On exam, his abdomen was grossly distended with a positive fluid wave and no peritoneal signs. His last paracentesis was done 2 weeks prior with 10L of fluid removed. IR was consulted but would not have availability until late afternoon, and after discussion with the patient, a paracentesis was performed in the ED. Ultrasound was used to visualize the fluid pocket and patient anatomy, to minimize risk to the patient.\u00a0<\/p>\n\n\n\n
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<\/figure>\n\n\n\nFigure 1: Perihepatic view. Cirrhotic, nodular liver and visible Morison\u2019s pouch. The pocket of ascitic fluid visualized is approximately 5cm deep\u00a0<\/p>\n\n\n\n Figure 2: Transverse pelvic view, hyperechoic bowel loops can be visualized, as well as a 8-10 cm deep fluid pocket\u00a0<\/p>\n\n\n\n Figure 3: Limited left upper quadrant view. While the splenorenal space can be visualized, the perisplenic space, where ascites tends to preferentially accumulate (over the splenorenal space), cannot be seen in this image.\u00a0<\/p>\n\n\n\n Therapeutic and diagnostic paracentesis for ascites is commonly performed in the ED. The most common etiology for ascites is alcoholic cirrhosis, which makes up 80% of cases in western countries\u00b9. Other causes include malignancy and heart failure\u00b9. Prior to widespread use of ultrasound for routine bedside exams, paracenteses in the ED were commonly performed based on landmarks and could be associated with complications such as bleeding and damage to surrounding structures. A 2005 clinical trial showed the benefits of using ultrasound to guide needle placement during this procedure, with the authors finding a 95% success rate (defined by fluid aspiration) when ultrasound was used compared to a 68% success rate with the traditional technique\u2075. A 2013 article also found that the use of ultrasound in paracenteses was associated with a 68% decrease in bleeding-related complications compared to the traditional technique\u2074. <\/p>\n\n\n\n A 2019 position statement by the Society of Hospital Medicine establishes recommendations for effective use of ultrasound to guide paracentesis. Ultrasound allows both identification of more superficial blood vessels to avoid with needle insertion as well as visualization of the peritoneal cavity to survey the anatomy and qualitatively and quantitatively describe any fluid within. Damage to abdominal wall vessels such as the inferior epigastric artery or vein can cause catastrophic bleeding, morbidity, and\u00a0mortality\u00b2. Identification of these vessels with color doppler prevents inadvertent vessel wall injury. As the ultrasound beam is only several millimeters wide, it is important to obtain views of multiple angles of the needle insertion site to ensure there are no vessels or underlying structures along the path of the needle\u00b2. <\/p>\n\n\n\n Ascitic fluid is hypoechoic, while bowel is often hyperechoic due to bowel gas. Organs may be more heterogenous and of intermediate echogenicity\u00b3. Ultrasound can also be used to assess the fluid pocket itself. For example, a fluid depth of 2cm is recommended for procedural safety\u00b3. Ultrasound is more sensitive than x-ray to fluid as it is able to detect as little as 100 ml of fluid, compared to 500 ml for x-ray\u00b2. Presence of heterogeneity within the fluid pocket can be suggestive of loculations, which may indicate a more likely malignant or inflammatory cause of ascites.\u00a0<\/p>\n\n\n\n The 66-year-old patient above had an uncomplicated paracentesis with needle placement in the left lower quadrant, and over 8 liters of fluid were removed from his abdomen. He tolerated it well and was discharged from the ED shortly after with follow-up with his PCP as well as a recommendation for regularly scheduled paracenteses with radiology.\u00a0<\/p>\n\n\n\n References:<\/p>\n\n\n\n 1. AGA Clinical Practice Update on the Management of Ascites, Volume Overload, and Hyponatremia in Cirrhosis: Expert Review Orman, Eric S. et al. Gastroenterology, Volume 169, Issue 7, 1547 - 1557 <\/p>\n\n\n\n 2. Cho J, Jensen TP, Reierson K, Mathews BK, Bhagra A, Franco-Sadud R, Grikis L, Mader M, Dancel R, Lucas BP; Society of Hospital Medicine Point-of-care Ultrasound Task Force; Soni NJ. Recommendations on the Use of Ultrasound Guidance for Adult Abdominal Paracentesis: A Position Statement of the Society of Hospital Medicine. J Hosp Med. 2019 Jan 2;14:E7-E15. doi: 10.12788\/jhm.3095. PMID: 30604780; PMCID: PMC8021127. <\/p>\n\n\n\n 3. Kumar A, Dancel R, Galen BT et al. Ultrasound Guidance for Paracentesis. N Engl J Med. 2022;386(7):e15. doi:10.1056\/NEJMvcm2119156 <\/p>\n\n\n\n 4. Mercaldi CJ, Lanes SF, Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis. (2013). Chest, 143(4), 1010\u20131015. https:\/\/doi.org\/10.1378\/chest.12-0447 <\/p>\n\n\n\n 5. Nazeer SR, Dewbre H, Miller AH. Ultrasound-assisted paracentesis performed by emergency physicians vs the traditional technique: a prospective,\u00a0randomized study. Am J Emerg Med. 2005 May;23(3):363-7. doi: 10.1016\/j.ajem.2004.11.001. PMID: 15915415.\u00a0<\/p>\n\n\n\n <\/p>\n","protected":false},"excerpt":{"rendered":"Angela Wang, Benjamin Liotta A 66-year old male with a longstanding history of alcoholic cirrhosis presents to the ED early in the morning requesting a paracentesis with 10 days of worsening abdominal distention in the setting of running out of his home furosemide several weeks prior. He denied fever, nausea, vomiting, or abdominal pain.\u00a0 \u00a0Vitals:\u00a0 … ![\"\"](\"https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2025\/12\/image-1.png?resize=525%2C319&ssl=1\")
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