Paracentesis Indications and Contraindications

Paracentesis Indications

New Onset Ascites

  • Establish etiology with the serum-ascites albumin gradient (SAAG)

Rule Out Spontaneous Bacterial Peritonitis (SBP)

  • Have a very low threshold to perform a diagnostic paracentesis in cirrhotics
  • Paracentesis should always be performed in a cirrhotic with new1
    • Encephalopathy
    • Fever
    • Acute kidney injury
    • Abdominal pain
    • Leukocytosis
    • Shock
  • Guidelines suggest performing a diagnostic paracentesis on ALL cirrhotics admitted to the hospital to rule out SBP because2
    • 12% of hospitalized cirrhotics have SBP
    • 50% of patients with SBP are asymptomatic
    • 50% of patients with SBP had another concurrent infection
      • If a septic cirrhotic has a “dirty” UA, still should perform a para as apart of the “full-fever work up”
  • Timely paracentesis can save lives
    • Hospitalized cirrhotics had a 25% relative risk reduction in mortality if they received a diagnostic paracentesis3

Symptomatic Volume Removal

  • Paracentesis is far superior to high dose diuretics to control large volume ascites4
    • Paracentesis was 95% effective, whereas diuretics were only effective 75% of the time
    • Paracentesis was associated with less AKI, encephalopathy, and a shorter length of stay compared to diuretics
  • Large volume therapeutic paracentesis is the preferred management strategy followed by maintenance diuretics5

Relative Contraindications

There are no absolute contraindications to paracentesis6, 7

  • Weigh the risks and benefits for each patient
  • Diagnostic paracentesis with a smaller gauge needle may be safer than the large bore needle used in therapeutic paracentesis

Hemodynamic instability and acute kidney injury

  • Large volume paracentesis should be avoided in these situations as large volume shifts can worsen hypotension and decrease renal perfusion

Proceed with caution and ultrasound guidance if suspecting intra-abdominal obstacles like:

  • Hepatosplenomegaly
  • Pregnancy
  • Bowel obstruction
  • Intra-abdominal adhesions
    • Avoid surgical scars
  • Distended bladder

Coagulopathy and Thrombocytopenia

  • See the next page

Next Page

References

  1. Runyon, B.A. Management of adult patients with ascites due to cirrhosis: an update. Hepatology 49, 2087-107 (2009).
  2. Borzio, M. et al. Bacterial infection in patients with advanced cirrhosis: a multicentre prospective study. Dig Liver Dis 33, 41-8 (2001).
  3. Orman, E.S., Hayashi, P.H., Bataller, R. & Barritt, A.S.t. Paracentesis is associated with reduced mortality in patients hospitalized with cirrhosis and ascites. Clin Gastroenterol Hepatol 12, 496-503 e1 (2014).
  4. Gines, P. et al. Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study. Gastroenterology 93, 234-41 (1987).
  5. Gines, P., Cardenas, A., Arroyo, V. & Rodes, J. Management of cirrhosis and ascites. N Engl J Med 350, 1646-54 (2004).
  6. Thomsen, T.W., Shaffer, R.W., White, B. & Setnik, G.S. Videos in clinical medicine. Paracentesis. N Engl J Med 355, e21 (2006).
  7. Wong, C.L., Holroyd-Leduc, J., Thorpe, K.E. & Straus, S.E. Does this patient have bacterial peritonitis or portal hypertension? How do I perform a paracentesis and analyze the results? JAMA 299, 1166-78 (2008).