Paracentesis

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Indications

  • Rule-out SBP
  • Ascites analysis
  • Clinical deterioration in a patient with ascites (e.g. fever, abdominal pain or tenderness, encephalopathy, acidosis, deterioration in renal function, peripheral leukocytosis)[1]

Contraindications

Paracentesis if coagulopathic

  • Coagulation studies are NOT required before performance of the procedure[2]
    • Incidence of clinically significant bleeding complications is low even if in liver failure with an elevated INR (< 0.2%)[3]
  • No data supports cutoff values beyond which paracentesis should be avoided/prophylactically transfused
  • Routine use of FFP and platelets is not recommended
  • Procedure is contraindicated if the patient is actively bleeding or in DIC

Equipment Needed

Procedure

  1. Use ultrasound to identify safe ascites pocket to drain
    • if no ultrasound available, can percuss to identify pocket
    • Try to pick site away from inferior epigastric artery
    • LLQ preferred over RLQ
    • Midline infraumbilicus is avascular (linea alba) but has lower success rate
  2. Prep area
  3. Anesthesize area with Lidocaine
  4. Use needle to enter peritoneum, advance catheter upon withdrawing ascitic fluid
  5. Attach cathether to vacuum bottles for therapeutic tap, Withdrawal with syringe for diagnostic tap

Pearls

  • Placing culture in blood culture tube increases yield
  • Consider albumin infusion in cirrhotics with SBP or with large volume paracentesis to reduces the risk of circulatory dysfunction[4]

Workup

SBP Work-Up of Ascitic Fluid via Paracentesis

  • Cell count with differential
  • Gram stain
  • Culture (10cc in blood culture bottle)
  • Glucose
  • Protein

Consider

  • Albumin and SERUM albumin
  • LDH and SERUM LDH at same time
  • Amylase

Specific circumstances

  • TB smear and culture
  • Cytology
  • TG
  • Billirubin

Evaluation

Diagnosis of SBP via Ascitic Fluid Analysis

Standard Evaluation

  • Paracentesis results supporting a diagnosis of SBP:
    • Absolute neutrophil count (PMNs) ≥250, pH <7.35, OR blood-ascites pH gradient >0.1[5]
    • Bacteria on gram stain (single type)
    • SAAG > 1.1
      • Diagnostic of portal hypertension with 97% accuracy[6]
      • SBP rarely develops in patients without portal hypertension
    • Protein < 1, Glucose > 50 (otherwise concern for secondary bacterial peritonitis)

For bloody tap, subtract 1 WBC for every 250 RBC[7]

If on Peritoneal Dialysis (CAPD)

SBP if:

  • >100 total WBCs OR >50% neutrophils

If on Nightly APD

SBP if:

  • >50% neutrophils
  • Amylase (>100 suggestive of intra-abdominal process)

Spontaneous versus secondary bacterial peritonitis

  • Importance of distinction
    • Mortality of secondary bacterial peritonitis (eg. perforated appendicitis, cholecystitis) ~100% if treatment is only antibiotics without surgery
    • Mortality of unnecessary surgery in patients with SBP ~80%
  • Laboratory findings
    • Secondary bacterial peritonitis strongly suggested by:
      • Neutrocytic fluid (PMN ≥250) with two or more of the following:
        • Total protein concentration >1 g/dL (10 g/L)
        • Glucose concentration <50 mg/dL (2.8 mmol/L)
        • LDH greater than upper limit of normal for serum
      • Ascitic alk phos >240
      • Gram stain
        • Large numbers of different bacterial forms
  • Imaging
    • If evidence of secondary bacterial peritonitis obtain abdominal imaging
      • If no evidence of free air or contrast extravasation then surgery is not indicated

Complications

  • Hemorrhage (0 to 0.93%)[8]
  • Abdominal wall hematoma
  • Mesenteric hematoma
  • Bladder or bowel perforation (6 out of 1000)
  • Inferior epigastric aneurysm
  • Vessel laceration (aorta, mesenteric artery, iliac artery)
  • Hypotension
  • Infection (0.58 to 0.63%)
  • Persistent ascitic fluid leak (5%)

See Also

External Links

Focus On: Ultrasound-Guided Paracentesis

References

  1. Runyon B. Diagnostic and therapeutic abdominal paracentesis. UpToDate. "Diagnostic and therapeutic abdominal paracentesis?" Published February 18, 2014. Accessed September 8, 2015.
  2. Wilkerson, Annals of Emerg Med, 2009
  3. Thomsen TW. Paracentesis. N Engl J Med 2006; 355: e21
  4. 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.
  5. Wilkerson R, Sinert, R. The Use of Paracentesis in the Assessment of the Patient With Ascites. Ann Emerg Med 2009, 54(3): 465-68.
  6. Runyon BA, Montano AA, Akriviadis EA, et al. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med 1992; 117:215.
  7. Hoefs JC "Increase in ascites white blood cell and protein concentrations during diuresis in patients with chronic liver disease."Hepatology. 1981;1(3):249. PMID 7286905
  8. Scheer D, Secko M, Mehta N. ACEP Focus On: Ultrasound-Guided Paracentesis. http://www.acep.org/Education/Continuing-Medical-Education-(CME)/Focus-On/Focus-On--Ultrasound-Guided-Paracentesis. Published on November 1, 2012. Accessed on September 8, 2015.