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Bergmans C, Tapper EB. Outpatient Management of Symptomatic Ascites: Bypassing the Path of Least Resistance. Dig Dis Sci 2024; 69:2284-2286. [PMID: 38700628 DOI: 10.1007/s10620-024-08403-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 03/21/2024] [Indexed: 07/19/2024]
Affiliation(s)
- Carrie Bergmans
- Division of Gastroenterology and Hepatology, University of Michigan, 3912 Taubman, SPC 5362, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, 3912 Taubman, SPC 5362, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.
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Beran A, Mohamed MFH, Vargas A, Aboursheid T, Aziz M, Hernaez R, Patidar KR, Nephew LD, Desai AP, Orman E, Chalasani N, Ghabril MS. Early Diagnostic Paracentesis Improves Outcomes of Hospitalized Patients With Cirrhosis and Ascites: A Systematic Review and Meta-Analysis. Am J Gastroenterol 2024:00000434-990000000-01206. [PMID: 38916217 DOI: 10.14309/ajg.0000000000002906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 06/06/2024] [Indexed: 06/26/2024]
Abstract
INTRODUCTION Diagnostic paracentesis is recommended for patients with cirrhosis admitted to the hospital, but adherence is suboptimal with unclear impact on clinical outcomes. The aim of this meta-analysis was to assess the outcomes of early vs delayed diagnostic paracentesis among hospitalized patients with cirrhosis and ascites. METHODS We searched multiple databases for studies comparing early vs delayed diagnostic paracentesis among hospitalized patients with cirrhosis and ascites. The pooled odds ratio (OR) and mean difference with confidence intervals (CIs) for proportional and continuous variables were calculated using the random-effects model. Early diagnostic paracentesis was defined as receiving diagnostic paracentesis within 12-24 hours of admission. The primary outcome was in-hospital mortality. Secondary outcomes were length of hospital stay, acute kidney injury, and 30-day readmission. RESULTS Seven studies (n = 78,744) (n = 45,533 early vs n = 33,211 delayed diagnostic paracentesis) were included. Early diagnostic paracentesis was associated with lower in-hospital mortality (OR 0.61, 95% CI 0.46-0.82, P = 0.001), length of hospital stay (mean difference -4.85 days; 95% CI -6.45 to -3.20; P < 0.001), and acute kidney injury (OR 0.62, 95% CI 0.42-0.92, P = 0.02) compared with delayed diagnostic paracentesis, with similar 30-day readmission (OR 1.11, 95% CI 0.52-2.39, P = 0.79). Subgroup analysis revealed consistent results for in-hospital mortality whether early diagnostic paracentesis performed within 12 hours (OR 0.51, 95% CI 0.32-0.79, P = 0.003, I2 = 0%) or within 24 hours of admission (OR 0.67, 95% CI 0.45-0.98, P = 0.04, I2 = 82%). Notably, the mortality OR was numerically lower when diagnostic paracentesis was performed within 12 hours, and the results were precise and homogenous ( I2 = 0%). DISCUSSION Findings from this meta-analysis suggest that early diagnostic paracentesis is associated with better patient outcomes. Early diagnostic paracentesis within 12 hours of admission may be associated with the greatest mortality benefit. Data from large-scale randomized trials are needed to validate our findings, especially if there is a greater mortality benefit for early diagnostic paracentesis within 12 hours.
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Affiliation(s)
- Azizullah Beran
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Mouhand F H Mohamed
- Department of Internal Medicine, Warren Alpert Medical School Brown University, Providence, Rhode Island, USA
| | - Alejandra Vargas
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Tarek Aboursheid
- Department of Internal Medicine, Ascension Saint Francis Hospital, Evanston, Illinois, USA
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, Bon Secours Mercy Health, Toledo, Ohio, USA
| | - Ruben Hernaez
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Kavish R Patidar
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Lauren D Nephew
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Archita P Desai
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Eric Orman
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Marwan S Ghabril
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
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Badal J, Badal B, Nawras M, Lee-Smith W, Stanley S, Hassan M, Ahmed Z. Diagnostic Paracentesis Within 1 Day Is Associated With Reduced Mortality and Length of Hospital Stay in Patients with Cirrhosis and Ascites. Dig Dis Sci 2024; 69:1454-1466. [PMID: 38217676 DOI: 10.1007/s10620-023-08249-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 10/09/2023] [Indexed: 01/15/2024]
Abstract
Spontaneous bacterial peritonitis (SBP) is the most common infection in patients with cirrhosis and is associated with high mortality. Although recent literature reports mortality benefits to early diagnostic paracentesis, current guidelines do not offer specific recommendations for how quickly diagnostic paracentesis should be performed in patients with cirrhosis and ascites who are admitted to the hospital. Therefore, we conducted a systematic review and meta-analysis to evaluate outcomes among patients admitted to the hospital with cirrhosis and ascites receiving paracentesis within ≤ 12, ≤ 1 day, and > 1 day. Eight studies with 116,174 patients were included in the final meta-analysis. The pooled risk of in-hospital mortality was significantly lower in patients who underwent early (≤ 12 h or ≤ 1 day) compared to delayed (> 12 h or > 1 day) paracentesis (RR: 0.69, p < 0.00001), and in patients who underwent paracentesis compared to no paracentesis (RR: 0.74, p < 0.00001). On subgroup analysis, in-hospital mortality was significantly lower in both paracentesis within ≤ 12 h (RR: 0.61, p = 0.02) vs. > 12 h, and within ≤ 1 day (RR: 0.70, p < 0.00001) vs. > 1 day. While there was a trend towards decreased mortality in those undergoing paracentesis within ≤ 12 h compared to ≤ 1 day, the difference did not reach statistical significance. The length of hospital stay was significantly shorter by 5.38 days in patients who underwent early (≤ 12 h) compared to delayed (> 12 h) paracentesis (95% CI 4.24-6.52, p < 0.00001). Early paracentesis is associated with reduced mortality and length of hospital stay. We encourage providers to perform diagnostic paracentesis in a timely manner, at least within 1 day of hospital admission, for all patients with cirrhosis and ascites.
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Affiliation(s)
- Joyce Badal
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA.
- UNC Faculty Physicians Center, 100 Eastowne Drive, Chapel Hill, NC, 27514, USA.
| | - Bryan Badal
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, VA, USA
| | - Mohamad Nawras
- University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | | | - Sara Stanley
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Mona Hassan
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Zohaib Ahmed
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
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Pandya N, Pendyala N, Fogel J, Szurnicki P, Choudhry M, Eng A, Abdullah M. Variables associated with antibiotic administration for performing paracentesis among patients with ascites in a community hospital. Clin Exp Hepatol 2024; 10:47-52. [PMID: 38765905 PMCID: PMC11100336 DOI: 10.5114/ceh.2024.136215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/06/2023] [Indexed: 05/22/2024] Open
Abstract
Aim of the study Early paracentesis before antibiotic administration reduces morbidity and mortality in patients with decompensated cirrhosis. We studied the association of variables with antibiotic administration before or after performing paracentesis. Material and methods This was a retrospective study of 137 patients with ascites secondary to cirrhosis admitted to a community hospital in New York City. Predictor variables were demographic, disease-related, admission timing, and serum measurement. Results We found a significantly increased relative risk for performing paracentesis after antibiotic administration for those admitted at night (relative risk ratio [RRR] = 3.01, 95% CI: 1.02-8.85, p = 0.046). Demographic, disease-related, and serum measurement variables were not significantly associated with performing paracentesis or order of antibiotic administration. Also, increased body mass index was significantly associated with decreased relative risk for paracentesis not done (RRR = 0.84, 95% CI: 0.74-0.96, p = 0.01). Conclusions In conclusion, there was increased relative risk for performing paracentesis after antibiotic administration for patients admitted at night. We recommend ongoing resident and hospitalist training to maintain competency in bedside procedures such as paracentesis for patients with cirrhosis. Also, increased staffing or the presence of a resident/hospitalist led interventional team during night shifts may also help optimize the rates of timely paracentesis.
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Affiliation(s)
| | | | | | | | | | - Amanda Eng
- South Brooklyn Health, Brooklyn, NY, USA
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Brown C, Aksan N, Chang P, Jagannathan P, Ochi MG, Pignone M, Feagins L. Delayed Diagnostic Paracentesis Is Associated with Increased Preventable Healthcare Utilization in Disadvantaged Patient Populations with Advanced Liver Disease and Elevated INR. Dig Dis Sci 2023:10.1007/s10620-023-07937-x. [PMID: 37052775 DOI: 10.1007/s10620-023-07937-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 03/25/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Patients hospitalized with cirrhosis, ascites, and elevated INR often experience delays in timely diagnostic paracentesis. AIMS Identify whether delays in diagnostic paracentesis were associated with adverse outcomes in a hospital system serving a large disadvantaged population. METHODS Retrospective cohort analysis of patients admitted from January 2017 to October 2019 with cirrhosis, ascites, and INR ≥ 1.5 across a multi-hospital health system in central Texas. We examined demographic and clinical characteristics of patients with diagnostic paracentesis (1) ≤ 24 h; (2) > 24 h; (3) therapeutic only or no paracentesis. We used logistic regression to examine differences in clinical outcomes controlling for confounders. RESULTS 479 patients met inclusion criteria. 30.0% (N = 143) were Latino, 6.7% (N = 32) African American, and 67.8% (N = 325) under or uninsured. 54.1% of patients received a diagnostic paracentesis ≤ 24 h of admission and 21.1% did not receive a diagnostic paracentesis during the hospitalization. Undergoing diagnostic paracentesis > 24 h of admission was associated with a 2.3 day increase in length of stay (95% CI 0.8-3.8), and OR 1.7 for an Emergency Room visit within 30 days of discharge (95% CI 1.1-2.7) compared to receiving a diagnostic paracentesis ≤ 24 h. Patients receiving diagnostic paracentesis in radiology were more likely to have a delay in procedure OR 5.8 (95% CI 2.8-8.6). CONCLUSION Delayed diagnostic paracentesis is associated with increased preventable healthcare utilization compared with timely diagnostic paracentesis. Health systems should support efforts to ensure timely diagnostic paracentesis for patients with advanced liver disease, including performance at the bedside.
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Affiliation(s)
- Cristal Brown
- Dell Medical School, University of Texas at Austin, Austin, USA.
- Gastroenterology and Hepatology, The University of Texas at Austin Dell Medical School, Health Discovery Building, 1601 Trinity St Z0900, Austin, TX, 78712, USA.
| | - Nazan Aksan
- Dell Medical School, University of Texas at Austin, Austin, USA
| | - Patrick Chang
- Dell Medical School, University of Texas at Austin, Austin, USA
| | | | | | - Michael Pignone
- Dell Medical School, University of Texas at Austin, Austin, USA
| | - Linda Feagins
- Dell Medical School, University of Texas at Austin, Austin, USA
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Amin AN, Nguyen PH, Tapper EB. Missed diagnosis of cirrhosis in the inpatient setting. J Hosp Med 2022; 17 Suppl 1:S1-S7. [PMID: 35972039 PMCID: PMC9387549 DOI: 10.1002/jhm.12918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 07/05/2022] [Accepted: 07/05/2022] [Indexed: 11/07/2022]
Abstract
Cirrhosis accounts for a large number of deaths in the United States and worldwide, leading to an increasing burden on the healthcare system. Cirrhosis is, however, a progressive disease with different potential complications related to liver dysfunction and portal hypertension. Often, patients may present with complications of cirrhosis without having been diagnosed previously. It is pertinent that clinicians recognize these signs to place patients on an appropriate course of management to help delay or avoid further disease progression while avoiding deleterious outcomes and unnecessary utilization. We will discuss the epidemiology of liver disease, cirrhosis, and its complications (hepatic encephalopathy, ascites, and varices). In this study, we will discuss the rationale and impact of missing these diagnoses on the healthcare system and patient.
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Affiliation(s)
- Alpesh N. Amin
- Department of Medicine, University of California, Irvine
| | | | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan
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