Cirrhotic with new ascites — the diagnostic and the large-volume paracentesis

(a) The indication (2 marks). Paracentesis should be performed in any patient with ascites and concern for spontaneous bacterial peritonitis, or who is being admitted for a complication of cirrhosis; fever, abdominal pain, worsening ascites and altered mental status are typical presentations.^[6]

(b) Pre-procedure considerations (3 marks). In suspected spontaneous bacterial peritonitis many patients have coagulation abnormalities, but routine transfusion is not recommended.^[6] Clinicians should not routinely correct thrombocytopenia and coagulopathy before low-risk paracentesis in patients with hepatic synthetic dysfunction; blood products increase portal pressure and carry transfusion risks, and commonly used INR thresholds are not supported by evidence.^[7] In 11,043 paracenteses, major bleeding complicated 0.3 per cent, with increased INR, liver impairment and the number of previous paracenteses as risk factors.^[8]

(c) Site and bleeding risk (6 marks). The ideal site has not been established; choose one that avoids the inferior epigastric artery and has a deep pocket of fluid. The left lower quadrant was superior to the infraumbilical midline in one comparison, and ultrasound-guided paracentesis has been shown to decrease the risk of bleeding.^[9]

(d) Diagnosis and management (4 marks). An ascitic absolute neutrophil count of 250 cells/mm³ or more is diagnostic of spontaneous bacterial peritonitis (here 520); inoculate blood culture bottles, and treat with a third-generation cephalosporin.^[6] In the randomised trial, adding intravenous albumin (1.5 g/kg at diagnosis and 1 g/kg on day 3) to cefotaxime reduced renal impairment from 33 to 10 per cent and in-hospital mortality from 29 to 10 per cent.^[3] The SAAG here is 25 − 8 = 17 g/L (1.7 g/dL); a high gradient is conventionally 1.1 g/dL or more, and the gradient identified portal-hypertensive ascites 96.7 per cent of the time.^[10][4]