Early Paracentesis in Patients Admitted With Cirrhotic Ascites

Cirrhosis refers to a chronic liver disease that causes the liver’s normal architecture to change. It leads to scarring, the formation of fibrous tissue, and fluid (ascites) in the abdomen. Some cases may require invasive hospital procedures.

Ascites is cirrhosis’ most frequent complication. Fifty-eight percent of patients who are diagnosed with cirrhosis have been known to develop ascites within ten years. It happens when the portal vein, which transports blood from the digestive system to the liver, experiences abnormally high pressures causing portal hypertension. 

If cirrhotic ascites is not treated promptly, the accumulation of fluid in the abdominal region can lead to severe complications including infection, spontaneous bacterial peritonitis (SBP). SBP can increase the risk of hepatorenal syndrome (HRS) and in extreme cases can be fatal. This is where early paracentesis comes into play. It is used for the diagnosis of SBP and to reduce associated risks

What Is Early Paracentesis?

Paracentesis is a procedure that is performed on patients with cirrhosis. It involves inserting a catheter under ultrasound guidance into the peritoneal cavity and aspirating ascitic fluid for ascitic fluid analysis and potentially as a therapeutic procedure to remove excess peritoneal fluid. This is done with a catheter or a needle and the procedure is performed under local or regional anesthesia. Once the fluid is removed, it is collected and sent to a laboratory for analysis to help determine the cause of the accumulation and whether the ascitic fluid is infected.

Research suggests that around 1 in 400 adults in the United States experiences cirrhosis, a condition that slows down blood flow through the liver and can lead to ascites and other complications of cirrhosis (gastroesophageal varices, hepatic encephalopathy, hepatopulmonary syndrome, hepatorenal syndrome, hepatic hydrothorax and congestive splenomegaly). In such cases, early paracentesis becomes extremely important for any patient admitted to the hospital. With early paracentesis, the procedure is performed within 24 hours of the patient’s hospital admission.

Why Is Early Paracentesis Important in Cirrhotic Ascites?

Early paracentesis is crucial in patients with cirrhotic ascites for several reasons:

  • Provides relief from symptoms: cirrhotic ascites can cause abdominal distension, pain, and discomfort. This can significantly impact the patient’s quality of life and have an adverse effect on their overall health and well-being. Paracentesis provides immediate relief from these symptoms and can be a life-saving procedure among critically ill patients.
  • Provides diagnostic insight and information: the fluid from the ascites is collected during paracentesis and can offer extremely useful insights into the patient’s condition. It is analyzed to determine the cause of fluid accumulation and to check for the presence of infections such as spontaneous bacterial peritonitis (SBP). It is used to detect and treat issues, thereby preventing further complications and reducing risks.
  • Encourages management of portal hypertension: cirrhotic ascites is caused by portal hypertension which can lead to variceal bleeding, congestive splenomegaly and other life-threatening complications. By performing paracentesis, the etiology of ascites can be diagnosed. If the patient has cirrhotic ascites, efforts can be made to decrease portal hypertension and minimize further complications.
  • Helps prevent renal failure: patients with cirrhosis often experience renal failure if cirrhotic ascites becomes infected. Paracentesis helps prevent this complication by detecting and treating SBP as early as possible.
  • Improves monitoring of fluid imbalance: paracentesis enables physicians to monitor the fluid balance in patients experiencing cirrhosis which is crucial for the treatment and management of associated complications.

As is the case with any medical issue, early treatment can be extremely crucial and effective in addressing it while preventing risks and fatalities. Early paracentesis is, therefore, important for patients with cirrhotic ascites to ensure positive outcomes.

The Connection Between Early Paracentesis and Inpatient Mortality

Paracentesis is a crucial procedure in the management of cirrhotic ascites. Its importance is further reinforced by studies that have shown that it is also associated with lower in-patient mortality among patients with cirrhotic ascites. 

In a study conducted by the American Association for the Study of Liver Diseases (AASLD), researchers discovered that patients who underwent early paracentesis had a lower mortality rate compared to those who did not receive treatment and undergo the procedure during the same time frame. 

Early paracentesis also prevents and treats several life-threatening complications such as spontaneous bacterial peritonitis (SBP), increased portal hypertension, and renal failure. These can cause severe morbidity and be fatal, making early paracentesis crucial. This is why the AASLD recommends that all patients with cirrhotic ascites should have a diagnostic paracentesis even if they do not have symptoms of spontaneous bacterial peritonitis.

Performing Paracentesis

Paracentesis is a safe procedure and can even be performed as an outpatient treatment, in the ER, hospital wards and in the ICU with only rare complications. 

The procedure begins with the administration of local anesthesia to the area where the needle or catheter will be inserted. A needle or catheter is inserted into the abdominal cavity and is used to sample the ascitic fluid and remove excessive ascitic fluid. The amount of fluid removed depends on the patient’s specific condition and the severity of the ascites. Once the fluid is removed, it is sent to the laboratory for tests and analysis to determine whether infections or other abnormalities are present.

The procedure is usually well tolerated. Patients can return to their regular activities soon after. Patients who undergo paracentesis are monitored for potential complications such as hypovolemia, electrolyte imbalances, and bacterial infections. The results from the fluid test are used to ensure proper medical care and management, address underlying causes for the ascites, and prevent recurrences. 

This can include medication therapy, lifestyle changes, and in some cases a liver transplant.

Final Thoughts

Early paracentesis is a life-saving procedure for patients with cirrhotic ascites. It provides instant relief from symptoms that adversely affect the patient’s life and overall well-being, helps with the diagnosis and management of cirrhosis, and prevents life-threatening complications. Though there are a number of invasive hospital procedures in cases of cirrhosis, paracentesis is a safe and minimally invasive procedure.

In addition, the procedure is also associated with lower inpatient mortality rates which highlights its importance for cirrhotic patients.

References:

Rosenblatt, R. Tafesh, Z. Shen, N. Cohen-Mekelburg,S. Kumar, S. Lucero, C. Early Paracentesis in High-Risk Hospitalized Patients: Time for a New Quality Indicator. Am J Gastroenterol. 2019 . 114(12) 1863-1869
[vii] AGA Clinical Practice Update: Coagulation in Cirrhosis. Jacqueline G. O’Leary et al. Gastroenterology. 2019; 157, No. 1: 34-43
Moore, K. Aithal,G. Guidelines on the management of ascites in cirrhosis. Gut. 2006. 55(suppl6) vi1–vi12
Tocia, C. Dumitru, A. Alexandrescu, L, Popescu, R. Dumitri, E. Timing of paracentesis and outcomes in hospitalized patients with decompensated cirrhosis. World J Hepatol. 2020. 12(12): 1267–1275
Orman, E. Hayashi, P. Bataller,R. Barrit, S. Paracentesis is associated with reduced mortality in patients hospitalized with cirrhosis and ascites. Clin Gastroenterol Hepatol. 2014;12(3):496-503

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