Makindo Medical Notes

Abdominal paracentesis is a bedside procedure to remove ascitic fluid, either for diagnosis (e.g. rule out spontaneous bacterial peritonitis, SBP) or therapy (to relieve tense ascites). 💡 Always consider diagnostic paracentesis on admission in a cirrhotic patient with ascites — SBP can be silent but life-threatening.

🧠 Pathophysiology Context

• Ascites is most commonly due to portal hypertension from cirrhosis → raised hydrostatic pressure + low oncotic pressure (hypoalbuminaemia) → fluid transudation.
• Other causes: malignancy, TB peritonitis, cardiac failure, pancreatitis.
• Paracentesis relieves intra-abdominal pressure, improving breathing, appetite, and comfort.

📌 About

• Diagnostic paracentesis: Small volume for fluid analysis (protein, SAAG, culture).
• Therapeutic paracentesis: Large-volume drainage (>5 L) for symptom relief.
• Routine coagulation or platelet testing is not required unless high bleeding risk (per guidelines).

✅ Indications

• All cirrhotic patients with ascites on admission (rule out SBP).
• New-onset ascites of uncertain cause.
• Clinical deterioration: fever, abdominal pain, encephalopathy, renal failure.
• Symptomatic tense ascites requiring relief.

🚫 Contraindications

• Severe uncorrectable coagulopathy (INR >1.5, platelets <40 ×10⁹/L).
• Distended bowel from obstruction, infected abdominal wall at puncture site.
• Relative: pregnancy, abdominal wall collaterals, large intra-abdominal masses.

⚠️ Cautions

• Hyponatraemia, renal impairment, anaemia, hypoalbuminaemia (<20 g/L).
• Poor cooperation, prior surgery with adhesions, pregnancy (USS guidance essential).

🔎 Complications

• Bleeding — intra-abdominal haemorrhage can be fatal.
• Bowel perforation → peritonitis.
• Persistent fluid leak from puncture site.
• Post-paracentesis circulatory dysfunction → hypotension, hyponatraemia.

🛠️ Procedure Essentials

• Consent, identity check, baseline obs, IV access.
• Empty bladder (void/catheterise).
• Position: supine, head on pillow.
• Site: left lower quadrant, lateral to rectus sheath; USS guidance reduces risk.
• Clean skin, drape sterile field. Anaesthetise skin & peritoneum (lidocaine).
• Use Z-track technique to reduce post-drain leakage.

🔬 Investigations from Ascitic Fluid

• SAAG (Serum-Ascites Albumin Gradient):
  • ≥1.1 g/dL → portal hypertension (cirrhosis, heart failure).
  • <1.1 g/dL → malignancy, TB, pancreatitis.
• Culture & microscopy (ascitic neutrophils >250/mm³ = SBP).
• Total protein (low in cirrhosis; high in malignancy, TB).
• Additional: cytology, amylase, BNP, ADA depending on suspicion.

💉 Post-Procedure Care

• Albumin infusion: Give 8 g per litre drained if >5 L removed (e.g. 20% albumin) to prevent circulatory dysfunction.
• For SBP with renal risk: 1.5 g/kg albumin on day 1, then 1 g/kg on day 3.
• Monitor vitals, puncture site, urine output.

⏱️ Drain Duration

• Usually removed after fluid evacuation (same day, within a few hours).
• Large-volume (>8 L): may need staged removal.
• Not usually left >24 h — infection and leakage risk rises significantly.

💡 Clinical Pearl: Do not delay diagnostic paracentesis in cirrhotic patients with ascites + fever or encephalopathy while awaiting clotting results. Early diagnosis and treatment of SBP improves survival.

📚 References

• EASL Guidelines on the management of ascites in cirrhosis (2020)
• BNF: Human Albumin Solution
• Albumin in cirrhosis: evidence and indications