### Date : 2024-12-10 15:32 ### Topic : Paracentesis #surgery ---- ### **Paracentesis** **Paracentesis** is a medical procedure used to remove **fluid** from the **peritoneal cavity** (the space surrounding the abdominal organs). It is commonly performed in patients who have **ascites**, which is the accumulation of excess fluid in the abdomen. Paracentesis can be both **diagnostic** and **therapeutic**, depending on the underlying condition and the clinical situation. --- ### **Indications for Paracentesis** 1. **Diagnostic Purposes**: - **Ascites of unknown origin**: To determine the cause of **ascites**, which could be due to liver disease (cirrhosis), cancer, infections, heart failure, or other conditions. - **Suspected spontaneous bacterial peritonitis (SBP)**: To test the ascitic fluid for infection, typically in patients with liver cirrhosis or advanced liver disease. - **Suspicion of malignancy**: To evaluate for the presence of cancer cells in ascitic fluid (e.g., in **peritoneal carcinomatosis**). - **Evaluation of serum-ascites albumin gradient (SAAG)**: This helps in differentiating between ascites caused by portal hypertension (e.g., cirrhosis) and other causes (e.g., cancer). 2. **Therapeutic Purposes**: - **Symptom relief**: To remove large volumes of fluid that are causing abdominal discomfort, difficulty breathing (due to diaphragm compression), or **pressure on other organs**. - **Management of tense ascites**: In patients with **massive ascites**, paracentesis may be performed to reduce **abdominal pressure** and **improve respiratory function**. --- ### **Procedure of Paracentesis** 1. **Preparation**: - **Informed consent**: The procedure requires the patient's consent, as it involves a needle or catheter insertion into the abdomen. - **Positioning**: The patient is usually positioned in a **supine** or **semi-recumbent position**, with the abdomen exposed. - **Sterilization**: The area of the abdomen where the needle will be inserted is cleaned with an antiseptic solution to minimize the risk of infection. - **Local anesthesia**: A local anesthetic (e.g., **lidocaine**) is injected at the planned insertion site to minimize discomfort during the procedure. 2. **Needle Insertion**: - **Location**: The needle is typically inserted in the **infraumbilical region** (below the belly button) or in an area where the ascitic fluid is most accessible. In some cases, **ultrasound guidance** is used to locate the fluid and avoid injury to underlying structures (such as blood vessels or organs). - **Aspiration**: Once the needle is properly positioned, the fluid is aspirated using a syringe or the fluid is allowed to flow out through a catheter. 3. **Fluid Collection**: - If the procedure is diagnostic, a small amount (typically 10-30 mL) of ascitic fluid is collected for analysis. If therapeutic, larger volumes (up to several liters) may be drained, depending on the patient's condition. 4. **Post-procedure Care**: - After fluid removal, the needle or catheter is removed, and a sterile dressing is applied to the insertion site. - The patient may be monitored for signs of complications (e.g., **infection**, **hypotension**, or **renal dysfunction**) following the procedure. --- ### **Complications of Paracentesis** Although paracentesis is generally considered a safe procedure, it can have some complications, including: 1. **Infection**: Infection of the peritoneal cavity (known as **peritonitis**) is a risk, especially if the procedure is performed in a patient with **spontaneous bacterial peritonitis (SBP)**. 2. **Bleeding**: There is a risk of bleeding, particularly in patients with **coagulopathy** or **liver disease** where clotting factors may be impaired. 3. **Organ Injury**: Accidental puncture of nearby structures, such as the **bowel**, **bladder**, or **blood vessels**, can occur if the needle is misdirected. 4. **Hypovolemia (fluid shift)**: Large-volume paracentesis may cause a sudden drop in **intravascular volume**, leading to **hypotension**. This can be prevented by giving the patient **albumin** or other fluids post-procedure. 5. **Herniation**: In rare cases, if the fluid removal is too rapid, there is a risk of **abdominal wall herniation**. --- ### **Analysis of Ascitic Fluid** The fluid obtained through paracentesis is analyzed for several key factors: 1. **Appearance**: - **Clear**: Suggests a benign cause like **cirrhosis**. - **Cloudy or turbid**: May indicate **infection** (e.g., **spontaneous bacterial peritonitis**). - **Milky**: May suggest **chylous ascites**, often seen in lymphatic obstructions or malignancies. - **Bloody**: May suggest **trauma** or malignancy. 2. **Cell Count and Differential**: - **WBC count**: A high white blood cell (WBC) count, especially **neutrophils**, is suggestive of **spontaneous bacterial peritonitis (SBP)**. - **Red blood cells (RBC)**: Elevated RBC count may indicate trauma or malignancy. 3. **Albumin and Protein Concentration**: - **Serum-ascites albumin gradient (SAAG)**: Used to differentiate between **portal hypertension-related ascites** (SAAG >1.1 g/dL, which is typical for cirrhosis or heart failure) and **non-portal hypertension causes** (SAAG <1.1 g/dL, such as cancer or peritoneal carcinomatosis). - **Total protein**: Low protein levels can indicate **hepatic cirrhosis**, whereas higher levels suggest malignancy or infection. 4. **Culture**: - Fluid cultures are obtained to identify **bacterial infections** like **SBP**. --- ### **Indications for Therapeutic Paracentesis** 1. **Large, tense ascites**: To relieve symptoms such as **abdominal distension**, **dyspnea**, and **discomfort**. 2. **Refractory ascites**: Ascites that does not respond to medical treatment, including **diuretics**. 3. **Diagnosis of ascitic fluid infections**: When infection such as **spontaneous bacterial peritonitis (SBP)** is suspected. --- ### **Summary** **Paracentesis** is a key procedure used in **diagnosing** and **treating** ascites. It allows for **fluid removal**, **analysis of ascitic fluid**, and **symptom relief** in patients with conditions like **cirrhosis**, **heart failure**, **cancer**, or **infection**. The procedure is generally safe, but complications such as **infection**, **bleeding**, and **organ injury** can occur, making it important for clinicians to be well-trained and aware of the risks. ### Reference: - ### Connected Documents: -