Who should I consult for a paracentesis procedure?

Who to Consult for Paracentesis

Paracentesis can and should be performed by trained internal medicine physicians, gastroenterologists/hepatologists, or interventional radiologists at the bedside or in the radiology suite, with bedside procedures by medicine-trained clinicians being preferred when feasible due to equal or better outcomes and lower costs. 1, 2, 3

Primary Providers Who Perform Paracentesis

Medicine-Trained Clinicians (Preferred for Most Cases)

• Internal medicine physicians, gastroenterologists, and hepatologists routinely perform paracentesis procedures and should be your first consultation for most inpatients with ascites. 2, 3
• At academic medical centers, medicine and medicine subspecialties (including gastroenterology/hepatology) perform 49% of all paracentesis procedures, demonstrating this is standard practice. 2
• Bedside paracentesis by medicine-trained clinicians results in equal or better patient outcomes compared to interventional radiology, with significantly lower hospital costs ($803-$1,308 less per admission). 2, 3
• Non-physician healthcare providers such as GI endoscopy assistants and specialist nurses can also be trained to perform therapeutic paracentesis effectively, with optimal training requiring 10 supervised procedures. 1

Interventional Radiology (For Select Cases)

• Interventional radiology should be consulted for paracentesis in patients with obesity, pregnancy, severe intestinal distension, history of extensive abdominal surgery, or when bedside attempts have failed. 1, 4
• IR performs approximately 29% of paracentesis procedures nationally, often for more technically challenging cases. 2
• Patients referred to IR tend to be female, obese, or have lower severity of illness. 2

When to Choose Each Provider

Consult Medicine/Gastroenterology First When:

• The patient has straightforward ascites with adequate fluid volume (>1,500 mL detectable by flank dullness). 1, 4
• The patient is not obese and has no history of extensive abdominal surgery. 1
• Bedside ultrasound is available if needed for guidance. 1
• This approach reduces hospital length of stay by 1.86 days compared to IR referral. 3

Consult Interventional Radiology When:

• The patient has significant obesity making lateral approaches difficult. 1, 4
• There is pregnancy (relative contraindication requiring special expertise). 1
• Severe intestinal distension is present. 1
• History of extensive abdominal surgery creates anatomical challenges. 1
• Previous bedside attempts have been unsuccessful. 1

Important Clinical Considerations

Coagulopathy Is NOT a Reason for IR Referral

• Paracentesis can be safely performed regardless of INR or platelet count—there is no data-supported cutoff beyond which the procedure should be avoided. 1, 4, 5
• Bleeding complications occur in less than 1 in 1,000 procedures, with most occurring in patients with renal failure rather than coagulopathy. 4, 5
• Routine prophylactic transfusion of fresh frozen plasma or platelets before paracentesis is not recommended. 1, 5

True Contraindications (Require Specialist Consultation)

• Clinically evident hyperfibrinolysis (three-dimensional ecchymosis/hematoma formation) is an absolute contraindication. 1, 4, 5
• Clinically evident disseminated intravascular coagulation is an absolute contraindication. 1, 4, 5
• These conditions occur in less than 1 per 1,000 procedures and would require hematology consultation before any paracentesis attempt. 1

Common Pitfalls to Avoid

• Do not delay or refer to IR based solely on elevated INR or low platelet counts—this represents overreliance on tests never validated for bleeding prediction in non-anticoagulated patients. 5
• Do not routinely refer all paracentesis procedures to IR—this increases hospital costs, length of stay, and rates of blood product transfusions and ICU transfers without improving outcomes. 2, 3
• Ensure the consulting physician has adequate training—competency in paracentesis is not currently required for internal medicine or family medicine board certification, though it should be. 2