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Paracentesis

  • Author: Gil Z Shlamovitz, MD, FACEP; Chief Editor: Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS  more...
 
Updated: Aug 17, 2015
 

Background

Paracentesis is a procedure in which a needle or catheter is inserted into the peritoneal cavity to obtain ascitic fluid for diagnostic or therapeutic purposes.[1, 2] Ascitic fluid may be used to help determine the etiology of ascites, as well as to evaluate for infection or presence of cancer. With regard to differentiation of transudate from exudate, the preferred means for characterizing ascites is the serum-ascitic albumin gradient (SAAG).[3]

The SAAG is calculated by subtracting the albumin concentration of the ascitic fluid from the albumin concentration of a serum specimen obtained on the same day. The SAAG correlates directly with portal pressure. Transudative ascites occurs when a patient's SAAG level is greater than or equal to 1.1 g/dL (portal hypertension). Exudative ascites occurs when patients have SAAG levels lower than 1.1 g/dL. (See the Ascites Albumin Gradient calculator.)

Causes of transudative ascites include the following:

Causes of exudative ascites include the following:

Spontaneous bacterial peritonitis

Infection of ascitic fluid without intra-abdominal infection usually occurs in patients with chronic liver disease due to translocation of enteric bacteria. Common pathogens include Escherichia coli, Klebsiella pneumoniae, enterococcal species, and Streptococcus pneumoniae.[4] Patients with renal failure who use abdominal peritoneal dialysis are also at increased risk, as are children with nephrosis or systemic lupus erythematosus. Anaerobic bacteria are not associated with spontaneous bacterial peritonitis (SBP).

An ascitic fluid polymorphonuclear leukocyte (PMN) count higher than 250/μL (neutrocytic ascites), with the percentage of PMNs in the fluid usually greater than 50%, is presumptive evidence of SBP. Patients whose level meets these criteria should be treated empirically, regardless of symptoms. Secondary bacterial peritonitis is defined as infected ascitic fluid associated with an intra-abdominal infection.

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Indications

Diagnostic tap is used for the following:

  • New-onset ascites - Fluid evaluation helps to determine etiology, differentiate transudate versus exudate, detect the presence of cancerous cells, or address other considerations
  • Suspected spontaneous or secondary bacterial peritonitis

Therapeutic tap is used for the following:

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Contraindications

An acute abdomen that requires surgery is an absolute contraindication.

Severe thrombocytopenia (platelet count <20 × 103/μL) and coagulopathy (international normalized ratio [INR] >2.0) are relative contraindications.

Patients with an INR greater than 2.0 should receive fresh frozen plasma (FFP) prior to the procedure. One strategy is to infuse one unit of fresh frozen plasma before the procedure and then perform the procedure while the second unit is infusing.

Patients with a platelet count lower than 20 × 103/μL should receive an infusion of platelets before the procedure.

In patients without clinical evidence of active bleeding, routine laboratory tests such as prothrombin time (PT), activated partial thromboplastin time (aPTT), and platelet counts may not be needed before the procedure.[5] In these patients, pretreatment with FFP, platelets, or both before paracentesis is also probably not needed.

A study of 608 patients (72% with alcohol-related liver disease) found a low overall rate of complications that required transfusions (0.2%) and a higher incidence of significant hemoglobin drop among those with severe renal failure (creatinine > 6 mg/dL).[5]

A prospective study of 171 patients undergoing paracentesis found that "major" complications occurred in 1.6% of procedures and included five episodes of bleeding and three infections, resulting in death in two cases. Major complications were associated with therapeutic but not diagnostic procedures and tended to be more prevalent in patients with low platelet counts (<50 × 109/L), patients who were Child-Pugh stage C, and patients with alcoholic cirrhosis.[6]

Other relative contraindications include the following:

  • Pregnancy
  • Distended urinary bladder
  • Abdominal wall cellulitis
  • Distended bowel
  • Intra-abdominal adhesions
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Technical Considerations

Best practices

Depending on the clinical situation, fluid may be sent for the following laboratory tests:

  • Gram stain - In a retrospective review of 796 peritoneal fluid samples, the evaluation of Gram stain results rarely provided clinically useful information for the detection of spontaneous bacterial peritonitis [7]
  • Cell count (elevated counts may suggest infection)
  • Bacterial culture
  • Total protein level
  • Triglyceride levels (elevated in chylous ascites)
  • Bilirubin level (may be elevated in bowel perforation)
  • Glucose level
  • Albumin level, used in conjunction with serum albumin levels obtained the same day (used to calculate SAAG; see the Ascites Albumin Gradient calculator)
  • Amylase level (elevation suggests pancreatic source)
  • Lactate dehydrogenase (LDH) level
  • Cytology

After proper antiseptic preparation and local anesthesia, a diagnostic tap can be performed with a 10- to 20-mL syringe and an 18-gauge needle.

After proper antiseptic preparation and local anesthesia, a therapeutic tap can be performed with an intravenous (IV) catheter over the needle connected to drainage tubing.

In patients who are afebrile, alert, and have no other signs of bacterial peritonitis, ascitic fluid labs are often not necessary to rule out SBP).[8, 9]

To minimize the risk of persistent leak from the puncture site, use a small-gauge needle or take a "Z" track during insertion of the needle. (During removal of the needle, the subcutaneous tissue seals on itself.)

In a retrospective review of 796 peritoneal fluid samples, the evaluation of Gram stain results rarely provided clinically useful information for the detection of SBP.[7]

Dietary sodium restriction and diuretics do not often provide symptomatic relief of refractory ascites in patients in advanced stages of cancer. Although paracentesis does effectively drain ascitic fluid, the condition invariably recurs, and repeated procedures are necessary. A 2008 study reported that a permanent peritoneal catheter to drain abdominal fluid greatly reduced the symptoms of ascites in these patients and avoided the costs and complications of frequent paracentesis procedures.[10]

A meta-analysis suggests that the use of albumin in cirrhotic patients undergoing paracentesis reduces paracentesis-induced circulatory dysfunction and reduces death and renal impairment.[11]

Complication prevention

In cases with a persistent leak, a single skin suture might solve the problem. The application of an ostomy bag around the puncture site keeps the leak contained until it is eventually sealed off.

Postparacentesis hypotension is a delayed complication that may occur more than 12 hours after a procedure in which large volumes are taken off. Patients can be pretreated with a colloid solution, such as albumin, to decrease the frequency of this complication, though no difference in survival has been noted relative to other plasma expanders.[12]

Timing of paracentesis

Whereas studies suggest that early paracentesis (<12 hours from admission) improves short term survival of hospitalized patients with SBP in comparison with delayed paracentesis, it seems that earlier administration of appropriate antibiotics in the early paracentesis group might have been a major contributing factor.[13, 14]

At this time and in the absence of prospective, randomized, controlled data, the authors recommend early diagnostic or therapeutic paracentesis and early empiric antibiotic administration in patient suspected of having SBP. When it appears that large-volume paracentesis is likely to be required, the authors suggest consideration of early small-volume paracentesis (ultrasound, syringe, and needle technique) followed by delayed and planned large-volume paracentesis (during hospitalization) under appropriate monitoring and hemodynamic support to minimize the risk of circulatory dysfunction induced by large-volume paracentesis.

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Contributor Information and Disclosures
Author

Gil Z Shlamovitz, MD, FACEP Associate Professor of Clinical Emergency Medicine, Keck School of Medicine of the University of Southern California; Chief Medical Information Officer, Keck Medicine of USC

Gil Z Shlamovitz, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association

Disclosure: Nothing to disclose.

Coauthor(s)

Nirav R Shah, MD, MPH SVP and COO, Kaiser Permanente Southern California

Nirav R Shah, MD, MPH is a member of the following medical societies: American College of Physicians, New York Academy of Medicine, Society of General Internal Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Royal College of Surgeons of England, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Additional Contributors

Andrew K Chang, MD Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center

Andrew K Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the assistance of Lars Grimm, MD, with the literature review and referencing for this article.

Medscape Drugs & Diseases also thanks George Y Wu, MD, PhD, Professor, Department of Medicine, Director, Hepatology Section, Herman Lopata Chair in Hepatitis Research, University of Connecticut School of Medicine, for assistance with the video contribution to this article

References
  1. Wong CL, Holroyd-Leduc J, Thorpe KE, Straus SE. Does this patient have bacterial peritonitis or portal hypertension? How do I perform a paracentesis and analyze the results?. JAMA. 2008 Mar 12. 299(10):1166-78. [Medline].

  2. Thomsen TW, Shaffer RW, White B, Setnik GS. Videos in clinical medicine. Paracentesis. N Engl J Med. 2006 Nov 9. 355(19):e21. [Medline].

  3. McGibbon A, Chen GI, Peltekian KM, van Zanten SV. An evidence-based manual for abdominal paracentesis. Dig Dis Sci. 2007 Dec. 52(12):3307-15. [Medline].

  4. Kuiper JJ, van Buuren HR, de Man RA. Ascites in cirrhosis: a review of management and complications. Neth J Med. 2007 Sep. 65(8):283-8. [Medline].

  5. McVay PA, Toy PT. Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion. 1991 Feb. 31(2):164-71. [Medline].

  6. De Gottardi A, Thévenot T, Spahr L, Morard I, Bresson-Hadni S, Torres F, et al. Risk of complications after abdominal paracentesis in cirrhotic patients: a prospective study. Clin Gastroenterol Hepatol. 2009 Aug. 7(8):906-9. [Medline].

  7. Chinnock B, Fox C, Hendey GW. Gram's Stain of Peritoneal Fluid Is Rarely Helpful in the Evaluation of the Ascites Patient. Ann Emerg Med. 2009 Feb 5. [Medline].

  8. Romney R, Mathurin P, Ganne-Carrie N, et al. Usefulness of routine analysis of ascitic fluid at the time of therapeutic paracentesis in asymptomatic outpatients. Results of a multicenter prospective study. Gastroenterol Clin Biol. 2005 Mar. 29(3):275-9. [Medline].

  9. Cadranel JF, Nousbaum JB, Bessaguet C, et al. Low incidence of spontaneous bacterial peritonitis in asymptomatic cirrhotic outpatients. World J Hepatol. 2013 Mar 27. 5(3):104-8. [Medline]. [Full Text].

  10. Mercadante S, Intravaia G, Ferrera P, Villari P, David F. Peritoneal catheter for continuous drainage of ascites in advanced cancer patients. Support Care Cancer. 2008 Aug. 16(8):975-8. [Medline].

  11. Kwok CS, Krupa L, Mahtani A, et al. Albumin Reduces Paracentesis-Induced Circulatory Dysfunction and Reduces Death and Renal Impairment among Patients with Cirrhosis and Infection: A Systematic Review and Meta-Analysis. Biomed Res Int. 2013. 2013:295153. [Medline]. [Full Text].

  12. Gines A, Fernandez-Esparrach G, Monescillo A, Vila C, Domenech E, Abecasis R. Randomized trial comparing albumin, dextran 70, and polygeline in cirrhotic patients with ascites treated by paracentesis. Gastroenterology. 1996 Oct. 111(4):1002-10. [Medline].

  13. Kim JJ, Tsukamoto MM, Mathur AK, Ghomri YM, Hou LA, Sheibani S, et al. Delayed paracentesis is associated with increased in-hospital mortality in patients with spontaneous bacterial peritonitis. Am J Gastroenterol. 2014 Sep. 109(9):1436-42. [Medline].

  14. Orman ES, Hayashi PH, Bataller R, Barritt AS 4th. Paracentesis is associated with reduced mortality in patients hospitalized with cirrhosis and ascites. Clin Gastroenterol Hepatol. 2014 Mar. 12(3):496-503.e1. [Medline]. [Full Text].

  15. Nazeer SR, Dewbre H, Miller AH. Ultrasound-assisted paracentesis performed by emergency physicians vs the traditional technique: a prospective, randomized study. Am J Emerg Med. 2005 May. 23(3):363-7. [Medline].

  16. Duggal P, Farah KF, Anghel G, Marcus RJ, Lupetin AR, Babich MM, et al. Safety of paracentesis in inpatients. Clin Nephrol. 2006 Sep. 66(3):171-6. [Medline].

  17. Reichman E, Simon RR. Emergency Medicine Procedures. 1st. New York, NY: McGraw-Hill Professional; 2003.

  18. Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 5th ed. 2009.

  19. Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, PA: WB Saunders Company; 2003.

 
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Paracentesis sites.
Ultrasound ascites.
Application of antiseptic solution.
Draping.
Paracentesis/thoracentesis tray.
Local anesthesia - skin wheal.
Local anesthesia - deeper injection.
Skin nick.
Insertion of needle into selected skin entry point.
Filling of syringe with ascitic fluid upon peritoneal entry.
Stabilization of needle and syringe.
Advancing the catheter over the needle.
Sample collection.
Peritoneal fluid in vials.
Collecting tube.
Vacuum bottle.
Catheter removal.
Advance catheter over the needle.
Sample collection.
Ultrasound-assisted large-volume paracentesis. Video courtesy of George Y Wu, MD, PhD.
 
 
 
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