Paracentesis

Question 1

What are the indications for paracentesis?

Answer 1

1. ) Diagnostic workup for new onset ascites of unknown causation.
2. ) Rule out of spontaneous bacterial peritonitis
3. ) Alleviation of discomfort or respiratory compromise.

Question 2

What are possible causes of ascites?

Answer 2

Portal hypertension
Cancer
Infection
Pancreatitis

Question 3

The paracentesis catheter/needle should not pass through sites of…

Answer 3

…cutaneous infection, visibly engorged cutaneous vessels, surgical scars, or abdominal-wall hematomas.

Question 4

What are two examples of prepackaged paracentesis kits?

Answer 4

Safe-T-Centesis Catheter Drainage Tray (made by Cardinal Health)
Large Volume Abdominal Paracentesis Kit (made by Arrow International)

Question 5

If using a midline insertion site, the needle should be inserted…

Answer 5

…about 2 cm below the umbilicus.

Question 6

What are the risks of paracentesis?

Answer 6

Bleeding
Infection
Injury to intra-abdominal organs
Post-procedure hypotension
Abdominal wall hematoma
Ascitic fluid leak 
Puncture of the inferior epigastric artery

Question 7

The advantage of the midline approach is that…

Answer 7

…the linea alba in this region is devoid of blood vessels.

Question 8

In obese patients, the left lateral approach may be preferable because the abdominal wall is…

Answer 8

…thinner and the depth of ascitic fluid is deeper in this region than in the midline.

Question 9

If you choose the lateral approach, you must…

Answer 9

…insert the needle lateral to the rectus sheath to avoid puncturing the inferior epigastric artery.

Question 10

How many mls of lidocaine is generally used?

Answer 10

3 to 5 ml

Question 11

The Z-tract method prevents…

Answer 11

…direct overlap of the cutaneous insertion site and the peritoneal insertion site, theoretically minimizing the risk of an ascitic leak after the procedure.

Question 12

The serum-ascites albumin gradient is calculated by…

Answer 12

…subtracting the albumin level in ascitic fluid from the serum albumin level. (These values need to be obtained at the same time.)

Question 13

In analysis of ascitic fluid, a total protein value that is > or = to 1 g/dL suggests…

Answer 13

…secondary peritonitis instead of spontaneous bacterial peritonitis (SBP).

Question 14

A lactate dehydrogenase value greater than the upper limit of normal for serum suggests…

Answer 14

…secondary peritonitis instead of SBP.

Question 15

A glucose value

Answer 15

…secondary peritonitis instead of

SBP.

Question 16

A carcinoembryonic antigen values >5 ng/ml suggests…

Answer 16

…hollow viscus perforation.

Question 17

An alkaline phosphatase values >240 U/liter suggests…

Answer 17

…hollow viscus perforation.

Question 18

An amylase value that is markedly elevated (often >2000 U/liter or five times serum levels) suggests…

Answer 18

…pancreatic ascites or hollow viscus perforation.

Question 19

A triglyceride value > 200 mg/dl suggests…

Answer 19

…chylous ascites.

Question 20

What is the differential diagnosis of ascites when the serum-ascites albumin gradient is > or = to 1.1 g/dl (portal hypertension).
(6 diagnoses)

Answer 20

cirrhosis
alcoholic hepatitis
cardiac ascites
portal-vein thrombosis
Budd-Chiari syndrome
Liver metastases

Question 21

What is the differential diagnosis of ascites when the serum-ascites albumin gradient is

Answer 21

Peritoneal carcinomatosis
Tuberculous peritonitis
Pancreatic ascites
Biliary ascites
Nephrotic syndrome
Serositis

Question 22

The diagnosis of SBP is suggested by a _________________ (___) ____ _____ in excess
of ___ cells per cubic millimeter in the absence of…

Answer 22

polymorphonuclear (PMN) cell count
250
…evidence of an alternative source
of infection (secondary peritonitis), such as viscus perforation or intraabdominal abscess.

Question 23

Patients diagnosed with SBP should be treated with…

Answer 23

…both antibiotics (typically a third-generation cephalosporin, i.e. ceftriaxone, cefotaxime) and IV albumin.