Can Paracentesis Be Performed in Patients with Spontaneous Bacterial Peritonitis?
Yes, diagnostic paracentesis must be performed immediately in all patients with suspected SBP—it is the essential diagnostic procedure and is not contraindicated by the presence of SBP itself. 1, 2
Diagnostic Paracentesis is Mandatory
Paracentesis should be performed without delay at hospital admission in all cirrhotic patients with ascites to rule out SBP, regardless of whether symptoms are present. 1, 2
When to Perform Diagnostic Paracentesis:
At hospital admission: All cirrhotic patients with ascites require diagnostic paracentesis upon admission, even if asymptomatic, as 16% of SBP cases present without symptoms 3, 4
With any clinical suspicion: Perform urgently if the patient develops fever, abdominal pain or tenderness, altered mental status/hepatic encephalopathy, shock, GI bleeding, worsening liver or renal function, acidosis, or peripheral leukocytosis 1, 2
Before starting antibiotics: Obtain at least 10 mL of ascitic fluid and inoculate blood culture bottles at bedside before initiating antibiotic therapy 2
Coagulopathy is NOT a Contraindication
Despite the fact that most cirrhotic patients have prolonged prothrombin time and coagulation abnormalities, paracentesis is not contraindicated and should be performed. 5, 6
Key Points About Bleeding Risk:
Routine correction of coagulopathy with fresh frozen plasma or other blood products is not recommended before paracentesis 6
The only potential limitation is severe thrombocytopenia: consider platelet transfusion only if platelets are <40,000-50,000/μL 5
Ultrasound guidance should be used to optimize the procedure and minimize complications 6
Follow-Up Paracentesis After Treatment
A repeat diagnostic paracentesis should be performed 48 hours after initiating antibiotic therapy to assess treatment response. 2
When Follow-Up Paracentesis is Indicated:
Routine monitoring: Repeat at 48 hours to confirm PMN count has decreased by ≥25% from baseline 2
Atypical presentations: If the clinical setting, symptoms, ascitic fluid analysis, organisms identified, or response to treatment are atypical, repeat paracentesis helps identify secondary bacterial peritonitis requiring surgical intervention 1
Treatment failure: If PMN count fails to decrease by 25% or rises despite treatment, this suggests secondary peritonitis requiring CT imaging and surgical evaluation 1, 2
Not routinely necessary: In typical SBP cases with dramatic clinical response, repeat paracentesis to document sterility is optional but not required 1
Common Pitfalls to Avoid
Delaying paracentesis due to coagulopathy concerns: This is the most critical error—each hour of delayed treatment increases hospital mortality by 3.3% 3
Waiting for symptoms to develop: SBP can be completely asymptomatic in a significant proportion of patients, making routine screening paracentesis essential 3, 4
Failing to perform follow-up paracentesis in atypical cases: This can lead to missed secondary peritonitis, which requires surgical intervention and has similar mortality to SBP when treated appropriately 1
Not using ultrasound guidance: This increases complication risk unnecessarily 6