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Paracentesis

Paracentesis is a minimally invasive medical procedure that involves the insertion of a needle and catheter into the peritoneal cavity to remove excess fluid accumulation known as ascites from the abdomen.^[1]^[2] This fluid buildup occurs between the layers of the peritoneum, the membrane lining the abdominal cavity, and is most commonly caused by liver cirrhosis, though it can also result from conditions such as cancer, infections, heart failure, or kidney disease.^[1]^[2] The procedure serves both diagnostic and therapeutic purposes: diagnostically, a small sample of fluid (typically 25-30 mL) is analyzed to identify underlying causes, such as spontaneous bacterial peritonitis or malignancy, through tests including cell counts, protein levels, and the serum-ascites albumin gradient (SAAG).^[1]^[2] Therapeutically, larger volumes—up to 5 liters or more in cases of large-volume paracentesis (LVP)—are drained to alleviate symptoms like abdominal distension, discomfort, shortness of breath, and reduced mobility associated with tense ascites.^[1]^[2] It is indicated for new-onset ascites, suspected infection, or respiratory compromise due to fluid pressure, and is particularly vital in patients with cirrhosis, where ascites affects up to 50% of cases and carries significant mortality risk.^[2] Performed at the bedside or in an outpatient setting under local anesthesia and often with ultrasound guidance for safety, paracentesis typically takes 20-45 minutes and involves positioning the patient supine, sterilizing the lower abdominal quadrant, numbing the site with lidocaine, and using a Z-track insertion technique to minimize leakage.^[1]^[2] Healthcare providers such as gastroenterologists or interventional radiologists conduct the procedure using specialized kits including 18-20 gauge needles, catheters, and drainage bags, with intravenous albumin infusion recommended after LVP exceeding 5 liters to prevent circulatory dysfunction.^[1]^[2] Although generally safe with low complication rates, potential risks include bleeding, infection, fluid leakage, bowel perforation, or hypotension, particularly in patients with coagulopathy or on blood thinners; absolute contraindications encompass acute surgical abdomen or severe bleeding disorders.^[1]^[2] Post-procedure recovery involves 24 hours of rest, monitoring for vital signs and signs of infection, wound care to address any seepage, and lifestyle measures like a low-sodium diet to manage recurrent ascites, which may necessitate repeated procedures or indwelling catheters.^[1]^[2]

Overview

Definition and Types

Paracentesis is a medical procedure that involves the percutaneous insertion of a needle or catheter into the peritoneal cavity to aspirate fluid, primarily ascitic fluid, which accumulates abnormally due to conditions such as liver cirrhosis, malignancy, or infection.^[2] The term derives from the Greek "parakentein," meaning "to pierce at the side," reflecting its historical roots in targeting fluid buildup in the abdomen.^[3] There are two main types of paracentesis: diagnostic and therapeutic. Diagnostic paracentesis entails the removal of a small volume of ascitic fluid, typically 25 to 50 mL, for laboratory analysis to determine the underlying cause of ascites or to exclude infections such as spontaneous bacterial peritonitis.^[2] In contrast, therapeutic paracentesis, often termed large-volume paracentesis (LVP), involves extracting larger quantities of fluid, generally exceeding 5 liters, to provide symptomatic relief in cases of tense ascites.^[3]^[2] The primary purposes of paracentesis are both diagnostic and palliative. Therapeutically, it alleviates intra-abdominal pressure that contributes to symptoms like dyspnea, abdominal pain, and early satiety, thereby improving patient comfort and quality of life.^[2] Diagnostically, it facilitates the identification of etiologies such as infection or malignancy through fluid examination.^[3] The procedure has been used since antiquity for ascites management, with Hippocrates describing it around 400 BCE, and underwent significant modern refinements in the 20th century, including the integration of ultrasound guidance for enhanced safety and precision.^[4] It is commonly performed for new-onset ascites or suspected spontaneous bacterial peritonitis.^[2]

Epidemiology

Paracentesis is most commonly performed to address ascites, a condition predominantly caused by liver cirrhosis, which accounts for 80-85% of all cases.^[5] Approximately 50% of patients diagnosed with cirrhosis develop ascites within 10 years, marking a critical progression to decompensated disease.^[6] Other etiologies include malignancy (10%), heart failure (3%), and infections such as tuberculous peritonitis, though these are less frequent.^[7] The global burden of ascites is disproportionately higher in regions with elevated rates of liver disease, particularly those driven by alcohol consumption or viral hepatitis like hepatitis B and C.^[8] The clinical significance of ascites in cirrhosis is underscored by its impact on patient outcomes, with a 1-year mortality rate of 20% among affected individuals, compared to 7% in those with compensated cirrhosis without ascites.^[9] In cases of suspected spontaneous bacterial peritonitis (SBP), a common complication necessitating diagnostic paracentesis, delaying the procedure beyond 12 hours from admission increases in-hospital mortality by 2.7-fold, even after adjusting for factors like MELD score and renal dysfunction.^[10] These statistics highlight the procedure's role in timely diagnosis and management to mitigate poor prognosis. Recent trends as of 2025 reflect an expansion in the performance of paracentesis by advanced practice providers (APPs), such as nurse practitioners and physician assistants, particularly in interventional radiology and outpatient settings, driven by growing procedure volumes and reimbursement opportunities.^[11] This shift supports broader access to therapeutic paracentesis for refractory ascites amid rising demand.^[12]

Indications and Contraindications

Indications

Paracentesis is indicated for both diagnostic and therapeutic purposes in patients with ascites, particularly those associated with cirrhosis. Diagnostic paracentesis is recommended for all patients presenting with new-onset ascites of unknown origin to determine the underlying etiology, such as portal hypertension via serum-ascites albumin gradient (SAAG) analysis.^[13] It is also essential in cases of suspected spontaneous bacterial peritonitis (SBP), including clinical features like fever, abdominal pain, or hepatic encephalopathy in cirrhotic patients, where ascitic fluid analysis for polymorphonuclear leukocyte count (>250 cells/mm³) and culture confirms the diagnosis.^[13]^[14] Guidelines strongly advise performing diagnostic paracentesis on admission for all hospitalized patients with cirrhosis and ascites, even in the absence of overt symptoms, to monitor for complications like SBP and assess disease progression.^[13]^[14] This is particularly relevant for evaluating potential malignancy through cytology or tuberculosis via acid-fast bacilli staining and adenosine deaminase levels in ascitic fluid when these etiologies are suspected.^[13] Therapeutic paracentesis, often as large-volume paracentesis (LVP) involving removal of more than 5 liters of fluid, is indicated for symptomatic tense ascites unresponsive to diuretics, providing rapid symptom relief and improving quality of life.^[13]^[14] It is also recommended for refractory ascites in end-stage liver disease, including scenarios of respiratory compromise due to diaphragmatic elevation, and as a palliative measure to alleviate discomfort in patients not eligible for liver transplantation.^[13]^[14] The alfapump system, approved by the US FDA in December 2024, is used for managing recurrent or refractory ascites due to liver cirrhosis as an outpatient option; it continuously transfers ascitic fluid from the peritoneal cavity to the bladder, reducing the need for repeated LVPs.^[15]

Contraindications

Paracentesis has few absolute contraindications, which represent conditions where the risks of the procedure significantly outweigh any potential benefits. These include an acute surgical abdomen, such as bowel perforation requiring laparotomy, disseminated intravascular coagulation (DIC) that is unresponsive to correction, and overt peritonitis accompanied by systemic sepsis.^[2]^[16]^[17] Relative contraindications are more common and often can be managed or mitigated, though they warrant careful evaluation. Uncorrectable coagulopathy, such as a platelet count below 20 × 10³/μL or an international normalized ratio (INR) greater than 2.0, is a key relative contraindication; however, the overall bleeding risk associated with paracentesis remains low, at approximately 0.2-0.6%, even in patients with mild to moderate coagulopathy.^[2]^[16]30407-5/fulltext) Other relative contraindications include pregnancy, due to potential risks to the fetus; bowel distention from ileus or obstruction; and site-specific issues such as skin infection at the entry point, enlarged organs (organomegaly), or vascular abnormalities like prominent abdominal wall vessels.^[2]^[16]^[17] Precautions are essential to minimize risks in patients with relative contraindications. Correctable coagulopathies should be addressed prior to the procedure, for example, through platelet transfusion for severe thrombocytopenia or administration of vitamin K or fresh frozen plasma for elevated INR.^[2]^[16] The procedure should be avoided at sites with multiple prior paracenteses due to the risk of adhesions and bowel adherence.^[17] Ultrasound guidance can help identify safe entry sites to avoid relative risks such as vascular structures or organ enlargement.^[18] Given the low overall complication rate, guidelines support proceeding with paracentesis in most cases of relative contraindications after appropriate precautions.^[2]^[16]

Procedure

Preparation and Equipment

Patient preparation for paracentesis begins with obtaining informed consent, during which the clinician explains the procedure's purpose, potential risks such as bleeding or infection, benefits including symptom relief, and alternatives like medical management.^[2]^[3] The patient is positioned supine or semi-recumbent at a 30- to 45-degree angle to facilitate fluid pooling in the lower quadrants, with the bladder emptied beforehand to reduce injury risk.^[2]^[19] Vital signs, including blood pressure and heart rate, are monitored before, during, and after the procedure to detect complications like hypotension.^[2] Prophylactic antibiotics are not routinely administered unless spontaneous bacterial peritonitis is suspected, in which case a third-generation cephalosporin may be given empirically if ascitic fluid neutrophil count exceeds 250 cells/mm³.^[2] Coagulation status is assessed via international normalized ratio (INR) and platelet count, but routine correction of coagulopathy is unnecessary even with INR up to 8.7 or platelets below 20 × 10³/μL, as the bleeding risk remains low; platelet transfusion may be considered only if counts are under 20 × 10³/μL.^[2]^[3] For large-volume paracentesis (LVP) involving removal of more than 5 L of fluid, intravenous albumin infusion is planned at 6 to 8 g of 25% albumin per liter removed to prevent post-paracentesis circulatory dysfunction.^[2]^[3] The procedure can be performed in a bedside, outpatient clinic, or interventional radiology suite setting, with no fasting required.^[2] Ultrasound is often used briefly to identify and mark the optimal entry site in a safe fluid pocket deeper than 2 cm.^[20]^[19] Essential equipment includes a sterile preparation kit with chlorhexidine or povidone-iodine solution, sterile drapes, and gloves; 1% lidocaine (typically 5 to 10 mL) with 25- or 27-gauge needles for local anesthesia; an 18- to 20-gauge access needle for diagnostic paracentesis; a catheter-over-needle system or 8- to 15-French angiocatheter for LVP; drainage tubing connected to a collection bag or vacuum bottles with up to 10 L capacity, or wall suction if available; and sample collection tubes (e.g., red-top, purple-top EDTA, and blood culture bottles) for 25 to 30 mL of diagnostic fluid.^[2]^[3]^[19] An ultrasound machine with a low-frequency curvilinear probe (3.5 MHz) and sterile sheath is recommended for guidance.^[20] Additional items such as 5- to 60-mL syringes, a #11 scalpel blade, gauze, and adhesive dressings ensure sterile technique and secure the site post-procedure.^[2]

Ultrasound Guidance

Ultrasound guidance in paracentesis serves to identify the optimal site for needle insertion by locating the deepest pocket of ascitic fluid, typically requiring a depth of at least 3 cm to ensure safe access, while avoiding interposed bowel, blood vessels, or solid organs such as the liver or spleen.^[2]^[21] This approach enhances procedural safety, particularly in patients with obesity or small-volume ascites, where physical landmarks may be unreliable.^[22] The technique involves using a curvilinear probe with a frequency of 3.5-5 MHz for initial fluid detection due to its deeper penetration, or a linear probe (8-12 MHz) for superficial assessment and real-time needle visualization if needed.^[20]^[23] Scanning begins in the lower abdominal quadrants lateral to the rectus sheath, with the left side preferred to minimize risk from epigastric vessels; the probe is applied in sagittal and transverse planes to confirm fluid depth and exclude vascular structures using color Doppler.^[22]^[20] The entry point is marked 2-3 cm below the umbilicus at the site of maximal fluid accumulation, either via static pre-procedure marking or dynamic real-time guidance during needle insertion.^[20]^[2] Guidelines from the Society of Hospital Medicine strongly recommend ultrasound guidance for all paracentesis procedures to reduce serious complications, such as bleeding, with evidence from large cohort studies showing a 68% lower odds of bleeding (OR 0.32, 95% CI 0.25-0.41) compared to blind techniques.^[22]^[24] Complication rates drop from 4.7% without guidance to 1.4% with it (OR 0.349), and success rates improve to 95-100% versus 61% for landmark-based methods.^[2]^[22] Dynamic guidance is particularly beneficial for visualizing the needle in challenging cases, though static marking suffices for larger fluid volumes in experienced operators.^[22] Limitations include limited availability of ultrasound equipment in some settings, which may necessitate reliance on clinical expertise for site selection.^[22] Additionally, while real-time guidance offers superior precision, evidence for its incremental benefit over static methods remains limited, and proficiency requires dedicated training.^[22]

Technique

Paracentesis is typically performed with the patient in a semi-recumbent position at 30 to 45 degrees to facilitate fluid pooling in the lower abdomen and minimize discomfort. The preferred site for insertion is the left lower quadrant, approximately 2 cm medial and superior to the anterior superior iliac spine, lateral to the rectus sheath, to avoid major vessels and bowel loops. This location is selected after percussion or imaging confirmation of a fluid pocket greater than 2 cm deep, with the skin marked using a permanent marker. The Z-track technique is employed by displacing the skin caudally prior to insertion to create a tortuous path that minimizes post-procedure fluid leakage.^[2]^[19]^[3] After ensuring the bladder is empty via voiding or catheterization, the area is prepared with chlorhexidine or povidone-iodine solution and sterile draping applied to create a working field. Local anesthesia is achieved by raising a skin wheal with 1% lidocaine using a 25-gauge needle, followed by deeper infiltration along the planned tract to the peritoneum using a 22-gauge needle, administering 5 to 10 mL total to anesthetize the abdominal wall, which may extend 2 to 4 cm in depth depending on patient habitus. A small nick in the skin is made with a No. 11 scalpel blade to facilitate entry.^[25]^[2]^[19] For insertion, an 18- to 20-gauge over-the-needle catheter or angiocatheter is advanced perpendicular to the skin in 5-mm increments while applying negative pressure with a syringe to aspirate; entry into the peritoneum is confirmed by the return of non-pulsatile ascitic fluid, at which point the needle is withdrawn and the catheter advanced 2 to 5 mm further. In the Z-track method, the skin is held displaced during insertion and released afterward to seal the tract. For diagnostic paracentesis, a single puncture suffices to aspirate 25 to 50 mL of fluid directly into syringes for analysis. If loculated ascites is suspected, multiple punctures may be required at different sites. The procedure is terminated immediately if resistance is encountered, frank blood is aspirated, or the patient reports significant pain, indicating potential organ injury.^[25]^[2]^[3] For therapeutic large-volume paracentesis (LVP), the catheter is connected via tubing to a vacuum collection bottle or gravity drainage bag using a three-way stopcock, allowing controlled aspiration by suction or passive flow at a rate of 300 to 500 mL per minute to avoid rapid hemodynamic shifts. Drainage is halted once symptoms resolve. Intravenous albumin (6 to 8 g per liter removed) is recommended if more than 5 L of fluid is removed to prevent circulatory dysfunction. The catheter is then removed, and the site covered with a sterile dressing and pressure applied for 5 minutes to achieve hemostasis.^[19]^[2]^[25] Variations include blind insertion in experienced hands for straightforward cases, though ultrasound guidance is standard to enhance safety; for refractory ascites, indwelling catheters like the Tenckhoff may be used for repeated access. The procedure duration is typically 15 to 30 minutes for diagnostic taps and 30 to 60 minutes for LVP, with continuous vital sign monitoring for hypotension or tachycardia throughout.^[25]^[3]^[19]

Fluid Analysis

Sample Collection

During diagnostic paracentesis, an initial volume of 25 to 30 mL of ascitic fluid is collected for analysis and divided into aliquots based on the suspected etiology.^[2] Typical distribution includes approximately 10 mL for cell count and culture, 5 mL for total protein and serum-ascites albumin gradient (SAAG) determination, and additional volume (ideally ≥80 mL if available) for cytology when malignancy is suspected to enhance diagnostic yield.^[2]^[3] The fluid is obtained by attaching a 60-mL syringe to a three-way stopcock connected to the paracentesis catheter, allowing controlled aspiration and direct transfer into collection tubes or vials while minimizing air bubble introduction, which could compromise sample integrity.^[25] Cultures require immediate transport to the laboratory at room temperature, with on-site inoculation of at least 10 mL into each of two blood culture bottles recommended when spontaneous bacterial peritonitis (SBP) is suspected to maximize sensitivity.^[2]^[26] Special considerations include collecting separate aliquots for targeted tests, such as amylase in cases of suspected pancreatitis or triglycerides for evaluating chylous ascites, using appropriate containers like sterile pots for biochemistry or serum-separating tubes.^[3] If processing is delayed, non-culture samples should be refrigerated at 4°C, while cytology specimens must avoid heparin to prevent interference with cellular analysis.^[27]

Laboratory Tests and Interpretation

Laboratory analysis of ascitic fluid obtained via paracentesis is essential for diagnosing the underlying cause of ascites and identifying complications such as infection. The gross appearance of the fluid provides initial clues: clear fluid is typical of uncomplicated cirrhotic ascites, cloudy appearance suggests infection, milky fluid indicates chylous ascites, and bloody fluid may result from trauma during the procedure or underlying malignancy.^[28] The primary tests include total nucleated cell count with differential, Gram stain, culture, total protein, and albumin levels to calculate the serum-ascites albumin gradient (SAAG). Spontaneous bacterial peritonitis (SBP) is diagnosed when the absolute neutrophil count in the ascitic fluid is ≥250 cells/mm³, even in the absence of symptoms.^[29] Gram stain and culture, with fluid inoculated directly into blood culture bottles at the bedside, identify the causative organism in approximately 80% of SBP cases, guiding targeted therapy.^[30] The SAAG is calculated as serum albumin minus ascitic fluid albumin; a value ≥1.1 g/dL indicates portal hypertension with high accuracy.^[31] Additional tests are selected based on clinical suspicion. Cytology examines for malignant cells in cases of suspected peritoneal carcinomatosis. Lactate dehydrogenase (LDH) and amylase levels help identify secondary causes: elevated LDH (> upper limit of normal for serum) suggests exudative processes, while high amylase points to pancreatic or gastrointestinal origins. Triglyceride levels >200 mg/dL confirm chylous ascites, often due to lymphatic disruption.^[32]^[31]^[33] Interpretation of results differentiates ascites etiologies. A high SAAG (≥1.1 g/dL) with low total protein (<2.5 g/dL) strongly suggests cirrhosis-related portal hypertension. Conversely, a low SAAG (<1.1 g/dL) with high total protein (>2.5 g/dL) indicates non-portal hypertensive causes, such as peritoneal carcinomatosis. Culture-negative neutrocytic ascites, defined as neutrophil count ≥250 cells/mm³ with negative cultures, represents a variant of SBP and is managed similarly.^[34]^[35] These findings inform clinical management. For SBP, empirical antibiotics such as cefotaxime are initiated immediately, with adjustments based on culture results; resolution is confirmed by a drop in neutrophils to <250 cells/mm³. In endemic areas, additional testing for tuberculosis or fungi may be warranted if initial cultures are negative.^[30]^[36]

Complications

Types and Risks

Complications of paracentesis are generally uncommon, with overall rates reported between 1% and 2% across large prospective studies.^[2] These can be categorized as common (incidence 1-5%) or serious and rare (incidence <1%), with the majority being self-limited or manageable. Persistent ascitic fluid leak at the puncture site occurs in 0.8-1.7% of procedures and is more likely in patients with low serum albumin or tense ascites.^[37] Abdominal pain, often mild and transient, affects up to 5% of patients immediately post-procedure.^[38] Minor bleeding or hematoma formation at the site is reported in approximately 1% of cases, typically resolving without intervention.^[39] Serious complications occur in fewer than 1% of paracenteses but can be life-threatening. Bowel perforation, with an incidence of 0.3-0.5%, is a rare but critical event often linked to underlying adhesions or improper site selection.^[40] Vascular injury, leading to significant intra-abdominal hemorrhage, shares a similar low incidence of <1%.^[39] Iatrogenic infection, including secondary peritonitis, develops in 0.1-0.5% of procedures, based on data from over 600 cases showing three infections total.^[38] Clinically significant hypotension and post-paracentesis circulatory dysfunction (PPCD) after large-volume paracentesis (>5 L removed) without albumin occur in approximately 15-20% of patients (subclinical PRA-based incidence up to 80%).^[41] PPCD is defined as a >50% increase in plasma renin activity from baseline, measured on day 6 post-procedure, reaching levels >4 ng/mL/h.^[41] Certain risk factors elevate complication rates. Large-volume paracentesis without albumin prophylaxis significantly heightens the risk of renal failure (approximately 10-20% without vs. <10% with albumin).^[13] Obesity or intra-abdominal adhesions increase the likelihood of bowel perforation by complicating needle navigation.^[42] The overall mortality attributable to the procedure remains low at <0.2%, with fatal outcomes primarily tied to severe hemorrhage or perforation in high-risk cohorts.^[38]

Prevention

Routine use of ultrasound guidance during paracentesis is recommended to identify optimal fluid pockets and reduce the risk of adverse events such as organ injury (reducing overall complications from 4.7% to 1.4%).^[2] Adherence to strict sterile technique, including skin preparation with povidone-iodine or chlorhexidine, sterile gloves, and drapes, is essential to minimize the risk of infection.^[2] Prior to the procedure, coagulopathy should be assessed and corrected if significant, such as through platelet transfusion for counts below 20 × 10³/μL, although routine correction is not required for mild elevations in INR or platelets.^[2] For therapeutic paracentesis, fluid removal should be limited to less than 5 L without albumin supplementation to avoid circulatory instability; for larger volumes, infusion of 6-8 g of 25% albumin per liter removed (up to a maximum of 200 g) is advised to prevent post-paracentesis circulatory dysfunction (PPCD).^[13]

Management

Post-procedure, patients should be monitored closely for vital signs, including blood pressure and pulse every 15 minutes for the first 2 hours, to detect early signs of hypotension or other hemodynamic changes.^[2] Leaks at the puncture site can be managed by applying a single skin suture or manual pressure.^[2] In cases of suspected infection such as peritonitis, prompt administration of broad-spectrum antibiotics, such as third-generation cephalosporins, is indicated.^[13] Hypotension requires immediate fluid resuscitation, often with albumin infusion if associated with large-volume paracentesis.^[2] Perforation, though rare, necessitates urgent surgical consultation for repair.^[2] In patients with spontaneous bacterial peritonitis (SBP), albumin administration at 1.5 g/kg on day 1 followed by 1 g/kg on day 3, alongside antibiotics, significantly reduces the incidence of acute kidney injury (10% versus 33%) and mortality (10% versus 29%).^[43]

Post-Care

Following paracentesis, patients should undergo bed rest for 1-2 hours and observation for 4-6 hours to monitor for delayed complications.^[2] They should be advised to report any fever, increasing abdominal pain, or other concerning symptoms promptly to facilitate early intervention.^[13]

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