Healthcare and Medicine Reference
In-Depth Information
CHAPTER 16
Therapeutic: Ascitic Drain
Sharat Putta
Queen Elizabeth Hospital, Birmingham, UK
Box 16.1 Causes of ascites
OVERVIEW
By the end of this chapter you should be able to:
discuss the indications for insertion of an ascitic drain
Transudative ascites
Cirrhosis of the liver
understand the anatomy relevant to insertion of the drain
Cardiac failure
explain how to insert an ascitic drain
Nephrotic syndrome
understand the potential complications of this procedure.
Exudative ascites
Cancer: gastric, ovarian, peritoneal carcinomatosis
Tuberculous peritonitis
Pancreatitis
Introduction
Ascitic drain or paracentesis refers to a procedure used to obtain fl uid
from the peritoneal cavity for diagnostic or therapeutic purposes.
Diagnostic paracentesis involves collection of 20-50 mL of fl uid,
for biochemical, cytological and microbiological investigation
(discussed in Chapter 8).
Therapeutic paracentesis refers to the drainage of larger quan-
tities of fl uid to alleviate symptoms. Large-volume paracentesis
(LVP) is a term used to denote the drainage of large quantities of
ascitic fl uid, typically greater than 5 L. Total paracentesis refers to
complete drainage of all ascitic fl uid. Volumes in excess of 15 L can
be drained safely in a single session, with careful monitoring and
intravenous fl uid replacement.
Cirrhosis of the liver accounts for 80% of all causes of ascites
(Box 16.1). It is therefore obvious that paracentesis is usually
undertaken in this setting. As discussed later in this chapter, this
is an exceedingly important issue, especially when consider-
ing therapeutic/large-volume paracentesis, due to the unique
physiological and circulatory changes in cirrhosis and the impact
of large-volume paracentesis on renal function and circulation.
Box 16.2 Recommendations by the British Society of
Gastroenterology for therapeutic paracentesis in cirrhosis
Therapeutic paracentesis is the fi rst-line treatment for patients
with large or refractory ascites. (Level of evidence: 1a;
recommendation: A.)
Paracentesis of 5 L of uncomplicated ascites should be followed
by plasma expansion with a synthetic plasma expander and does
not require volume expansion with albumin (Level of evidence:
2b; recommendation: B.)
Large-volume paracentesis should be performed in a single session
with volume expansion once paracentesis is complete, preferably
using 8 g albumin/L of ascites removed (that is,100 mL of 20%
albumin/3 L ascites). (Level of evidence: 1b; recommendation: A.)
to or intolerant of diuretic therapy. Paracentesis enables effective
symptom control in this group of patients in the short and long
term, and is often required on a periodic basis. Therapeutic
paracentesis is the fi rst-line treatment for large or refractory ascites
in the presence of cirrhosis (Box 16.2).
Ascites from malignant causes tends not to respond to diuretic
therapy. Treatment of the underlying cause may lead to resolution
of ascites, but a signifi cant proportion of patients with malignant
ascites have incurable metastatic disease and paracentesis is often
required for palliation.
Indications for therapeutic paracentesis
When large in volume or causing a tense abdomen, ascites leads
to abdominal pain and mechanical effects such as respiratory
compromise, early satiety, scrotal and leg swelling and frequently
a poor quality of life.
Ascites from cirrhosis is often controlled with diuretic ther-
apy, but a signifi cant proportion of patients are either resistant
Contraindications
Although there are no absolute contraindications that preclude
the procedure, caution needs to be exercised under the following
circumstances.
 
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