Ascitic Tap Procedures

Question 1

Diagnostic indications for ascitic tap?

Answer 1

1. Bacterial peritonitis
2. TB
3. Intra-abdominal malignancy

Question 2

Therapeuric indicatiosn for ascitic tap?

Answer 2

High pressure ascites e.g. liver disease

Question 3

Ascitic drain technique?

Answer 3

1. Explain and consent of patient
   - Risks and benefits
2. Collect equipment
   - Before starting procedure!
3. Uncover and position patient
   - Supine
4. Review available images / USS marked area
5. Examine and identify site
   - masses, organomegaly
   - Percuss to find fluid level
6. Clean skin
   - x2, spirals
7. Create sterile field
   - Under and around patient
8. Equipment onto sterile field
9. Anaesthetic
10. Insert needle +/- Bonnano catheter or cannula
    - 90 degrees until fluid comes
11. Take sample or attach drainage bag + secure
    - Purple and red or yellow tubes
12. Remove needle
13. Cover site

Question 4

Site for the ascitic tap?

Answer 4

3 cm medial to the anterior superior iliac spine and 3 cm superior

Question 5

Ascitic tap contraindications?

Answer 5

1. Bleeding diathesis
2. Low platelets, clotting factors…
3. Infection at skin site
4. Initial Hypotension - taking large volumes out of the abdomen can drop the BP
5. Hyponatraemia (Na < 126mmol/L)

Question 6

Ascitic tap risks?

Answer 6

1. Bleeding (uncontrolled) – major vessels or liver / splenic injury
2. Infection – Peritonitis or Skin
3. Bowel perforation - peritonitis
4. Hypotension - secondary to peritoneal volume loss

Question 7

What is post paracentesis circulatory dysfunction?

Question 8

What causes post paracentesis circulatory dysfunction?

Answer 8

Withdrawal of 5 litres or more

Question 9

Features of post paracentesis circulatory dysfunction?

Answer 9

1. Hyponatraemia
2. Acute kidney injury
3. Increased plasma renin activity

Question 10

Treatment of post paracentesis circulatory dysfunction?

Answer 10

1. albumin replacement (20 to 25% solution) dose of 8g of albumin/l of ascites removed
2. Haemacel 200mls/litre removed

Question 11

What is the serum ascites albumin gradient?

Answer 11

• Correlates directly with portal pressure
• Patients with normal portal pressures have a gradient of <1.1g/dl

Question 12

Exudative vs Transudative SAAG?

Answer 12

SAAG > 1.1g/dl = transudative
SAAG < 1.1g/dl = exudative

Question 13

Liver disorders that cause SAAG > 1.1g/dl?

Answer 13

1. cirrhosis/alcoholic liver disease
2. acute liver failure
3. Liver metastases

Question 14

Cardiac causes of SAAG > 1.1g/dl?

Answer 14

1. right heart failure
2. constrictive pericarditis

Question 15

Other causes of SAAG > 1.1g/dl?

Answer 15

1. budd-Chiari syndrome
2. portal vein thrombosis
3. veno-occlusive disease
4. myxoedema

Question 16

Causes of SAAG < 1.1g/dl?

Answer 16

1. Hypoalbuminemia
2. nephrotic syndrome
3. severe malnutrition (e.g. kwashiorkor)
4. Malignancy e.g. peritoneal carcinomatosis
5. Infectious e.g. TB
6. pancreatitis
7. Bowel obstruction, connective tissue diseases(serositis)
8. Postoperative lymphatic leak
9. Biliary ascites