Case report of a lady with ascites with rib pain treated successfully with intercostal nerve blocks
History of patient with rib pain secondary to ascites
I reviewed a patient in the clinic with sclerosis of the liver, which she had secondary to Hepatitis B. Despite anti-viral therapy and other treatments, she had developed very severe ascites manifest as a large volume of acidic fluid in her abdomen. This caused the abdomen to swell greatly with fluid and for her tissues to retain fluid including widespread oedema, particularly in the lower limbs.
The lady was particularly troubled by pain emanating from the 9th-12th ribs on the right side. She described getting sharp stabbing pains in this area, starting around the lateral part of the lower right rib cage, with electric shock-like pains and shooting forward. She also had a dull burning pain present continuously.
Examination findings in rib pain associated with ascites
On examination, this lady had widespread lower limb oedema. She also had a markedly enlarged abdomen secondary to her ascites and she was yellow from jaundice secondary to sclerosis of the liver.
On examination of the right lower ribs, there was evidence of increased pain from pin prick sensation (hyperalgesia) and pain from light touch (allodynia). A diagnosis of intercostal neuralgia was made.
Treatment of rib pain associated with ascites- intercostal nerve blocks
Treatment wise, unfortunately, given her severe liver disease, the majority of medications we wanted to use to help alleviate her intercostal neuralgia were contraindicated, as with such liver disease these drugs would not be metabolised and cleared, leading to potential adverse effects with their use.
I therefore decided to do a series of intercostal nerve blocks. The lady had intercostal nerve blocks performed under x ray guidance. A small amount of local anaesthetic was administered to the skin of the lower 4 ribs on the right.
A very fine needle was passed underneath the rib to lie adjacent to the intercostal nerve at the 9th, 10th, 11th and 12th ribs. A small amount of long acting local anaesthetic and Cortisone were then injected around the nerves.
The lady was reviewed 5 weeks later and I was extremely pleased to see that the pain had completely disappeared. She will be followed up in 3-4 months time.
