Paracentesis is a procedure commonly performed in patients with advanced liver disease and cirrhosis. The fluid that builds up in the abdomen, called ascites, is a result of a complication of cirrhosis, called portal hypertension. The scarring in the liver, which occurs in cirrhosis, results in reduced blood flow through the liver, and increased pressure in the portal vein. The portal vein is the main vein which drains blood from the abdomen to the liver. Any abnormalities in the blood flow through the portal vein results in increased pressure, and leakage of fluid into the abdominal cavity, resulting in the development of ascites.
Ascites in the abdomen can lead to abdominal pain, infection of the fluid, which is called peritonitis, as well as problems related to eating and breathing. While small amounts of ascites fluid in the abdomen can be treated with a low salt diet and diuretics, larger amounts of ascites can lead to additional problems for patients.
At the point where the ascites is becoming problematic for the patient, we would recommend that a paracentesis be performed. Typically, the paracentesis is performed in radiology under ultrasound guidance. The skin on the abdomen is clean, and a small amount of lidocaine is used to deaden the skin. A needle is then inserted to the abdominal cavity where the fluid is present, and the fluid is drained. In the most circumstances, between one and 4 L may be removed. The fluid is sent to the laboratory for analysis, making sure there is no infection present. In more than 75% of the cases, patients can control their ascites with diet and diuretics. Large volume paracentesis is typically reserved for patients with more advanced liver disease, or those that are unresponsive to medical and dietary intervention. The presence of ascites in patients with cirrhosis would be an indication to consider liver transplantation
Complications of paracentesis include bleeding, the risk of infection, and the potential perforation of other internal organs such as the colon or small bowel. In most situations, patients do not require any additional pain medication or anesthesia when the procedure is being performed. Likewise, when patients are discharged home, no additional pain medication is needed. In fact, most patients feel comforted when the fluid, and its associated abdominal pressure, is relieved. In most cases, the paracentesis is done as an out-patient procedure.
In situations where patients require large volume paracentesis more than once every two weeks, this would be an indication that they have developed refractory ascites. In such a situation, we would discuss with the patient that a procedure called transjugular intrahepatic portosystemic shunt (TIPSS) be considered. The endovascular radiologists perform the TIPSS procedure, and they are able to insert a stent between the portal vein and the hepatic vein, restoring blood flow through the liver, reducing the portal hypertension that was created by the cirrhosis. Additional information on the TIPSS procedure can be found here.