eMedicine Specialties > Clinical Procedures > Gastrointestinal Procedures

Paracentesis

Author: Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Coauthor(s): Nirav R Shah, MD, MPH, Assistant Professor and Associate Director for Research, Division of General Internal Medicine, New York University, School of Medicine; Associate Investigator, Center for Health Research, Geisinger Health
Contributor Information and Disclosures

Updated: Sep 4, 2009

Introduction

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

Characterization of ascites

 Ascitic fluid may be used to help determine its etiology as well as to evaluate for infection or presence of cancer. With regard to differentiation of transudate from exudates, 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 less than 1.1 g/dL.

Causes of ascites

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 (PMN) count of more than 250 cells/μ L (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.

Indications

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

Contraindications

Absolute contraindication

  • Acute abdomen that requires surgery
Relative contraindications 
  • Severe thrombocytopenia (platelet count <20 X 103/μL), coagulopathy (international normalized ratio [INR] >2.0), or both
    • 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 platelet counts less than 20 X 103/μL should receive an infusion of platelets prior to performing the procedure.
  • In patients without clinical evidence of active bleeding, routine labs such as prothrombin time (PT), activated partial thromboplastin time (aPTT), and platelet counts may not be needed prior to the procedure.5 In these patients, pretreatment with FFP, platelets, or both before the 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).
  • Pregnancy
  • Distended urinary bladder
  • Abdominal wall cellulitis
  • Distended bowel
  • Intra-abdominal adhesions

More on Paracentesis

Overview: Paracentesis
Treatment & Medication: Paracentesis
Multimedia: Paracentesis
References
Further Reading
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References

  1. [Best Evidence] 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. Mar 12 2008;299(10):1166-78. [Medline].

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

  3. McGibbon A, Chen GI, Peltekian KM, van Zanten SV. An evidence-based manual for abdominal paracentesis. Dig Dis Sci. Dec 2007;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. Sep 2007;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. Feb 1991;31(2):164-71. [Medline].

  6. 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. May 2005;23(3):363-7. [Medline].

  7. 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. Mar 2005;29(3):275-9. [Medline].

  8. 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. Feb 5 2009;[Medline].

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

  10. 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. Oct 1996;111(4):1002-10. [Medline].

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

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

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

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Keywords

paracentesis, abdominal tap, ascites tap, peritoneal tap, abdominal fluid, abdominal fluid drainage, SAAG, serum-ascites albumin gradient, peritonitis, liver disease, cancer, ascites, tense ascites, peritoneal cavity, transudative ascites, exudative ascites, spontaneous bacterial peritonitis, SBP, intra-abdominal fluid

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Contributor Information and Disclosures

Author

Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Gil Z Shlamovitz, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Nirav R Shah, MD, MPH, Assistant Professor and Associate Director for Research, Division of General Internal Medicine, New York University, School of Medicine; Associate Investigator, Center for Health Research, Geisinger Health
Nirav R Shah, MD, MPH is a member of the following medical societies: American College of Physicians, New York Academy of Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Medical Editor

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, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Luis M Lovato, MD, Associate Clinical Professor, David Geffen School of Medicine at UCLA; 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, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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