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Digestive Diseases and Sciences

, Volume 52, Issue 12, pp 3307–3315 | Cite as

An Evidence-Based Manual for Abdominal Paracentesis

  • Angela McGibbon
  • Grant I. Chen
  • Kevork M. Peltekian
  • Sander Veldhuyzen van ZantenEmail author
Review Paper

Abstract

The purpose of this study was to provide evidence-based approaches to detect ascites, perform paracentesis, order tests, and interpret the results. A Medline search was performed to identify relevant articles. Of 731 identified articles, 50 articles were used. The most sensitive findings for ascites detection are ankle edema (93%), increased abdominal girth (87%), flank dullness (84%), and bulging flanks (81%). Paracentesis is safe, with bleeding rates and leakage of <1%. An ascitic fluid polymorphonuclear cell count ≥250 cells/mm3 is the most sensitive test (86%–100%) to diagnose spontaneous bacterial peritonitis. The serum-ascites albumin gradient is the most useful test in identifying portal hypertension-related ascites. Large-volume paracentesis is effective in the treatment of refractory ascites. We conclude that paracentesis is a safe and vital procedure in patients with new-onset ascites. Once detected, an algorithmic approach to ordering tests and their interpretation is useful to determine etiology and direct further management.

Keywords

Ascites Paracentesis Diagnosis Review Systematic review 

References

  1. 1.
    Runyon BA (2004) Management of adult patients with ascites due to cirrhosis. Hepatology 39:841–856PubMedCrossRefGoogle Scholar
  2. 2.
    Garcia-Tsao G (2001) Current management of the complications of cirrhosis and portal hypertension: variceal hemorrhage, ascites, and spontaneous bacterial peritonitis. Gastroenterology 120:726–748PubMedCrossRefGoogle Scholar
  3. 3.
    Moore KP, Wong F, Gines P, Bernardi M, Ochs A, Salerno F, Angeli P, Porayko M, Moreau R, Garcia-Tsao G, Jimenez W, Planas R, Arroyo V (2003) The management of ascites in cirrhosis: Report on the consensus conference of the International Ascites Club. Hepatology 38:258–266Google Scholar
  4. 4.
    Gines P, Cardenas A, Arroyo V, Rodes J (2004) Management of cirrhosis and ascites. N Engl J Med 350:1646–1654PubMedCrossRefGoogle Scholar
  5. 5.
    Boey JH (1994) Peritoneal cavity. In: Way LW (ed). Current surgical diagnosis and treatment, 10th ed. Appleton & Lange, Norwalk, CT, p 453Google Scholar
  6. 6.
    Williams JW, Simel DL (1992) Does this patient have ascites? How to divine fluid from the abdomen. JAMA 267:2645–2648PubMedCrossRefGoogle Scholar
  7. 7.
    Seidel HM, Ball JW, Dains JE, Benedict GW (1999) Mosby’s guide to physical examination, 4th ed. Mosby, St. LouisGoogle Scholar
  8. 8.
    Chongtham DS, Singh MM, Kalantri SP, Pathak S, Jain AP (1998) Accuracy of clinical manoeuvres in detection of minimal ascites. Indian J Med Sci 52:514–520PubMedGoogle Scholar
  9. 9.
    Runyon BA, Montano AA, Akriviadis EA, Antillon MR, Irving MA, McHutchison JG (1992) The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med 117:215–220PubMedGoogle Scholar
  10. 10.
    Rimola A, Garcia-Tsao G, Navasa M, Piddock LJ, Planas R, Bernard B, Inadomi JM (2000) Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: A consensus document. International Ascites Club. J Hepatol 32:142–153PubMedCrossRefGoogle Scholar
  11. 11.
    Hoefs JC, Runyon BA (1985) Spontaneous bacterial peritonitis. Dis Mon 31:1–48PubMedCrossRefGoogle Scholar
  12. 12.
    Altman C, Grange JD, Amiot X, Pelletier G, Lacaine F, Bodin F, Etienne JP (1995) Survival after a first episode of spontaneous bacterial peritonitis. Prognosis of potential candidates for orthotopic liver transplantation. J Gastroenterol Hepatol 10:47–50PubMedGoogle Scholar
  13. 13.
    Akriviadis EA, Runyon BA (1990) Utility of an algorithm in differentiating spontaneous from secondary peritonitis. Gastroenterology 98:127–133PubMedGoogle Scholar
  14. 14.
    Runyon BA (1986) Paracentesis of ascitic fluid: A safe procedure. Arch Intern Med 146:2259–2261PubMedCrossRefGoogle Scholar
  15. 15.
    Bard C, Lafortune M, Breton G (1986) Ascites: Ultrasound guidance or blind paracentesis? CMAJ 135:209–210PubMedGoogle Scholar
  16. 16.
    Mallory A, Schaefer JW (1978) Complications of diagnostic paracentesis in patients with liver disease. JAMA 239:628–630PubMedCrossRefGoogle Scholar
  17. 17.
    McVay PA, Toy PT (1991) Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion 31:164–171PubMedCrossRefGoogle Scholar
  18. 18.
    Pache I, Bilodeau M (2005) Severe haemorrhage following abdominal paracentesis for ascites in patients with liver disease. Aliment Pharmacol Ther 21:525–529PubMedCrossRefGoogle Scholar
  19. 19.
    Qureshi WA, Harshfield D, Shah H, Netchvolodoff C, Banerjee B (1992) An unusual complication of paracentesis. Am J Gastroenterol 87:1209–1211PubMedGoogle Scholar
  20. 20.
    Aagaard J, Jensen LI, Sorensen TI, Christensen U, Burcharth F (1982) Recanalized umbilical vein in portal hypertension. Am J Radiol 139:1107–1110Google Scholar
  21. 21.
    Oelsner DH, Caldwell SH, Coles M, Driscoll CJ (1998) Subumbilical midline vascularity of the abdominal wall in portal hypertension observed at laparoscopy. Gastrointest Endosc 47:388–390PubMedCrossRefGoogle Scholar
  22. 22.
    Conn HO (1979) Bacterial peritonitis: Spontaneous or paracentetic? Gastroenterology 77:1145–1146PubMedGoogle Scholar
  23. 23.
    Runyon BA (2002) Ascites and spontaneous bacterial peritonitis. In: Feldman M, Friedman LS, Sleisenger MH (eds). Sleisenger & Fordtran’s gastrointestinal and liver disease, 7th ed. Saunders, Philadelphia, pp 1519–1521Google Scholar
  24. 24.
    Hale BR Jr, Girzadas DV Jr (2001) Application of 2-octyl-cyanoacrylate controls persistent ascites fluid leak. J Emerg Med 20:85–86PubMedCrossRefGoogle Scholar
  25. 25.
    Antillon MR, BA Runyon (1991) Effect of marked peripheral leukocytosis on the leukocyte count in ascites. Arch Intern Med 151:509–510PubMedCrossRefGoogle Scholar
  26. 26.
    Castellote J, Lopez C, Gornals J, Tremosa G, Farina ER, Baliellas C, Domingo A, Xiol X (2003) Rapid diagnosis of spontaneous bacterial peritonitis by use of reagent strips. Hepatology 37:893–896PubMedCrossRefGoogle Scholar
  27. 27.
    Thevenot T, Cadranel JF, Nguyen-Khac E, Tilmant L, Tiry C, Welty S, Merzoug N (2004) Diagnosis of spontaneous bacterial peritonitis in cirrhotic patients by use of two reagent strips. Eur J Gastroenterol Hepatol 16:579–583PubMedCrossRefGoogle Scholar
  28. 28.
    Vanbiervliet G, Rakotoarisoa C, Filippi J, Guerin O, Calle G, Hastier P, Marine-Bajoan E, Schneider S, Piche T, Broussard JF, Dor JF, Benzaken S, Hebuterne X, Rampal P, Tran A (2002) Diagnostic accuracy of a rapid urine-screening test (Multistix8SG) in cirrhotic patients with spontaneous bacterial peritonitis. Eur J Gastroenterol Hepatol 14:1257–1260PubMedCrossRefGoogle Scholar
  29. 29.
    Butani RC, Shaffer RT, Szyjkowski RD, Weeks BE, Speights LG, Kadakia SC (2004) Rapid diagnosis of infected ascitic fluid using leukocyte esterase dipstick testing. Am J Gastroenterol 99:532–537PubMedCrossRefGoogle Scholar
  30. 30.
    Sapey T, Mena E, Fort E, Laurin C, Kabissa D, Runyon BA, Mendler MH (2005) Rapid diagnosis of spontaneous bacterial peritonitis with leukocyte esterase reagent strips in a European and in an American center. J Gastroenterol Hepatol 20:187–192PubMedCrossRefGoogle Scholar
  31. 31.
    Hoefs JC (1981) Increase in ascites white blood cell count and protein concentrations during diuresis in patients with chronic liver disease. Hepatology 1:249–254PubMedCrossRefGoogle Scholar
  32. 32.
    DeSitter L, Rector WG Jr (1984) The significance of bloody ascites in patients with cirrhosis. Am J Gastroenterol 79:136–138PubMedGoogle Scholar
  33. 33.
    Hoefs JC (1983) Serum protein concentration and portal pressure determine the ascitic fluid protein concentration in patients with chronic liver disease. J Lab Clin Med 102:260–273PubMedGoogle Scholar
  34. 34.
    Siersema PD, de Marie S, van Zeijl JH, Bac DJ, Wilson JH (1992) Blood culture bottles are superior to lysis-centrifugation tubes for bacteriological diagnosis of spontaneous bacterial peritonitis. J Clin Microbiol 30:667–669PubMedGoogle Scholar
  35. 35.
    Runyon BA (1986) Low-protein-concentration ascitic fluid is predisposed to spontaneous bacterial peritonitis. Gastroenterology 91:1343–1346PubMedGoogle Scholar
  36. 36.
    Runyon BA, Hoefs JC (1985) Ascitic fluid chemical analysis before, during and after spontaneous bacterial peritonitis. Hepatology 5:257–259PubMedCrossRefGoogle Scholar
  37. 37.
    Runyon BA (1987) Amylase levels in ascitic fluid. J Clin Gastroenterol 9:172–174PubMedCrossRefGoogle Scholar
  38. 38.
    Cardenas A, Chopra S (2002) Chylous ascites. Am J Gastroenterol 97:1896–1900PubMedGoogle Scholar
  39. 39.
    Runyon BA (1987) Ascitic fluid bilirubin concentration as a key to choleperitoneum. J Clin Gastroenterol 9:543–545PubMedCrossRefGoogle Scholar
  40. 40.
    DiBonito L, Falconieri G, Colautti I, Bonifacio D, Dudine S (1993) The positive peritoneal effusion. A retrospective study of cytopathologic diagnoses with autopsy confirmation. Acta Cytol 37:483–488PubMedGoogle Scholar
  41. 41.
    Runyon BA, Hoefs JC, Morgan TR (1988) Ascitic fluid analysis in malignancy-related ascites. Hepatology 8:1104–1109PubMedCrossRefGoogle Scholar
  42. 42.
    Muneef MA, Memish Z, Mahmoud SA, Sadoon SA, Bannatyne R, Khan Y (2001) Tuberculosis in the belly: a review of forty-six cases involving the gastrointestinal tract and peritoneum. Scand J Gastroenterol 36:528–532PubMedCrossRefGoogle Scholar
  43. 43.
    Hillebrand DJ, Runyon BA, Yasmineh WG, Rynders GP (1996) Ascitic fluid adenosine deaminase insensitivity in detecting tuberculous peritonitis in the United States. Hepatology 24:1408–1412PubMedCrossRefGoogle Scholar
  44. 44.
    Uzunkoy A, Harma M, Harma M (2004) Diagnosis of abdominal tuberculosis: Experience from 11 cases and review of the literature. World J Gastroenterol 10:3647–3649PubMedGoogle Scholar
  45. 45.
    Xiao WB, Liu YL (2003) Elevation of serum and ascites cancer antigen 125 levels in patients with liver cirrhosis. J Gastroenterol Hepatol 18:1315–1316PubMedCrossRefGoogle Scholar
  46. 46.
    Shaheen NJ, Grimm IS (1996) Comparison of the Caldwell needle/cannula with Angiocath needle in large volume paracentesis. Am J Gastroenterol 91:1731–1733PubMedGoogle Scholar
  47. 47.
    Gines P, Guevara M, De Las Heras D, Arroyo V (2002) Review article: Albumin for circulatory support in patients with cirrhosis. Aliment Pharmacol Ther 16(Suppl 5):24–31PubMedCrossRefGoogle Scholar
  48. 48.
    Webster ST, Brown KL, Lucey MR, Nostrant TT (1996) Hemorrhagic complications of large volume abdominal paracentesis. Am J Gastroenterol 91:366–368PubMedGoogle Scholar
  49. 49.
    Arnold C, Haag K, Blum HE, Rossle M (1997) Acute hemoperitoneum after large-volume paracentesis. Gastroenterology 113:978–982PubMedGoogle Scholar
  50. 50.
    Martinet O, Reis ED, Mosimann F (2000) Delayed hemoperitoneum following large-volume paracentesis in a patient with cirrhosis and ascites. Dig Dis Sci 45:357–358PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Angela McGibbon
    • 1
  • Grant I. Chen
    • 1
  • Kevork M. Peltekian
    • 1
  • Sander Veldhuyzen van Zanten
    • 1
    • 2
    Email author
  1. 1.Division of Gastroenterology, Department of MedicineDalhousie UniversityHalifaxCanada
  2. 2.Queen Elizabeth II Health Sciences Center Victoria General Hospital SiteHalifaxCanada

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