Should ascitic tapping be performed in patients with hepatic encephalopathy and ascites?

Ascitic Tapping in Hepatic Encephalopathy

Yes, diagnostic paracentesis should be performed in patients with hepatic encephalopathy and ascites to rule out spontaneous bacterial peritonitis (SBP), which is a critical and potentially life-threatening complication that can precipitate or worsen encephalopathy. 1

Mandatory Diagnostic Paracentesis

Diagnostic paracentesis must be performed without delay in all cirrhotic patients with ascites who develop hepatic encephalopathy, as SBP is present in approximately 15% of hospitalized cirrhotic patients with ascites and can directly trigger or exacerbate encephalopathy. 1

Key Indications for Immediate Paracentesis:

• Hepatic encephalopathy of any grade 1
• Fever or signs of systemic inflammation 1
• Worsening liver or renal function 1
• Gastrointestinal bleeding 1
• Any clinical deterioration in a patient with ascites 1

Essential Ascitic Fluid Analysis

When performing diagnostic paracentesis in patients with hepatic encephalopathy, the following tests are critical:

• Ascitic fluid neutrophil count: >250 cells/mm³ is diagnostic of SBP 1
• Ascitic fluid culture: Bedside inoculation of blood culture bottles to guide antibiotic selection 1
• Serum-ascites albumin gradient (SAAG): To confirm portal hypertension-related ascites 1
• Total protein concentration: To assess infection risk 1

Safety of Paracentesis in Hepatic Encephalopathy

Paracentesis is safe even in the presence of coagulopathy, which is common in cirrhotic patients with hepatic encephalopathy. 1, 2

Safety Evidence:

• Bleeding complications occur in <1 in 1,000 procedures 2
• Can be safely performed with platelet counts as low as 19,000 cells/mm³ and INR as high as 8.7 2
• Routine measurement of prothrombin time and platelet count before paracentesis is not recommended 1
• Prophylactic transfusion of blood products is not recommended 1

Absolute Contraindications (Rare):

• Clinically evident disseminated intravascular coagulation 2
• Clinically evident hyperfibrinolysis with three-dimensional ecchymosis 2

Therapeutic Paracentesis Considerations

While diagnostic paracentesis is mandatory, therapeutic large-volume paracentesis (LVP) should be approached with caution in patients with hepatic encephalopathy, particularly when considering TIPS placement as definitive management.

TIPS Contraindications Related to Hepatic Encephalopathy:

TIPS is not recommended in patients with: 1

• Current hepatic encephalopathy grade ≥2 1
• Chronic hepatic encephalopathy 1
• History of recurrent encephalopathy 1

The rationale is that TIPS precipitates hepatic encephalopathy in 30-50% of patients 1, making it unsuitable for those already experiencing encephalopathy.

Preferred Management for Refractory Ascites with Encephalopathy:

• Repeated LVP plus albumin (8 g/L of ascites removed) as first-line treatment 1
• This approach avoids the high risk of worsening encephalopathy associated with TIPS 1

Albumin Administration Protocol

For therapeutic paracentesis >5 L, albumin infusion is mandatory to prevent post-paracentesis circulatory dysfunction: 1

• Dose: 8 g albumin per liter of ascites removed 1
• Formulation: 20% or 25% albumin solution 1
• For paracentesis <5 L, albumin should be considered in patients with acute-on-chronic liver failure or high risk of acute kidney injury 1

Critical Pitfall to Avoid

The most common error is delaying diagnostic paracentesis due to concerns about coagulopathy. 1, 2 This delay can be fatal if SBP is present, as infection is a major precipitant of hepatic encephalopathy and carries significant mortality risk. The evidence clearly demonstrates that coagulopathy is not a contraindication to paracentesis, and routine correction of coagulation parameters is unnecessary and potentially harmful. 1, 2

Monitoring After Paracentesis

Diuretics should be discontinued in patients with hepatic encephalopathy if they develop diuretic-induced complications including worsening encephalopathy, renal impairment, or electrolyte abnormalities. 1, 3 In patients with refractory ascites and encephalopathy, diuretics should only be continued if urinary sodium excretion exceeds 30 mmol/day. 1