What criteria indicate the need for paracentesis (percutaneous abdominal paracentesis) in a patient with liver failure?

From the Guidelines

Paracentesis should be performed in patients with liver failure who have new-onset ascites, clinical deterioration, or signs of spontaneous bacterial peritonitis (SBP), as indicated by the most recent guidelines 1. To assess the need for paracentesis, the following signs and symptoms should be evaluated:

• New-onset ascites
• Clinical deterioration
• Signs of SBP, such as fever, abdominal pain, altered mental status, worsening renal function, or unexplained clinical deterioration
• GI bleeding, shock, fever or other signs of systemic inflammation, gastrointestinal symptoms, hepatic encephalopathy, and worsening liver or renal function 1 A physical examination should be performed to look for signs of significant ascites, such as shifting dullness, fluid wave, or bulging flanks. Laboratory findings that suggest the need for paracentesis include:
• Elevated white blood cell count
• Worsening liver function tests
• Rising serum creatinine When performing diagnostic paracentesis, typically 50-100 mL of fluid is sufficient, while therapeutic paracentesis for symptom relief may require removal of larger volumes (up to 5-6 liters) 1. The ascitic fluid should be analyzed for cell count with differential, total protein, albumin, culture, and glucose, with a polymorphonuclear neutrophil count ≥250 cells/mm³ in ascitic fluid being diagnostic of SBP and warranting immediate antibiotic therapy 1. For large-volume paracentesis, administer intravenous albumin (6-8 g per liter of fluid removed) to prevent post-paracentesis circulatory dysfunction. The choice of antibiotic should be guided by local resistance patterns and protocol, with cefotaxime being widely studied but not necessarily the first choice 1. In patients who have recovered from an episode of SBP, treatment with norfloxacin, ciprofloxacin, or co-trimoxazole may be considered to prevent further episodes of SBP, although the quality of evidence for this is low 1.

From the Research

Assessment of Patients with Liver Failure for Paracentesis

To determine if a patient in liver failure needs a paracentesis, the following factors should be considered:

• Presence of new-onset ascites or changes in the patient's condition, such as fever, abdominal pain, renal insufficiency, or encephalopathy 2
• High-risk patients, including those with concomitant hepatic encephalopathy or acute kidney injury, should undergo early paracentesis (within 1 hospital day) 3
• Clinical features with high diagnostic suspicion for spontaneous bacterial peritonitis (SBP), such as abdominal pain or tenderness, should prompt diagnostic paracentesis 4

Diagnostic Criteria for Paracentesis

The decision to perform paracentesis should be based on the following diagnostic criteria:

• Serum-ascites albumin gradient greater than 1.1 g/dL, which indicates portal hypertension 2, 5
• Ascitic fluid polymorphonuclear cell count greater than or equal to 250 cells/mm^3, which is the most sensitive test for diagnosing SBP 5, 6
• Presence of > 250 mm^3 neutrophil polymorphonuclear (PMN) in ascites, which is required for the final diagnosis of SBP 4

Timing and Outcomes of Paracentesis

The timing of paracentesis is crucial, and early paracentesis (within 1 hospital day) is associated with:

• Reduced inpatient all-cause mortality 3
• Reduced SBP-related mortality 3
• Reduced 30-day readmission 3 High-risk patients, including those with concomitant hepatic encephalopathy or acute kidney injury, have lower rates of early paracentesis, but it is still associated with improved outcomes 3