Update October 23, 2017

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Paracentesis is a procedure that involves removing ascitic fluid from the abdominal cavity with a needle or catheter. Using local anesthesia, hospitalists, other internists, Emergency Medicine physicians, proceduralists, and radiologists perform this procedure in either an outpatient or inpatient setting. A diagnostic paracentesis can determine the cause of ascites and rule out spontaneous bacterial peritonitis. A therapeutic paracentesis will remove excess fluid.

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Dating back to the time of Hippocrates, paracentesis using large bore catheters was the only available option to remove ascitic fluid. In the 1950s, oral diuretics and sodium restriction were introduced as a safer alternative, typically requiring an extended hospital stay. In the mid 1980s, large-volume paracentesis was reintroduced without plasma expanders and was once again deemed a safe practice that would not cause a change in plasma volume. Abdominal imaging has replaced the practice of evaluating abdominal trauma by performing a diagnostic paracentesis.

 

Diagnostic paracentesis is indicated for patients who have new ascites or who have been hospitalized for a complication of cirrhosis; it reduces mortality, especially if performed within 12 hours of admission (eFigures 16–31and 16–32).

Serious complications of paracentesis, including bleeding, infection, or bowel perforation, occur in 1.6% of procedures and are associated with therapeutic (vs diagnostic) paracentesis and possibly with Child-Pugh class C, a platelet count less than 50,000/mcL (50 × 109/L), and alcoholic cirrhosis. In patients with coagulopathy, however, pre-paracentesis prophylactic transfusions do not appear to be necessary. In addition to a cell count and culture, the ascitic albumin level should be determined: a serum-ascites albumin gradient (serum albumin minus ascitic fluid albumin) greater than or equal to 1.1 suggests portal hypertension. An elevated ascitic adenosine deaminase level is suggestive of tuberculous peritonitis, but the sensitivity of the test is reduced in patients with portal hypertension. Occasionally, cirrhotic ascites is chylous (rich in triglycerides); other causes of chylous ascites are malignancy, tuberculosis, and recent abdominal surgery or trauma.

 

 

When should you use ultrasound guidance or involve interventional radiology?

  • When should you correct a coagulopathy?

  • What is the role of albumin administration?

  • What is the best site location to enter to reduce the risk of complications?

 

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