GGR SERVICE LINE

THE ESSENTIALS OF GGR MANAGEMENT PROCEDURES

Brought to you by:
Procedural Education Committee of the GI/GU/Reproductive Service Line- Resident and
Fellow Section, Society of Interventional Radiology
For comments or suggested edits, please email SIRSurvivalGuide@gmail.com

AUTHORS:

Bipin Rajendran, MD, PGY-4,

Virginia Commonwealth
University Health System

EDITORS:

Joseph DeMarco, DO, SIR-RFS

Clinical Education Survival
Guide Liaison
Geogy Vatakencherry, MD,
Chair SIR-RFS

PARACENTESIS
INDICATIONS
1. Performed in all patients with new-onset or worsening ascites of unknown etiology for
diagnostic or therapeutic purposes, or in patients with recurrent symptomatic ascites of
known etiology for therapeutic purposes.
A. 5 Fr centesis needle is typically used. Commercial pre-packaged paracentesis
kits are also available. Traditionally, these kits include a 6 Fr or 8 Fr drainage
catheter introduced into the peritoneum by an obturator which becomes blunt
upon entering the abdominal cavity, preventing damage to the viscera.
ABSOLUTE CONTRAINDICATIONS
1. Disseminated intravascular coagulation
PREOPERATIVE PREPARATION
1. Clinical evaluation: Detailed medical and surgical history, physical examination
A. In particular, if performing large volume paracentesis, determine if etiology of
ascites is cirrhotic versus non-cirrhotic.
B. Patients with chronic liver disease may be hypoalbuminemic at baseline and may
benefit from IV albumin repletion at the end of the procedure (see "pertinent
calculations.)"
2. Review imaging: If not apparent on clinical examination and no prior imaging is
available, consider performing ultrasonography to determine volume of ascites, location
of adjacent bowel/organs. Color flow imaging may be beneficial in detecting
subcutaneous varices as well as mapping the course of the inferior epigastric arteries.
3. Hold clopidogrel 5 days before procedure. Hold one dose of LMWH before procedure.
No need to hold ASA.
CONSENT
1. Discuss possible complications/risks including:
A. Local anesthesia
B. Entry site hematoma
C. Bleeding
D. Infection
E. Persistent leakage of ascitic fluid
F. Paracentesis-induced circulatory dysfunction (PICD)
PROCEDURE
1. Obtain pre-procedural laboratory testing.
A. INR (if receiving warfarin anticoagulation or known suspected liver disease). Per
SIR guidelines, correct INR <2.0 with FFP, Vitamin K.
i.
This is controversial, as a retrospective study of 4500 paracenteses reported
severe hemorrhage in < 0.2% of cases.
B. aPTT (if receiving intravenous unfractionated heparin): no consensus on
management.
C. Platelets: check if warranted by clinical history, replete if < 50,000/l.
2. NPO except medications for 6 hours prior to procedure if sedation is being administered.
3. Position patient supine, head slightly elevated.
4. Using ultrasound guidance, mark access site (preferentially right or left paracolic gutters).
5. Perform sterile prep of abdominal entry site.
6. Administer local anesthetic (typically 1% or 2% lidocaine) - start with skin wheal then
anesthetize entry tract through the peritoneum.
7. Perform dermatotomy at entry site. Attach syringe to end of catheter and advance through
peritoneum. Consider "Z-track technique" to minimize post-procedure ascitic leak. With
this technique, the skin and subcutaneous tissues are held taut while the catheter is
advanced, and then released upon entry into the peritoneum.
2

8.

Ascitic fluid should enter syringe upon entering peritoneum. Remove syringe and inner
stylet to form pigtail, confirming positioning with ultrasound guidance.
A. If diagnostic paracentesis, obtain 30-50 mL of ascites and obtain appropriate
laboratory testing (ascitic fluid cell count and differential, ascitic fluid total protein,
LDH, triglycerides, amylase, glucose, CEA, and serum-ascites albumin gradient).
B. Serum-ascites albumin gradient (SAAG): used to determine etiology of ascites
(= serum albumin ascites albumin). If greater than 1.1 g/dL, related to portal
hypertension and consider cirrhosis workup. If <1.1 g/dL, non-portal hypertension
related (peritonitis, peritoneal carcinomatosis, vasculitis, hypoalbumenic state,
Meigs syndrome, bowel obstruction/infarction, postoperative lymphatic leak).
C. Ascitic fluid total protein (AFTP): Helpful if SAAG > 1.1 g/dL. Can distinguish
cirrhosis (AFTP <2.5 g/dL) from cardiac ascites (AFTP > 2.5 g/dL)
D. Spontaneous bacterial peritonitis (SBP): Presents with abdominal pain, fever,
altered mental status, renal failure, acidosis and/or leukocytosis. Risk factors:
AFTP < 1 g/dL, history of prior SBP, GI hemorrhage. Diagnosis: >250 PMNs/mm3
without an evident intra-abdominal, surgically treatable infection. Typically GNR
(70%) or GPC (30%). Diagnostic paracentesis should be performed before empiric
antimicrobial therapy; however therapy should not be withheld until culture results
return. If no significant improvement, paracentesis should be repeated after 48
hours after initiation of treatment.
9. Attach tubing to pigtail catheter; opposite end can be attached to three-way stopcock and
drainage bag, or vacuum bottle.
10. Once fluid stops freely flowing, attempt to slightly reposition catheter and apply slight
manual pressure on abdomen to get more fluid.
11. Remove catheter and apply manual compression for hemostasis. Apply sterile occlusive
dressing and/or suture incision, particularly if persistent ascitic leak.
POST-OPERATIVE CARE
1. Although controversial, the use of albumin has been suggested in large volume
paracentesis (defined as > 5 liters). General consensus is 6-8 g of IV albumin for every
liter removed, administered at the end of the procedure.
2. Other studies have suggested that 3 mg of terlipressin may be equally beneficial in
preventing PICD and less expensive than IV albumin.
POSSIBLE EARLY COMPLICATIONS
1. Abdominal wall hematoma
2. Persistent ascitic leak
3. Hypotension
POSSIBLE LATE COMPLICATIONS
1. Paracentesis-Induced Circulatory Dysfunction
A. After large volume paracentesis, hypovolemia triggers activation of the reninangiotensin-aldosterone (RAA) system; if albumin is not replaced, can develop
impaired renal function and rapid recurrence of ascites. Severe cases can lead to
hepatorenal syndrome and/or death
B. Associated with hypotension, hyponatremia, elevated plasma catecholamine and
renin levels
C. PICD is estimated to occur in 80% of cases of large volume paracentesis without
albumin substitution; this drops to 15-35% when volume expanders are used.
FOLLOW UP
1. No routine follow-up indicated. If recurrent large volume ascites, consider tunneled
peritoneal drainage catheter for management.

REFERENCES
1. Gins P, Crdenas A, Arroyo V, Rods J. Management of cirrhosis and ascites. N Engl J
Med. 2004;350(16):1646-54.
2. Lindsay AJ, Burton J, Ray CE. Paracentesis-induced circulatory dysfunction: a primer for
the interventional radiologist. Semin Intervent Radiol. 2014;31(3):276-8.
3. Patel IJ, Davidson JC, Nikolic B, et al. Consensus guidelines for periprocedural
management of coagulation status and hemostasis risk in percutaneous image-guided
interventions. J Vasc Interv Radiol. 2012;23(6):727-36.
4. Runyon BA. Introduction to the revised American Association for the Study of Liver
Diseases Practice Guideline management of adult patients with ascites due to cirrhosis
2012. Hepatology. 2013;57(4):1651-3.
5. Thomsen TW, Shaffer RW, White B, Setnik GS. Videos in clinical medicine.
Paracentesis. N Engl J Med. 2006;355(19):e21.