Indications
Ascites is defined as the buildup of fluid in the abdomen and pelvis. Ascites can cause a great degree of abdominal pain, making it difficult to breath, and result in severe electrolyte abnormalities. Many patients with cirrhosis have ascites; in fact, ascites is the most common complication seen in patients with ascites. The development of ascites also has prognostic significance. More often than not, ascites can often be managed with a combination of dietary salt restriction and oral diuretics (AASLD Practice Guidelines, Runyon BA, 2009).
In general, all patients with the new onset of ascites undergo a diagnostic paracentesis. A paracentesis is a minimally invasive procedure where an interventional radiologist drains the ascites by placing a small needle into the ascitic fluid under ultrasound guidance. Not only does this provide immediate symptomatic relief, the fluid obtained can be tested to help determine the cause of the fluid accumulation. Fluid occurring due to portal hypertension can usually be differentiated from fluid caused by other disorders. In addition, paracentesis is performed on most patients who are admitted to a hospital with ascites in order to determine if the fluid is infected; this is a condition known as spontaneous bacterial peritonitis (or SBP). SBP occurs in 30% of patients with ascites (Wong F, et al. 2005) and can have a mortality rate as high as 20% (Tandon P, et al. 2008) which is why it is important to diagnose.
Procedural Details
A paracentesis procedure is performed to remove accumulated fluid from the abdomen. We perform paracentesis procedures using ultrasound for guidance. In other words, we perform an ultrasound examination of the abdomen and then mark the skin in the location of the largest amount of fluid. Once the skin is marked, we numb that area with local anesthesia and then place a small needle into the abdomen. Fluid is then able to be removed from the abdomen through that needle. If a large volume of fluid (>5 liters), we will often give albumin through an IV to prevent significant dehydration.
There is a subset of patients that have refractory ascites, which means that ascites is unresponsive to a salt-restricted diet and high-dose diuretics and that recurs rapidly after a therapeutic paracentesis. <10% of patients with cirrhosis and ascites are refractory to standard medical therapy (Stanley MM, et al. 1989). Patients who suffer from refractory ascites are under constant distress. As interventional radiologists, we are able to offer patients suffering with ascites a multitude of options to improve their quality and longevity of life.
Options for these patients include liver transplant, TIPS, peritoneal-venous (Denver) shunts, pleurx catheter placement, and serial large volume paracentesis (Runyon BA, 2009). Serial paracentesis procedures can remove a large volume of fluid, and this tends to be the first course of action for many patients as well as the last course if they are not candidates for one of the above procedures. In that case, patients return on a weekly or biweekly basis corresponding to when the fluid accumulation is causing them a large amount of discomfort. After spending a few minutes at the hospital as an outpatient, they are able to gain days or weeks worth of relief.
- TIPS (Transjugular Intrahepatic Portosystemic Shunt): This is often the preferred option in patients who are candidates for this procedure. This is the only option that is able to directly address the portal hypertension that is often causing the ascites.
- Denver Shunt: A Denver shunt is a subcutaneous tunneled peritoneovenous shunt. In other words, it is a catheter that runs under the skin bridging the ascitic fluid to a major vein. This catheter is able to transport the fluid from the abdomen right back into a major vein. By doing so, a Denver shunt is able to recycle the protein and electrolytes within the ascites back into the bloodstream so that your body can use them. Denver shunt placement is an outpatient procedure performed under conscious sedation. Patients are able to go home the day of the procedure with a fully functioning shunt. Patient selection is key for this procedure since only a minority of patients are candidates.
- Pleurx Catheter Placement: A Pleurx catheter is another type of a subcutaneous tunneled catheter. The catheter enters the body, runs under the skin, and terminates within the ascites. The Pleurx catheter allows patients to manage their own ascites by providing them a way to drain the fluid themselves at home. This permanent catheter allows patients to gain control of their own lives as opposed to needing to come to the hospital for repeated large volume paracenteses. Pleurx catheter placement is an outpatient, same day, minimally invasive procedure. After catheter placement, drainage bottles are delivered to the patient’s home on a weekly basis.
Results
Paracentesis procedures are certainly effective at removing fluid from the abdomen. This helps to diagnose the condition causing the fluid and also helps to ease the symptoms of patients presenting with ascites. However, we know that if the condition causing ascites is not corrected, ascites will reaccumulate which may require repeat procedures or other options as described above.
If you, your primary care physician, hepatologist, or gastroenterologist feel that you are interested in any of these options, we typically begin with a consultation in our outpatient office. During your visit, we answer your questions, discuss options for treatment, and can discuss which procedure is most appropriate for you in more detail.