Ascites paracentesis

In the individual case, these short-term measures (possibly also reinfusion of ascitic fluid) lead to a temporary improvement of hypoalbuminaemia and hypovolaemia, so that a diuretic therapy, which has been hitherto insufficient, can nevertheless be continued and successfully completed. If stages I-III fail to be efficacious in eliminating ascites, paracentesis is indicated. 

Replace with 8-10 g albumin/L of ascitic fluid removed o Avoid large-volume paracentesis in patients with pre-existing hemodynamic compromise, acute renal insufficiency, active infection, or active upper gastrointestinal bleed. Cautious large-volume paracentesis in patients with tense... 

Serial therapeutic paracentesis (as above under tense ascites)... 

Consider large-volume paracentesis if evidence of abdominal compartment syndrome is secondary to tense ascites... 

Signs and symptoms of SBP in a patient with cirrhosis and ascites should prompt a diagnostic paracentesis (Fig. 19-4). In SBP, there is decreased total serum protein, elevated white blood cell count (with left shift), and the ascitic fluid contains at least 0.250 x 103/mm3 (0.250 x 109/L) neutrophils. Bacterial culture of ascitic fluid may be positive, but lack of growth does not exclude the diagnosis. 

In the case of tense ascites, relief of acute discomfort may be accomplished by therapeutic paracentesis. Often the removal of just 1 to 2 L of ascitic fluid provides relief of pain and fullness. When removing 5 L or more of fluid at once, volume resuscitation with 8 to 10 g of albumin given intravenously should be provided for each liter of fluid removed. If less than 5 L of fluid is removed in a hemodynamically stable patient, albumin is not warranted.22... 

The patient should be evaluated for clinical signs of ascites and managed with pharmacologic treatment (e.g., diuretics) and paracentesis. Careful... 

If tense ascites is present, a 4- to 6-L paracentesis should be performed prior to institution of diuretic therapy and salt restriction. 

Paracentesis with removal of up to 5 litres of ascitic fluid in fhose with tense ascites appears safe. 

Larger volumes can only be safely removed if there is simultaneous albumin replacement intravenously (with about 8 g of albumin per litre of ascites). Synthetic plasma-expanders may not be greatly inferior to albumin in the short term. Transjugular intrahep-atic portal systemic shunting (TIPS) appears at least as effective as paracentesis in relieving refractory ascites without increasing mortality but with a raised risk of encephalopathy. 

Accessory measures insertion of a peritoneo-venous shunt to allow transfer of ascitic fluid to the venous compartment has largely been abandoned due to frequent shunt obstruction, peritoneal infection and the occurrence of encephalopathy. TIPS is as effective in relieving ascites as paracentesis with albumin replacement, but shunts can quickly become obstructed, and hepatic encephalopathy is a common complication. 

In addition to spironolactone, ascites can be managed by paracentesis. That is the removal ( tapping ) of ascitic fluid from the peritoneal cavity under aseptic conditions. A colloid (human albumin solution (20%)) is infused (40 mL (8 g of albumin) per litre of ascites drained) intravenously during paracentesis, in order to prevent intravascular volume depletion and the onset of renal failure. Following paracentesis, ascites recurs in the majority (93%) if diuretic therapy is not reinstituted, but recurs in only 18% of patients treated with... 

Patient 4 is a 58-year-old with a history of excess alcohol intake approximately 60 units per week for the past four years. Recent admissions have been for ascites requiring paracentesis, spontaneous bacterial peritonitis, and large variceal bleeds. Over the last six months the patient has had a reduced appetite, poor nutrition and a significant loss of muscle mass. 

Abdominal paracentesis is useful particularly when ascites is tense rapid drainage of 5 litres leads to prompt relief of discomfort and improves circulatory dynamics. Provided renal function is not compromised, extensive paracentesis is safe and can be used as an adjunct to diuretic therapy to shorten hospital stay. When more than 5 litres are drained it is customary to infuse colloid or albumin (6-8 g per litre of fluid removed) to prevent hypovolaemia. 

Prevention is achieved through simply reducing the ascitic volume by means of efficient diuretic therapy, so that the total protein and complement factors in ascites rise significantly. Paracentesis can also be helpful if the protein deficiency is compensated at the same time. 

Replacement of sodium-free albumin (40 g or 6-8 g/litre ascitic fluid), half the amount prior to starting paracentesis or administration of 100-150 ml of a sodium-free plasma expander prior to paracentesis and prior to the replacement of albumin. 

Results The results of paracentesis have generally been good up to now the number of successfully treated patients was higher, inpatient hospitalization was shorter, and complications were less frequent or less severe. The response to diuretic therapy improved considerably discontinued diuretic therapy could be successfully taken up again. (158,159) Plasma values of renin, aldosterone and norepinephrine dropped. There was an improvement in lung volume (141,143) as well as in cardiac function values. (152,153,156) The pressure in the oesophageal varices fell. (150) Paracentesis of 6 litres of ascitic fluid removes 6 X 130 mmol sodium. 

An ascites fistula following paracentesis can be widely avoided by displacing the skin tangentially to the site of puncture, so that a Z-shaped puncture channel is created once the needle has been removed. 

With reliable cooperation on the part of the patient, precise adherence to stepwise therapy (possibly including repeated paracentesis) and almost total exclusion of the causes of therapy resistance, it becomes clear that true refractory ascites or sequestered ascites is present in merely 5-15% of patients with portal ascites. 

In all patients, conservative therapy is initially founded on basic and diuretic therapy, which is successful in 60-80% of cases. In individual instances, the therapeutic measures of stage III are recommended. Apparent refractory forms of ascites call for paracentesis (stage IV), unless there are reasons against this. Some 80-90% of all patients with portal ascites can be successfully treated conservatively. Given the appropriate indication, reinfusion of ascitic fluid is also feasible. 

Fevery, J., Roey, van, G., Steenbergen, van, W. Ascites medical therapy and paracentesis. Acta Gastroenterol. Belg. 1996 59 198-201... 

Large volume paracentesis and intravenous dextran to treat tense ascites. J. Chn. Gastroenterol. 1992 14 31 -35... 

Angnelra, C.E., Kadakia, S. Effects of large-volume paracentesis on pulmonary function in patients with tense cirrhotic ascites. Hepatology 1994 20 825-828... 

Cadranel, XF., Gargot, D., Grippon, R, Lunel, F., Bernard, B., Valla, D., Opolon, R Spontaneous dialytic ultrafiltration with intraperitoneal reinfusion of the concentrate versus large paracentesis in cirrhotic patients with intractable ascites a randomized study. Int. J. Artif Org. 1992 15 432-435... 

Fasslo, E., Terg, R., Landelra, G., Abecasls, R., Salemne, M., Podesta, A., Rodriguez, R, Levi, D., Kravetz, D. Paracentesis with dextran 70 vs. paracentesis with albumin in cirrhosis with tense ascites. Results of a randomized study. J. Hepatol. 1992 14 310-316... 

Garcla-Compean, D., Zacarias Villarreal, J., Bahena Cuevas, H., Garcia Cantu, D.A., Estrella, M., Garza Tamez, E., Valadez Castillo, R., Barragan, R.F. Total therapeutic paracentesis (TTP) with and without intravenous albumin in the treatment of cirrhotic tense ascites a randomized controlled trial. Liver 1993 13 233-238... 

Luca, A., Feu, F., Garda-Pagan, J.C., Jimenez, W., Arroyo, V., Bosch, J., Rodes, J. Eavorable effects of total paracentesis on splanchnic hemodynamics in cirrhotic patients with tense ascites. Hepatology 1994 20 30- 33... 

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