand droit gauche. Le lendemain une embolisation du pseudoan\u00e9vrysme \u00e9tait r\u00e9alis\u00e9e avec des suites favorables. <\/p>\n

A notre connaissance il n\u2019y a pas de facteurs de risque clairement identifi\u00e9s du risque h\u00e9morragique apr\u00e8s ponction dans la litt\u00e9rature. Il a \u00e9t\u00e9 mis en \u00e9vidence une possible augmentation du risque de complications h\u00e9morragiques de la ponction d\u2019ascite au cours de la cirrhose en cas de MELD ou de CHILD \u00e9lev\u00e9 ou d\u2019insuffisance r\u00e9nale (1,2). Dans une revue de la litt\u00e9rature regroupant 61 patients avec complication h\u00e9morragique on observait la pr\u00e9sence dans 59 % des cas d\u2019un INR>2, dans 8 % des cas une thrombop\u00e9nie s\u00e9v\u00e8re (d\u00e9finie par un taux de plaquettes < 50,000\/\u00b5L) et dans 70 % des cas une insuffisance r\u00e9nale (d\u00e9finie par un DFG <60 ml\/min) (3). Dans cette \u00e9tude la mortalit\u00e9 \u00e0 J30 \u00e9tait de 43.3 % (3). \nLa ponction d\u2019ascite est consid\u00e9r\u00e9e comme un geste \u00e0 faible risque de complication (1,4,5). Notre exp\u00e9rience rappelle qu\u2019une surveillance pendant et apr\u00e8s la ponction est n\u00e9cessaire car il existe un risque de complication h\u00e9morragique pouvant engager le pronostic vital. Un angioscanner abdominal en urgence doit \u00eatre r\u00e9alis\u00e9 pour rep\u00e9rer le vaisseau responsable du saignement et discuter l\u2019indication d\u2019une embolisation.\nDes complications \u00e0 distance sont possibles justifiant d\u2019informer les patients de la n\u00e9cessit\u00e9 d\u2019une nouvelle consultation en urgence en cas de douleur abdominale post ponction.\n<\/p>\n","protected":false},"excerpt":{"rendered":"

2021 Charlotte Vanveuren (1), Ambroise Lalieu (1), Xavier Pauwels (2), Benjamin Le Coq (3), Elodie Warmoes (1), Faustine Wartel (1), Arnaud Boruchowicz (1). Services des Maladies de L\u2019Appareil Digestif (1), de Radiologie Interventionnelle (2) et de Chirurgie Visc\u00e9rale (3). Centre Hospitalier de Valenciennes. Gastroent\u00e9rologie – \u00a02021-05-20 –\u00a0CO – ________________________________ La ponction d\u2019ascite (diagnostique et th\u00e9rapeutique) […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"footnotes":""},"categories":[4],"tags":[34],"class_list":["post-2380","post","type-post","status-publish","format-standard","hentry","category-gastroenterologie","tag-34"],"yoast_head":"\nComplications h\u00e9morragiques s\u00e9v\u00e8res apr\u00e8s ponctions d\u2019ascite th\u00e9rapeutiques. - Abstracts des congr\u00e8s de l'ANGH<\/title>\n<meta name=\"description\" content=\"ANGH R\u00e9sum\u00e9s congr\u00e8s H\u00e9patologie Gastroent\u00e9romogie Hepatology Gastroenterology Etudes cliniques Clinical study\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/angh.net\/abstracts\/complications-hemorragiques-severes-apres-ponctions-dascite-therapeutiques\/\" \/>\n<meta property=\"og:locale\" content=\"fr_FR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Complications h\u00e9morragiques s\u00e9v\u00e8res apr\u00e8s ponctions d\u2019ascite th\u00e9rapeutiques. - 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