Is a therapeutic tap (paracentesis) indicated in a patient with alcoholic liver disease and septicemia?

Therapeutic Paracentesis in Alcoholic Liver Disease with Septicemia

Yes, therapeutic paracentesis is indicated and should be performed in this patient with alcoholic liver disease and septicemia—both for diagnostic purposes to rule out spontaneous bacterial peritonitis (SBP) and for therapeutic relief if tense ascites is present. 1

Diagnostic Paracentesis is Mandatory

A diagnostic paracentesis must be performed in all cirrhotic patients with ascites who develop signs of infection, including septicemia, to exclude or diagnose SBP. 1

• Approximately 15% of cirrhotic patients with ascites admitted to hospital have SBP, and this can present as septicemia without obvious peritoneal signs 1
• The diagnostic tap should be performed immediately upon hospital admission or when septicemia is identified 1
• An ascitic fluid neutrophil count >250 cells/mm³ is diagnostic of SBP and requires immediate empiric antibiotic therapy 1
• Ascitic fluid should be inoculated into blood culture bottles at the bedside to maximize bacterial yield 1

Therapeutic Paracentesis is Safe and Effective

Therapeutic paracentesis can be safely performed even in the presence of septicemia and coagulopathy, which are common in alcoholic liver disease. 1

• Paracentesis is not contraindicated by abnormal coagulation profiles—complications occur in only 1% of patients (mostly minor abdominal wall hematomas) and serious bleeding is rare (<1/1000 procedures) 1
• Routine measurement of prothrombin time and platelet count before paracentesis and prophylactic transfusion of blood products are not recommended 1
• In one study of 1,100 large-volume paracenteses, there were no hemorrhagic complications despite platelet counts as low as 19,000 cells/mm³ and INRs as high as 8.7, with no prophylactic transfusions given 1

Active Infection is NOT a Contraindication

The presence of septicemia does not preclude therapeutic paracentesis—in fact, it makes diagnostic paracentesis even more urgent. 1

• The 2021 Gut guidelines specifically note that caution with TIPSS is required in patients with "active infection," but this refers to TIPSS placement, not paracentesis 1
• Patients with alcoholic liver disease have impaired immunity and increased susceptibility to infections, making early diagnosis of SBP critical 2
• Therapeutic paracentesis is the first-line treatment for tense ascites and is more effective than diuretics alone, with fewer complications 1, 3, 4

Volume and Albumin Replacement

If large-volume paracentesis (>5L) is performed, albumin replacement is mandatory to prevent post-paracentesis circulatory dysfunction. 1

• Administer 8g of albumin per liter of ascites removed after paracentesis is completed 1
• For paracentesis <5L in patients with septicemia (which qualifies as acute-on-chronic liver failure or high risk for acute kidney injury), albumin can be considered 1
• If SBP is confirmed and the patient has elevated or rising creatinine, give 1.5 g/kg albumin within 6 hours of diagnosis, followed by 1 g/kg on day 3 1

Practical Execution

Perform the paracentesis in the left lower quadrant, 3 cm cephalad and 3 cm medial to the anterior superior iliac spine, using ultrasound guidance when available. 1

• Ultrasound guidance reduces the risk of adverse events and should be considered when available 1
• Avoid the midline inferior epigastric arteries and visible collateral vessels 1
• For diagnostic purposes, withdraw 10-20 mL of ascitic fluid for neutrophil count, culture, and albumin measurement 1
• Obtain informed consent before the procedure 1

Critical Pitfall to Avoid

Do not delay paracentesis to correct coagulopathy with fresh frozen plasma or platelets—this is not data-supported and delays critical diagnosis and treatment. 1

• The only contraindications to paracentesis are clinically evident hyperfibrinolysis (three-dimensional ecchymosis/hematoma) or disseminated intravascular coagulation 1
• If thrombocytopenia is severe (<40,000 cells/mm³), most clinicians would give pooled platelets, though this is not evidence-based 1