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GOALS: To evaluate gastric emptying before and after paracentesis in patients with cirrhosis. BACKGROUND: Patients with ascites often report early satiety. The effect of paracentesis on gastric emptying has not been studied previously. STUDY: Twelve patients who required therapeutic paracentesis were studied (mean age, 57 years; range, 47-69 years). Gastric emptying was performed with radionuclide scintigraphy. Satiety was evaluated with a visual analogue scale. Wilcoxon signed-rank tests were used for comparison between pre-and poststudies. RESULTS: The causes of cirrhosis included alcohol (seven patients), a combination of alcohol and hepatitis C (two), chronic hepatitis C only (one), primary biliary cirrhosis (one), and cryptogenic (one). The median volume of ascitic fluid removed at paracentesis was 5,450 mL (range, 2,500-7,200 mL). Median 2-hour gastric emptying was 65.5% before paracentesis and 61.5% after ( p > 0.05). Median 4-hour gastric emptying was 92.5% before paracentesis and 96.5% after ( p > 0.05). Both satiety score and caloric intake were significantly improved after paracentesis ( p < 0.05). CONCLUSIONS: Although satiety and calorie intake improve after large-volume paracentesis in patients with cirrhosis, these changes do not seem to correspond with improved gastric emptying. Therefore, other mechanisms most likely contribute to satiety.
BACKGROUND: Hemodynamic changes, including systemic vascular resistance, in cirrhotic patients during massive paracentesis have been reported, but large and small artery compliance has not yet been investigated. OBJECTIVE: To investigate hemodynamic variables, including small and large artery compliance, in cirrhotic patients during total paracentesis. METHODS: The study included 15 cirrhotic patients admitted for an episode of tense diuretic-resistant ascites. Hemodynamic variables including vascular compliance were measured using an HDI pulse wave cardiovascular profiling instrument CR-2000. The variables were measured in these patients before, immediately after, and 24 hours following large volume (mean 5.6 L) paracentesis. RESULTS: Cardiac output increased immediately after paracentesis due to increment in stroke volume, with no change in heart rate. However, 24 hours later the cardiac output decreased to below the basal level. The fluctuation was statistically significant (P < 0.05). There was no change in large artery compliance, but small artery compliance increased after paracentesis (P < 0.05) and partially retumed to the basal level after 24 hours. Systemic vascular resistance measurement showed the same pattern of change: vasodilatation occurred during paracentesis and was attenuated 24 hours later. CONCLUSIONS: Large volume paracentesis with albumin replacement caused an accentuation of the vasodilatation (small but not large artery) already present in these patients. This may be the first sign of enhanced vasodilatation due to large volume paracentesis before the clinical expression of impaired hemodynamics and deterioration of renal function.
OBJECTIVE: To evaluate a protocol of active outpatient management, including outpatient paracentesis and albumin administration, in women at risk for severe ovarian hyperstimulation syndrome (OHSS). DESIGN: Prospective cohort. SETTING: Freestanding IVF program. PATIENT(S): Thirteen women progressing from moderate to severe OHSS. INTERVENTION(S): Bed rest and home monitoring with intermittent outpatient paracentesis and albumin administration. MAIN OUTCOME MEASURE(S): Procedural outcomes and time to resolution of OHSS symptoms. RESULT(S): The initial paracentesis occurred 14.1 +/- 3.3 days after oocyte retrieval, removing 1,735 +/- 506 mL of ascitic fluid. Eleven women required a second paracentesis and five women required a third paracentesis over the next 8 days. Six women received albumin on seven occasions because of hypoalbuminemia. The onset of diuresis occurred 2.8 +/- 1.9 days and recovery occurred 7. 4 +/- 3.0 days after the first paracentesis. There were no hospitalizations for OHSS symptoms and no complications. All 13 women had viable intrauterine pregnancies. CONCLUSION: Active outpatient intervention in the early stages of OHSS, including paracentesis and albumin administration, can avoid hospitalization while minimizing the progression and complications of OHSS.
A questionnaire on ovarian cancer ascites management was sent to members of the British Gynaecological Cancer Society (BGCS), the National Gynaecological Oncology Nurses, and the Assoication of Palliative Medicine. Questions were asked on diuretics, hematologic investigations, paracentesis, and duration of stay. Nine hundred ninety-five questionnaires were distributed, of which 492 replies were received (49% response rate). Fifty-five percent of responders used paracentesis as first-line management of ovarian cancer ascites (15% diuretics). Seventy-five percent performed some blood tests in relation to paracentesis. Ultrasound was used by 43.6% during paracentesis (15.7% for direct visualization, 27.9% to mark an entry site). Seventy-seven percent used a Bonanno catheter. Eighty-three percent used no intravenous fluids during paracentesis, and there was a wide variation in the amount and rate of drainage of ascites (1 L maximum up to free drainage of all ascites, median 5 L; 0.5 L per hour to free drainage). Gynecologists tended to use more interventions (paracentesis, ultrasound, and intravenous fluids) than palliative care physicians or medical oncologists, while palliative care physicians used fewer interventions but admitted patients for longer periods of time. This identified several areas for future study: the value of hematologic investigations, the use of outpatient management for paracentesis, and the use of ultrasound and the rate of drainage of ascites.
OBJECTIVE: To study the effectiveness of serial paracenteses in eyes with symptomatic elevated intraocular pressure (IOP). DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: Five eyes of four patients with acute elevations in IOP. METHODS: A 5-year review of records was performed in one practice (LP) to identify patients who underwent more than one paracentesis for control of symptomatic increases in IOP when greater than 30 mmHg. Five eyes of four patients were identified, and charts were analyzed for cause and duration of elevated pressure, control of symptoms associated with elevated pressure, number of paracenteses, and visual outcome. All patients received topical anesthetic (proparacaine 0.5%) before paracentesis, and topical ciprofloxacin, 0.35%, or tobramycin, 0.3%, before and after paracentesis, which was performed at the temporal limbus with a 0.75-mm sterile surgical blade. RESULTS: Paracentesis provided almost immediate symptomatic relief in all cases. The procedure could be repeated easily whenever symptoms recurred. The average number of paracenteses performed was three. No complications of paracentesis were noted. Visual outcomes were variable and dependent on the etiology of elevated IOP. Two eyes with neovascular glaucoma had poor visual outcomes. None of the other three eyes lost vision because of increased IOP. CONCLUSIONS: Acute symptomatic elevations of IOP in patients with a deep anterior chamber can be effectively treated with paracentesis. In selected cases, serial paracenteses may obviate the need for filtration surgery. If filtration surgery is required, serial paracenteses may allow it to be scheduled electively rather than emergently.
The effects of ascites and body position on gas exchange were evaluated in 22 male cirrhotics. All underwent spirometry and plethysmography in the sitting (erect) position. Single breath carbon monoxide diffusing capacity (DLco) was measured in the erect and supine positions in a random sequence. A significantly negative correlation was found between Kco (DLco corrected by alveolar volume [VA]) and lung volumes. DLco was significantly higher in the erect than in the supine position. On the other hand, Kco was significantly higher in the supine position. The differences of DLco and Kco between the erect and supine positions (the data in the supine minus those in the erect position) correlated highly with FEV1 and FVC. Thirteen patients underwent large volume paracentesis, and pulmonary function tests were done one day before and after paracentesis. Lung volumes and DLco increased significantly after paracentesis. In contrast, Kco decreased significantly. A significantly negative correlation was found between the change of Kco before and after paracentesis and that of lung volumes (the data after minus those before paracentesis). There was no remarkable change in the differences of DLco and Kco between the two positions after paracentesis. It is concluded that ascites may prevent further worsening of gas exchange and attenuate the postural effect on gas exchange in cirrhotic patients with significant amounts of ascites.
BACKGROUND & AIMS: Protein calorie malnutrition and weight loss are common among patients with cirrhosis and ascites. The cause of these symptoms is unclear, with several putative mechanisms proposed. The primary aims of this study were to compare gastric volumes and accommodation between patients with cirrhosis complicated by ascites and healthy controls, and to evaluate the effect of large-volume paracentesis in the patient group. METHODS: Patients with cirrhosis and ascites underwent assessment of gastric volumes as measured by single-photon emission computed tomography, gastric sensation assessed by a validated nutrient drink test, and a 3-day assessment of caloric intake before and after large-volume paracentesis. Age- and sex-adjusted linear regression models were used to compare gastric volumes and accommodation ratios between patients and healthy volunteers. Paired Wilcoxon rank-sum tests were used to compare gastric measures before and after paracentesis among the patient group. RESULTS: Fifteen patients (median age, 54 y) were compared with 112 healthy (age- and sex-matched) controls. Median postprandial gastric volumes (627 mL patients vs 721 healthy controls) and gastric accommodation were reduced significantly in patients compared with healthy controls (P = .02 and .006, respectively). After paracentesis: (1) fasting gastric volumes were increased (median 312 mL post- vs 241 mL pre-, P = .04), (2) patients tolerated ingestion of larger maximum volumes (median 964 mL post- vs 738 mL pre-, P = .04), and (3) caloric intake was increased (median 34% kcal post- vs 3110 kcal pre-, P = .005). CONCLUSIONS: Postprandial gastric volumes and accommodation ratios are reduced in patients with cirrhosis and ascites compared with healthy controls. In addition, large-volume paracentesis increases fasting gastric volumes, volumes ingested until maximal satiation, and caloric intake.
This study aimed to establish the diagnostic value of paracentesis (peritoneal tap) in the assessment of patients with blunt abdominal trauma. Paracentesis, using a four-quadrant puncture technique, was performed in blunt abdominal trauma victims presenting to the emergency department of a tertiary-care university medical centre. Pregnant patients, those under 18 or those having an abdominal scar were excluded from the study. All patients then underwent one of the following procedures as indicated: emergency ultrasound, abdominal computed tomography scan, diagnostic peritoneal lavage or laparotomy. Paracentesis results were compared with the results of other tests and surgery in diagnosing haemoperitoneum. Haemoperitoneum was confirmed surgically in six of the seven patients with a positive paracentesis. Nine out of 65 patients with positive clinical findings but negative taps underwent surgical intervention, and abdominal bleeding was confirmed in eight. Three seriously injured patients died before diagnostic studies or laparotomy could be performed. In conclusion, a positive paracentesis result may be used to guide decision-making in the setting of blunt abdominal trauma if other diagnostic methods are unavailable. Its high false-negative rate limits its overall usefulness.
BACKGROUND: Some cirrhotic patients with tense ascites who undergo paracentesis develop a circulatory dysfunction syndrome, manifested by an increase in plasma renin activity. Recently, a significant inverse correlation between postparacentesis changes in plasma renin activity and systemic vascular resistance has been demonstrated in these patients, suggesting that peripheral arterial vasodilatation could be responsible for this circulatory dysfunction, but the mechanisms by which tense ascites removal induces such changes are unknown AIM: To investigate the role of a decrease in intra-abdominal pressure (IAP) in the development of early postparacentesis haemodynamic changes METHODS: Eleven cirrhotic patients with tense ascites received a large volume paracentesis. A specially designed pneumatic girdle was used to compress the abdomen to avoid a decrease in IAP during ascites removal. Haemodynamic studies were performed before paracentesis, one hour after ascites flow stopped, and 30 minutes after pneumatic girdle deflation RESULTS: When IAP was maintained at its original level, no haemodynamic changes were observed, despite large volume paracentesis. However, a significant decrease in systemic vascular resistance was seen immediately after pneumatic girdle deflation CONCLUSIONS: Early haemodynamic changes after paracentesis are avoided if IAP is maintained at its original level. The abrupt decrease in IAP could be the trigger for the development of the initial haemodynamic changes that eventually produce postparacentesis circulatory dysfunction.
AIM: To assess clinical and neurohumoral response to posture, physical exercise, and ascites treatment in patients with Child-Pugh C liver cirrhosis and tense ascites. METHOD: Fifty patients with Child-Pugh C liver cirrhosis and tense ascites were randomly allocated into 5 groups. Thirty patients were treated with paracentesis of 6 L of acites paralleled by plasma volume expansion with 200 mL of 20% low sodium albumin (10 patients), 600 mL fresh frozen plasma (10 patients), or 900 mL solution of synthetic gelatine (10 patients), ie, doses with comparable oncotic power, and bed rest for 24 h before and after the procedure. They were compared with 10 patients treated with paracentesis of 6 L of ascites without plasma volume expansion and no bed rest, and 10 patients treated with 40 mg of furosemide IV daily and no bed rest. Mean arterial pressure, heart rate, body weight loss, urine flow rate, creatinine clearance, plasma renin activity, plasma aldosterone concentration, and plasma atrial natriuretic peptide (ANP) were measured before the procedure and 6 hours, 2, 3, and 6 days after the procedure. RESULTS: Diuretic treatment and paracentesis of 6 L of ascites without plasma volume expansion and no bed rest 24 h before and after the procedure were associated with significant hypotension (p<0.01) during 6 days of the trial, tachycardia (p<0.01) on day 1 and 2 (p=0.012), lower total body weight loss (p=0.007), increase in plasma renin activity 6 hours after the beginning of the study (p=0.025) and on day 6 (p=0.024), increase in plasma aldosterone concentration on day 6 (p=0.030), no significant change in plasma ANP levels, and decrease in creatinine clearance on day 6 (p=0.046). Albumin was superior to the other plasma expanders. Comparison between groups treated with plasma volume expansion did not show significant differences in measured parameters at any time during the study. The differences were found in the amount of needed volume of each substitute, daily sodium balance on day 1 of the trial, increase in plasma aldosterone concentration in bed rest-paracentesis-polygeline group on day 6, and the increase in plasma ANP on day 1 (p=0.077), which was proportional to the amount of infused volume. CONCLUSION: Therapeutic paracentesis of 6 L of ascites, bed rest 24 h before and after the procedure, and intravenous substitution of volume with albumin, fresh frozen plasma, and solution of synthetic gelatine were safe, rapid, and effective treatments, provided that intravascular volume was substituted simultaneously.
Spontaneous bacterial peritonitis is an infection of the ascitic fluid of patients who, in general, have severe chronic liver disease. Several variants of this disease exist including bacterascites, culture-negative neutrocytic ascites, and secondary bacterial peritonitis. Spontaneous bacterial peritonitis is frequently manifested by signs and symptoms of peritonitis although the findings may be subtle; however, occasionally it may be completely without clinical manifestation. The clinician must have a high index of suspicion in order to make this diagnosis at a relatively earlier stage of infection. An abdominal paracentesis is required to make the diagnosis of spontaneous bacterial peritonitis. This paracentesis should be performed on all patients who are admitted to the hospital for ascites and should be repeated if there is any manifestation of bacterial infection during the hospitalization. Patients with severe intrahepatic shunting--as manifested by marked redistribution of activity from the liver to the spleen and to the bone marrow on liver-spleen scan as well as patients with an ascitic fluid total protein concentration of less than 1 g/dl--appear to be particularly susceptible to bacterial infection of their ascites. In order to optimize the yield of ascitic fluid culture, it is probably appropriate to inject blood culture bottles with ascites at the bedside immediately after the abdominal paracentesis. The mortality of spontaneous bacterial peritonitis continues to be very high. Perhaps routine admission paracentesis and prompt empiric antibiotic therapy with a third-generation cephalosporin will decrease the mortality of this infection if the Gram stain of the ascitic fluid demonstrates bacteria or the ascitic fluid neutrophil count is greater than 250 cells/cu mm. Repeating the paracentesis after 48 hours of treatment to reculture the fluid and reassess the ascitic fluid neutrophil count appears to be the best way to assess efficacy of treatment. After 48 hours of treatment the ascitic fluid neutrophil count should be less than 50% of the original value if the antimicrobial therapy is appropriate. The optimal duration of antibiotic treatment is unknown; however, until controlled trials provide data regarding duration of treatment it is appropriate to treat with parenteral antibiotics for 10 to 14 days. Research is also needed to determine if there are measures which can be taken to prevent the development of spontaneous peritonitis.
Epidemiological studies have shown that up to 80% of all pre-school children develop Eustachian tube dysfunction with middle ear effusion and corresponding conductive hearing loss. The therapy of choice for hyperplastic adenoids is adenoidectomy, often in combination with paracentesis. The objective of this study was to determine whether regular middle ear aeration (Otovent-system) could obviate the need for paracentesis. To this end treatment of 146 children from four to ten years old was conducted within the guidelines of a study protocol. In one group of children, Otovent-supported middle ear aeration was carried out before and after adenoidectomy. In the control group, adenoidectomy was followed by paracentesis. Parents and children were then assigned to follow-up treatment. As additional supportive therapy, children in both groups received decongestant nose drops and a mucolytic agent for a period of 2 weeks. The success of the treatment was evaluated by tympanometry, tone-wave audiometry and ear microscopy. The patients were followed-up at intervals of two and four weeks after the initiation of treatment. The results show that within the study time frame, Otovent treatment compares well to paracentesis. In summary, regular Otovent-supported aeration of the middle ear in many cases can be an alternative to paracentesis.