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Severe Ascites

This is a 78 year-old Female, who has a massive ascites due to a liver cirrhosis, a parasentesis was performed, extracted 3 gallons of fluid in one session.

Accumulation of fluid within the peritoneal cavity results in ascites. ascites is most often due to portal hypertension resulting from cirrhosis. Other common causes include malignancy and heart failure. Successful treatment of ascites depends upon an accurate diagnosis of its cause.

 

In 2013, the American Association for the Study of Liver Diseases (AASLD) updated its. Guideline on the management of adult patients with ascites due to cirrhosis 

 

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Causes of ascites

• Cirrhosis – 81%
• Cancer – 10%
• Mixed ascites – more than one cause (e.g., cirrhosis
plus another cause) – 5%
• Heart failure – 3%
• Tuberculous peritonitis – 2%
• Pancreatitis – 1%
• Nephrotic syndrome – 1%
• Alcoholic hepatitis
• Acute liver failure
• Budd-Chiari syndrome
• There are many other rare causes of ascites

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Abdominal paracentesis is a simple bedside or clinic procedure in which a needle is inserted into the peritoneal cavity and ascitic fluid is removed. Diagnostic paracentesis refers to the removal of a small quantity of fluid for testing. Therapeutic paracentesis refers to the removal of 5 liters or more of fluid to reduce intra-abdominal pressure and relieve the associated dyspnea, abdominal pain, and early satiety.

Ascites due to cirrhosis can be mobilized in approximately 90 percent of patients with a treatment regimen consisting of dietary sodium restriction (usually 88 mEq [2000 mg] per day) and oral diuretics (usually consisting of spironolactone and furosemide).

True diuretic-resistant ascites is usually associated with advanced cirrhosis, marked neurohumoral activation (of the sympathetic and renin-angiotensin-aldosterone systems), and very low urinary excretion of sodium, frequently less than 10 mEq/day despite maximal tolerated doses of diuretics

 

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Indications — There are several generally accepted indications for abdominal paracentesis

Evaluation of new onset ascites

Testing of ascitic fluid in a patient with preexisting ascites who is admitted to the hospital, regardless of the reason for admission

Evaluation of a patient with ascites who has signs of clinical deterioration, such as fever, abdominal pain/tenderness, hepatic encephalopathy, peripheral leukocytosis, deterioration in renal function, or metabolic acidosis

Performing a paracentesis at the time of admission to the hospital in patients with cirrhosis and ascites may decrease mortality rates

In addition to helping to clarify the cause of ascites and evaluating for infection, paracentesis can identify unexpected diagnoses, such as chylous, hemorrhagic, or eosinophilic ascites.

Relative contraindications — The benefits of abdominal paracentesis in patients with appropriate indications almost always outweigh the risks. An analysis of the fluid helps determine the cause(s) of the ascites and the likelihood of bacterial infection, and it can identify antibiotic susceptibility of any organisms that are cultured.

 

 

 

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However, there are some relative contraindications to paracentesis:

Patients with clinically apparent disseminated intravascular coagulation and oozing from needle sticks. This occurs in <1/1000 patients with ascites in our experience. Paracentesis can be performed once the bleeding risk is reduced by administering platelets and, in some cases, fresh frozen plasma.

Primary fibrinolysis (which should be suspected in patients with large, three-dimensional bruises). Paracentesis can be performed once the bleeding risk is reduced with treatment.

Paracentesis should not be performed in patients with a massive ileus with bowel distension unless the procedure is image-guided to ensure that the bowel is not entered.

The location of the paracentesis should be modified in patients with surgical scars so that the needle is inserted several centimeters away from the scar. Surgical scars are associated with tethering of the bowel to the abdominal wall, increasing the risk of bowel perforation.

 

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Abnormal coagulation studies and thrombocytopenia

 An elevated international normalized ratio (INR) or thrombocytopenia is not a contraindication to paracentesis, and in most patients there is no need to transfuse fresh frozen plasma or platelets prior to the procedure. Seventy percent of patients with ascites have an abnormal prothrombin time, but the actual risk of bleeding following paracentesis is very low (less than 1 percent of patients require transfusion) . Exceptions are patients with clinically apparent disseminated intravascular coagulation or clinically apparent hyperfibrinolysis, who do require treatment to decrease their risk of bleeding.

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The safety of paracentesis in patients with cirrhosis has been documented in several studies:

A prospective study of 1100 large-volume paracenteses documented no bleeding complications with no pre- or post-procedure transfusions required despite INRs as high as 8.7 and platelet counts as low 19,000/mL.

In another report (in which occasional patients received prophylactic fresh frozen plasma, platelets, or desmopressin [DDAVP]), severe bleeding was observed in only 9 of 4729 paracenteses (0.19 percent). The mortality rate attributable to the procedure was 0.016 percent. Eight of the nine patients who bled had renal failure, suggesting that the qualitative platelet dysfunction associated with renal failure contributed to the bleeding risk. Thus, it may be reasonable to use DDAVP before performing paracentesis in patients with cirrhosis and renal failure, although no studies have formally established a benefit. 

 

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WHEN TO PERFORM PARACENTESIS — Diagnostic paracentesis should be performed promptly, especially if there is concern for spontaneous bacterial peritonitis (eg, the patient is febrile or has abdominal pain). In our experience, delays are often due to a lack of available clinicians experienced with paracentesis and/or undue concern about its safety.

In some settings, the procedure is performed by interventional radiologists, which not only causes a delay, but has the potential to lead to miscommunication regarding appropriate testing of samples. It can be helpful to provide the interventional radiologist with preprinted labels for the desired tests and to send those labels with the patient. This prevents confusion regarding which tests are requested.


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Ascites Image 1 of 12.

This a 82 year-old Female, who has a massive ascites due to liver cirrhosis.

An Exaggerated bulging of the abdomen due to accumulation of ascites fluid

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Scar of previous surgery and a peritoneum cutaneous fistula, for which abundant ascitic fluid drained spontaneously at around this injury is observed necrotic material.

 

 

 

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Spontaneous Bacterial Peritonitis

SBP occurs in approximately 10% of patients with cirrhosis and ascites, and this complication can be asymptomatic. Paracentesis should be performed in all patients with new-onset ascites or those symptomatic with signs of infection, abdominal pain, encephalopathy, nausea or vomiting, or gastrointestinal bleeding. The diagnosis of SBP should be considered likely if ascitic fluid contains more than 250 polymorphonuclear leukocytes (PMNs)/µL. Bacteria in SBP are invariably aerobic or microaerophilic enteric organisms. Skin organisms such as staphylococci can be introduced by previous paracentesis. Up to 40% of patients with symptoms and signs of SBP will have negative ascites cultures, but they should still be treated with antibiotics. Bacterascites can occur, evidenced by a positive bacterial culture in the absence of ascitic leukocytosis. If the patient is asymptomatic, ascitic fluid should be recultured, and if the repeat culture is positive, the patient should be treated with antibiotics. If the repeat culture is negative, the patient can be observed.

SBP may follow an upper gastrointestinal (GI) bleed in patients with cirrhosis and ascites.[8] Administration of antibiotics such as oral fluoroquinolones or broad-spectrum antibiotics to patients with upper GI bleeding can reduce the risk for SBP. Patients with low protein ascites and recurrent SBP might also benefit from antibiotic prophylaxis.

 

 

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Exaggerated fall of the abdomen which the ascites drained expontaneously through the fistula.

 

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The ascites liquid

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A close up to the lesion of abdominal wall

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