From the Guidelines
Paracentesis is indicated in all patients with ascites due to cirrhosis who are emergently admitted to the hospital, even in the absence of symptoms or signs of infection, as well as in those who develop signs, symptoms, or laboratory abnormalities suggestive of infection. This recommendation is based on the most recent and highest quality study by the American Association for the Study of Liver Diseases, published in 2021 1. The guidance emphasizes the importance of diagnostic paracentesis in these patients to rule out spontaneous bacterial peritonitis (SBP) and other complications.
Indications for Paracentesis
- Diagnostic paracentesis should be performed in all patients with new-onset ascites, those with existing ascites who are hospitalized, or when there is clinical suspicion of SBP or other complications, as suggested by the 2021 practice guidance 1.
- Therapeutic paracentesis is indicated for patients with tense or refractory ascites causing respiratory distress, abdominal discomfort, early satiety, or mobility limitations.
- The procedure is crucial for diagnosing the cause of ascites, detecting infections like SBP, and providing symptomatic relief by reducing intra-abdominal pressure, which improves respiratory function and patient comfort.
Key Considerations
- The ascitic fluid should be cultured at the bedside in aerobic and anaerobic blood culture bottles before initiation of antibiotics, as recommended by the 2021 practice guidance 1.
- The diagnosis of SBP is established with a fluid polymorphonuclear (PMN) leukocyte count >250/mm3, as stated in the 2021 practice guidance by the American Association for the Study of Liver Diseases 1.
- For large-volume paracentesis (removal of more than 5 liters), albumin replacement at 6-8 g per liter of fluid removed is recommended to prevent post-paracentesis circulatory dysfunction, although this specific recommendation is not directly mentioned in the provided evidence, it is a well-established practice in clinical medicine.
Contraindications and Precautions
- Contraindications include severe coagulopathy, thrombocytopenia (platelets <20,000), pregnancy with a viable fetus, skin infection at the puncture site, or intestinal obstruction, although these are not explicitly mentioned in the provided evidence, they are general considerations in the performance of paracentesis.
From the Research
Paracentesis Indication
- Paracentesis is indicated in patients with refractory ascites, where it is performed in combination with albumin infusion 2.
- The procedure is also recommended for patients with cirrhosis and ascites who are admitted to the hospital, with early diagnostic paracentesis (within 1 day) associated with reduced mortality and length of hospital stay 3.
- Paracentesis may be necessary for patients with spontaneous bacterial peritonitis (SBP), a complication of ascites that confers a high mortality rate 4, 5, 6.
- The procedure can help diagnose and manage SBP, and may be performed in conjunction with antibiotic therapy and albumin infusion to decrease mortality and prevent renal insufficiency 6.
Key Considerations
- Patients with cirrhosis and ascites should be evaluated for liver transplantation, as ascites impairs both quality of life and survival 2.
- The management of ascites and SBP requires a comprehensive approach, including dietary sodium restriction, diuretic therapy, and consideration of alternative treatments such as transjugular intrahepatic portosystemic shunt (TIPS) placement and vasoconstrictors 2, 4, 5.
- Early recognition and prompt treatment of SBP are essential to prevent serious morbidity and mortality 5, 3.