You have always been told to do a diagnostic paracentesis on admission in cirrhotics with ascites, but why? Can you just get away with clinical judgement to rule out SBP? Is faculty judgement any better? And if you’re going to do a paracentesis on admission, do you need to do it right away? Go deeper with Dr. Steve Liu and Dr. Janine Knudsen!
- 1:51 What do guidelines say about diagnostic paracentesis in cirrhotics with ascites?
- 3:13 Can we just use clinical judgement to decide if paracentesis is warranted?
- Do attendings have better clinical judgement than residents to rule out SBP?
- 6:33 Does timing of paracentesis on admission matter for mortality?
- AASLD and European Association for the Study of the Liver guidelines recommend patients with cirrhosis and ascites admitted to the hospital should undergo a diagnostic abdominal paracentesis.
- In a prospective observational trial, physician clinical impression had a sensitivity of 76% and specificity of 34% for spontaneous bacterial peritonitis on admission
- Faculty tended to be more sensitive than residents, but not statistically significant.
- Don’t forget about asymptomatic SBP!
- Delayed paracentesis is associated with increased in-hospital mortality in patients with SBP comparing early paracentesis within 12 hours of admission vs. delayed between 12- 72 hours from admission.
- This corresponded to an increase in mortality of 3.3% for every hour delayed.
- 1:57 – What does the AASLD recommend regarding abdominal paracentesis on arrival to the hospital? Runyon BA. “AASLD guidelines. Management of Adult Patients with Ascites Due to Cirrhosis: Update 2012” https://www.aasld.org/sites/default/files/guideline_documents/141020_Guideline_Ascites_4UFb_2015.pdf
- 3:17 – Chinnock B, et al. “Physician clinical impression does not rule out spontaneous bacterial peritonitis in patients undergoing emergency department paracentesis.” Ann Emerg Medˆ 2008 Sep;52(3)268-73. https://www.ncbi.nlm.nih.gov/pubmed/18433932
- 4:42 – Pinzello G, Simonetti RG, Craxi A, Di Piazza S, Spano C, Pagliaro L. “Spontaneous bacterial peritonitis: a prospective investigation in predominantly nonalcoholic cirrhotic patients.” Hepatology 1983 Jul-Aug;3(4):545-9 http://onlinelibrary.wiley.com.ezproxy.med.nyu.edu/doi/10.1002/hep.1840030411/abstract
- 5:43 – Angeli KL. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. https://www.easl.eu/medias/cpg/issue4/English-report.pdf
- 6:36 – Orman ES, Hayashi PH, Bataller R, Sidney Barritt IV A. “Paracentesis is associated with reduced mortality in patients hospitalized with cirrhosis and ascites.” Clin Gastroenterol Hepatol 2014 Mar;12(3):496-503 https://www.ncbi.nlm.nih.gov/pubmed/23978348
- 7:25 – Kim et al. “Delayed paracentesis is associated with increased in-hospital mortality in patients with spontaneous bacterial peritonitis.” Am J Gastroenterol 2014 Sep;109(9):1436-42 http://search.ebscohost.com.ezproxy.med.nyu.edu/login.aspx?direct=true&db=mnh&AN=25091061&site=ehost-liv
Tags: AASLD, Ascites, Clinical Practice, family medicine, FOAMed, gastroenterology, Internal Medicine, Medical Student, Mind the Gap, Nurse Practitioner, Physician Assistant, resident, spontaneous bacterial peritonitis
2 comments on “Mind The Gap on Admission Paracentesis, Part 1”
Excellent episode and thanks for this. My name is Rohan and I am a PGY-2 IM resident at Boston Medical Center, and I am actually doing a chalk talk about this topic! I did have a question which I was not able to find evidence for, if for some reason the overnight/weekend team is uncomfortable doing the paracentesis and we are approaching the 12 hour mark, do we treat empirically for SBP? Thanks so much.
Hi Rohan! I hope this comes in time before your chalk talk. This is from Dr. Steve Liu: “The short answer is I agree that there does not appear to be clear data for the question that was asked.
Thinking about the question more, it’s a sensible question from a clinician’s perspective but I think doesn’t really set up for an answer. Basically your approach for evaluating the data would be looking at folks that are admitted to the hospital and discharged with a provisional diagnosis of SBP, but ironically that would miss the majority of patients who the doctor is asking about as these folks often leave with alternative diagnoses. Alternatively you could have a study with overly broad diagnostic criteria like anyone with cirrhosis with sepsis could be considered. Rather than getting stuck on creating a study that would probably have dubious results because of its overly broad or too narrow inclusion criteria, let me suggest reframing the question.
SBP has a specific definition (distinguishing it from CNNA and non neutrocytic bacterioascites) and the data are clear that our ability to predict these laboratory results a priori based on clinical suspicion is not particularly good. Typically we expect a tappable pocket to form secondary to the intra-abdominal inflammation from infection, but we know that SBP exists on a spectrum of disease that involves bacterial invasion of ascites and in this spectrum some people can be minimally symptomatic or asymptomatic. We should remind ourselves that we empirically treat for SBP all the time as often initial data only suggests neutrocytic ascites as cultures for SBP are notoriously bad (this is an exaggeration since of course as I believe we mention in the episode CNNA is thought to have similar overall outcomes to SBP but I’m doing this to make a point in that we are treating empirically already).
With that in mind, let’s reframe. I suggest we ask ourselves two questions: how do I make a provisional diagnosis of SBP, and how should I approach my management decision making with that in mind.
Fortunately the rational clinical exam series does give us a few data points for determining if a patient has SBP. The next question is what threshold do I have to treat a patient? The answer I’d give is that given the high rate of mortality the answer is if you have a moderate suspicion you should treat them.
Also one last thing I’m not familiar with any 12 hour rule. I quickly re-read the guidelines and they don’t mention that. Once you decided that abx are appropriate they should be started.”