Last updated: September 4, 2023

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Summarytoggle arrow icon

Paracentesis is a procedure in which fluid is removed from the peritoneum for diagnostic and/or therapeutic purposes. Diagnostic paracentesis is the removal of a small volume of intraperitoneal fluid for the evaluation of newly diagnosed ascites or to assess for spontaneous bacterial peritonitis in patients with chronic ascites. Therapeutic paracentesis is the removal of large volumes of intraperitoneal fluid to relieve associated abdominal pain and/or respiratory symptoms. Relative contraindications include pregnancy, visceral distention, severe coagulopathy, and infection over the procedure site. The procedure is always performed using sterile technique and is usually guided by ultrasound. Complications include a persistent fluid leak, postparacentesis circulatory dysfunction, and hepatic encephalopathy.

Definitiontoggle arrow icon

  • Diagnostic paracentesis: aspiration of a small volume of fluid from the peritoneum to aid in the diagnosis and management of ascites and other intraabdominal conditions
  • Therapeutic paracentesis: removal of a large volume of fluid from the peritoneum to relieve symptoms caused by ascites
  • Large volume paracentesis: removal of > 5 L of fluid from the peritoneum during one procedure [2]

Indicationstoggle arrow icon

Diagnostic paracentesis [2][3][4]

Occult SBP is common in patients with ascites and cirrhosis, and delays in diagnosis result in increased mortality. [5]

Therapeutic paracentesis [2][3][6][7]

Contraindicationstoggle arrow icon

Transfusion of clotting factors and/or platelets prior to paracentesis in patients with coagulopathy is not routinely recommended unless there is active DIC. [3]

We list the most important contraindications. The selection is not exhaustive.

Landmarks and positioningtoggle arrow icon

Landmarks [3][8]

Choose a needle entry site that avoids abdominal scars, underlying blood vessels, and inflamed or infected skin. Preferred sites include:

Positioning [3][8]

Ultrasound guidance [3][9]

Recommended because it can locate fluid collections, inform patient positioning, and identify conditions that increase procedural risk

  • Use color flow Doppler to identify avoidable blood vessels in the abdominal wall.
  • Static guidance (most common): Optimal needle entry site is identified and marked prior to skin prep.
  • Dynamic guidance: real-time ultrasound guidance of needle movements, e.g., for small volumes of fluid and/or enlarged viscera
  • See “FAST” for the basic principles of abdominal ultrasound.

Consider performing paracentesis under ultrasound guidance to reduce the risk of serious complications and improve success rates. [9]

Equipment checklisttoggle arrow icon

All patients [3][8][10]

Diagnostic paracentesis [3][8][10]

Therapeutic paracentesis [3][8][10]

  • Prepackaged set, e.g., 18-gauge needle with preloaded 8 Fr catheter
  • Or 14–18-gauge peripheral IV catheter [10]

Drainage set-up (if indicated)

Preparationtoggle arrow icon

Procedure/applicationtoggle arrow icon

  1. Pull the skin ∼ 2 cm caudad prior to needle insertion (Z-track technique).
  2. Insert the needle perpendicular to the skin at the marked location.
  3. Apply negative pressure on the syringe plunger and advance slowly until fluid returns.
  4. Advance another few millimeters, then fix the needle in this location or slide the catheter off the needle.
  5. Diagnostic paracentesis: Aspirate 60 mL of fluid into large syringes.
  6. Therapeutic paracentesis: Connect high-pressure tubing from the needle to the drainage system.
  7. Large volume paracentesis: Infuse albumin during or immediately after the procedure. [2][12][13]
  8. Once fluid collection is complete, remove the needle or catheter.
  9. Apply an occlusive dressing.

Pitfalls and troubleshootingtoggle arrow icon

The following can be prevented by using real-time ultrasound guidance and needle-catheter systems with side ports (e.g., Caldwell needle) to improve flow.

Interruption of fluid flow [3][8]

  • Cause: obstruction likely, e.g. kinked catheter, orifice obstructed by omentum or other intraabdominal structure
  • Management: inject a small amount of intraperitoneal fluid back through the needle or catheter, then reattempt aspiration.

No fluid flow [3][8]

  • Causes
    • Obstruction
    • Small volume of fluid or loculated fluid, or obstruction
  • Management

Do not reposition the needle while the tip is within the peritoneum, as it may injure the bowel, omentum, and/or blood vessels. [8]

Postprocedure checklisttoggle arrow icon

Interpretation/findingstoggle arrow icon

Complicationstoggle arrow icon

Postprocedural fluid leak [3][8]

  • Prevention: Z-track technique
    • Pull the skin ∼ 2 cm caudad prior to needle insertion and do not release until the needle has passed into the peritoneum.
    • Once the needle has been removed, the skin will return to its original position and seal the peritoneal insertion site.
  • Management [6][8][10]
    • Position the patient so that the needle site is nondependent.
    • Consider a skin suture or tissue adhesive.

Postparacentesis circulatory dysfunction (PPCD) [2][14][15]

Other complications

PPCD rarely manifests during the procedure. Albumin should be administered even if the patient is asymptomatic and normotensive. [2][12][13]

We list the most important complications. The selection is not exhaustive.

Referencestoggle arrow icon

  1. $Contributor Disclosures - Paracentesis. All of the relevant financial relationships listed for the following individuals have been mitigated: Alexandra Willis (copyeditor, was previously employed by OPEN Health Communications). None of the other individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.
  2. Biggins SW, Angeli P, Garcia‐Tsao G, et al. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021; 74 (2): p.1014-1048.doi: 10.1002/hep.31884 . | Open in Read by QxMD
  3. Roberts JR. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. Elsevier ; 2018
  4. Angeli P, Bernardi M, Villanueva C, et al. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018; 69 (2): p.406-460.doi: 10.1016/j.jhep.2018.03.024 . | Open in Read by QxMD
  5. Kim JJ, Tsukamoto MM, Mathur AK, et al. Delayed Paracentesis Is Associated With Increased In-Hospital Mortality in Patients With Spontaneous Bacterial Peritonitis. Am J Gastroenterol. 2014; 109 (9): p.1436-1442.doi: 10.1038/ajg.2014.212 . | Open in Read by QxMD
  6. Aithal GP, Palaniyappan N, China L, et al. Guidelines on the management of ascites in cirrhosis. Gut. 2021; 70 (1): p.9-29.doi: 10.1136/gutjnl-2020-321790 . | Open in Read by QxMD
  7. Khungar V, Saab S. Cirrhosis With Refractory Ascites: Serial Large Volume Paracentesis, TIPS, or Transplantation?. Clin Gastroenterol Hepatol. 2011; 9 (11): p.931-935.doi: 10.1016/j.cgh.2011.04.028 . | Open in Read by QxMD
  8. Reichman EF. Reichman's Emergency Medicine Procedures, 3rd Edition. McGraw Hill Professional ; 2018
  9. Reichman E. Emergency Medicine Procedures. McGraw-Hill ; 2013
  10. Shrestha DB, Budhathoki P, Sedhai YR, et al. Safety and efficacy of human serum albumin treatment in patients with cirrhotic ascites undergoing paracentesis: A systematic review and meta-analysis. Ann Hepatol. 2021; 26: p.100547.doi: 10.1016/j.aohep.2021.100547 . | Open in Read by QxMD
  11. Flamm SL, Wong F, Ahn J, Kamath PS. AGA Clinical Practice Update on the Evaluation and Management of Acute Kidney Injury in Patients With Cirrhosis: Expert Review. Clin Gastroenterol Hepatol. 2022; 20 (12): p.2707-2716.doi: 10.1016/j.cgh.2022.08.033 . | Open in Read by QxMD
  12. McGibbon A, Chen GI, Peltekian KM, van Zanten SV. An Evidence-Based Manual for Abdominal Paracentesis. Dig Dis Sci. 2007; 52 (12): p.3307-3315.doi: 10.1007/s10620-007-9805-5 . | Open in Read by QxMD
  13. Lindsay A, Burton J, Ray C. Paracentesis-Induced Circulatory Dysfunction: A Primer for the Interventional Radiologist. Semin Intervent Radiol. 2014; 31 (03): p.276-278.doi: 10.1055/s-0034-1382799 . | Open in Read by QxMD
  14. Kulkarni AV, Kumar P, Sharma M, et al. Pathophysiology and Prevention of Paracentesis-induced Circulatory Dysfunction: A Concise Review. J Clin Transl Hepatolo. 2020; 8 (X): p.1-7.doi: 10.14218/jcth.2019.00048 . | Open in Read by QxMD
  15. Cho J, Jensen TP, Reierson K, et al. Recommendations on the Use of Ultrasound Guidance for Adult Abdominal Paracentesis: A Position Statement of the Society of Hospital Medicine. J Hosp Med. 2019; 14 (1).doi: 10.12788/jhm.3095 . | Open in Read by QxMD

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