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Tan JL, Lokan T, Chinnaratha MA, Veysey M. Risk of bleeding after abdominal paracentesis in patients with chronic liver disease and coagulopathy: A systematic review and meta-analysis. JGH Open 2024; 8:e70013. [PMID: 39161798 PMCID: PMC11331248 DOI: 10.1002/jgh3.70013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 07/16/2024] [Accepted: 07/22/2024] [Indexed: 08/21/2024]
Abstract
Abdominal paracentesis is a common procedure performed for both diagnostic and therapeutic purposes in patients with chronic liver disease and ascites. This review aims to provide an overview of the current evidence on the risk of bleeding associated with abdominal paracentesis. Electronic search was performed using PubMed, MEDLINE, and Ovid EMBASE from inception to 29 October 2023. Studies were included if they examined the risk of bleeding post-abdominal paracentesis or the efficacy of interventions to reduce bleeding in patients with chronic liver disease. Random-effects model was used to calculate the pooled proportions of bleeding events following abdominal paracentesis. Heterogeneity was determined by I 2, τ2 statistics, and P-value. Eight studies were included for review. Six studies reported incident events of post-abdominal paracentesis bleeding. Pooled proportion of bleeding events following abdominal paracentesis was 0.32% (95% CI: 0.15-0.69%). The mean values for pre-procedural INR and platelet count of patients in these studies ranged between 1.4 and 2.0, and 50 and 153 × 109/L, respectively. The highest recorded INR was 8.7, and the lowest platelet count was 19 × 109/L. Major bleeding after abdominal paracentesis occurred in 0-0.97% of the study cohorts. Two studies demonstrated that the use of thromboelastography (TEG) before paracentesis in patients with chronic liver disease identified those at risk of procedure-related bleeding and reduced transfusion requirements. The overall risk of major bleeding after abdominal paracentesis is low in patients with chronic liver disease and coagulopathy. TEG may be used to predict bleeding risk and guide transfusion requirements.
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Affiliation(s)
- Jin Lin Tan
- Faculty of Health and Medical SciencesThe University of AdelaideAdelaideSouth AustraliaAustralia
- Department of Gastroenterology and HepatologyLyell McEwin HospitalElizabeth ValeSouth AustraliaAustralia
| | - Thomas Lokan
- Department of Gastroenterology and HepatologyLyell McEwin HospitalElizabeth ValeSouth AustraliaAustralia
| | - Mohamed Asif Chinnaratha
- Faculty of Health and Medical SciencesThe University of AdelaideAdelaideSouth AustraliaAustralia
- Department of Gastroenterology and HepatologyLyell McEwin HospitalElizabeth ValeSouth AustraliaAustralia
| | - Martin Veysey
- Department of GastroenterologyTop End Health ServiceDarwinNorthern TerritoryAustralia
- School of MedicineFlinders UniversityBedford ParkSouth AustraliaAustralia
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2
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Loffredo L, Maggio E, Vestri AR, Di Rocco A, Pignatelli P, Violi F. Effect of severe thrombocytopenia on bleeding in chronic liver disease after low risk surgical procedures: a meta-analysis. HPB (Oxford) 2024; 26:726-728. [PMID: 38395677 DOI: 10.1016/j.hpb.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 01/27/2024] [Accepted: 02/11/2024] [Indexed: 02/25/2024]
Affiliation(s)
- Lorenzo Loffredo
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy.
| | - Enrico Maggio
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy
| | | | | | - Pasquale Pignatelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy
| | - Francesco Violi
- Mediterranea Cardiocentro, Naples, Italy; Sapienza University of Rome, Rome, Italy.
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3
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Hanai T, Kawaratani H, Nagano J, Suii H, Sakamaki A, Arase Y, Nakanishi H, Kogiso T, Okubo T, Miwa T, Shimizu S, Hige S, Atsukawa M, Shimizu M, Kurosaki M, Terai S, Kagawa T, Tokushige K, Yoshiji H. Cell-free and concentrated ascites reinfusion therapy versus large-volume paracentesis for the treatment of cirrhotic patients with refractory ascites: A multicenter prospective observational study. Hepatol Res 2023; 53:238-246. [PMID: 36433862 DOI: 10.1111/hepr.13860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 11/06/2022] [Accepted: 11/11/2022] [Indexed: 11/27/2022]
Abstract
AIM Cell-free and concentrated ascites reinfusion therapy (CART) and large-volume paracentesis (LVP) with albumin infusion are useful for managing refractory ascites (RA). However, it remains unclear which therapy is more effective in patients with cirrhosis with RA. METHODS From June 2018 to March 2022, 25 patients with RA treated with CART or LVP with albumin infusion were enrolled in this multicenter prospective observational study to investigate the number of abdominal paracenteses, albumin preparations used, and drainage volume during an 8-week observation period. RESULTS Among all patients at entry (median age, 63 years; 52% men; 60% Child-Pugh B and 40% Child-Pugh C), 92% were treated with furosemide (median, 20 mg/day), 92% with spironolactone (25 mg/day), and all with tolvaptan (7.5 mg/day). Patients with RA had a poor health-related quality of life (HRQOL) and prominent ascites-related symptoms. Four of the 20 eligible patients were treated with CART, 11 with LVP with albumin infusion, and five with their combination. The median number of paracenteses, total drainage volume, and albumin infusions were 1.5, 7.4 L, and 0, respectively, in the CART group; 5.0, 22.0 L, and 5.0, respectively, in the LVP group; and 5.0, 30.0 L, and 5.0, respectively in their combination group. The treatment effects did not differ significantly among the three groups regarding weight loss, liver function, renal function, electrolytes, and HRQOL. However, patients treated with CART had fewer paracenteses and albumin infusions than those treated with LVP. CONCLUSIONS CART and LVP have comparable therapeutic efficacy for RA in patients with cirrhosis.
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Affiliation(s)
- Tatsunori Hanai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hideto Kawaratani
- Department of Gastroenterology, Nara Medical University, Nara, Japan
| | - Junji Nagano
- Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Hirokazu Suii
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Hokkaido, Japan
| | - Akira Sakamaki
- Division of Gastroenterology and Hepatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yoshitaka Arase
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Hiroyuki Nakanishi
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo, Japan
| | - Tomomi Kogiso
- Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Tomomi Okubo
- Division of Gastroenterology, Department of Internal Medicine, Nippon Medical School Chibahokusoh Hospital, Chiba, Japan
| | - Takao Miwa
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shogo Shimizu
- Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Shuhei Hige
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Hokkaido, Japan
| | - Masanori Atsukawa
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Nippon Medical School, Tokyo, Japan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masayuki Kurosaki
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Tatehiro Kagawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Katsutoshi Tokushige
- Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, Nara, Japan
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Biolato M, Vitale F, Galasso T, Gasbarrini A, Grieco A. Minimum platelet count threshold before invasive procedures in cirrhosis: Evolution of the guidelines. World J Gastrointest Surg 2023; 15:127-141. [PMID: 36896308 PMCID: PMC9988645 DOI: 10.4240/wjgs.v15.i2.127] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/09/2022] [Accepted: 02/07/2023] [Indexed: 02/27/2023] Open
Abstract
Cirrhotic patients with severe thrombocytopenia are at increased risk of bleeding during invasive procedures. The need for preprocedural prophylaxis aimed at reducing the risk of bleeding in cirrhotic patients with thrombocytopenia who undergo scheduled procedures is assessed via the platelet count; however, establishing a minimum threshold considered safe is challenging. A platelet count ≥ 50000/μL is a frequent target, but levels vary by provider, procedure, and specific patient. Over the years, this value has changed several times according to the different guidelines proposed in the literature. According to the latest guidelines, many procedures can be performed at any level of platelet count, which should not necessarily be checked before the procedure. In this review, we aim to investigate and describe how the guidelines have evolved in recent years in the evaluation of the minimum platelet count threshold required to perform different invasive procedures, according to their bleeding risk.
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Affiliation(s)
- Marco Biolato
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Federica Vitale
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Tiziano Galasso
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Antonio Gasbarrini
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Antonio Grieco
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome 00168, Italy
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Hidaka H, Uojima H. Ultrasonography in the diagnosis of complications in patients with portal hypertension. J Med Ultrason (2001) 2021; 49:347-358. [PMID: 34787743 DOI: 10.1007/s10396-021-01158-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 08/19/2021] [Indexed: 11/28/2022]
Abstract
This review focuses on ultrasonography (US) to diagnose patients with complications in portal hypertension. Clinicians first use US to evaluate patients with suspected portal hypertension, because US is quick, simple, and radiation free. US is necessary for grading and performing paracentesis for ascites. Doppler US-based detection of reverse splanchnic vein flow or the presence of a spontaneous portosystemic shunt is highly specific in patients with cirrhosis. Since it is important to estimate spleen size in patients with portal hypertension, spleen size is usually measured by US. Spleen volume can be more accurately measured with 3D-US. Estimation of viable residual splenic volume after partial splenic embolization should be limited to cases with total splenic volume less than 1000 ml. Portal vein thrombosis is often detected during the US examination performed when symptoms first appear or during the follow-up. Two-dimensional transthoracic echocardiography is an excellent noninvasive screening test in patients with pulmonary portal hypertension who can undergo it. By measuring the maximum and minimum diastolic blood flow velocities in the renal arteries using renal color Doppler US, the pulsatility index (PI) and resistive index (RI) can be calculated. The PI and RI in cirrhotic patients were significantly higher than those in healthy subjects and patients with chronic hepatitis, and showed a significant positive correlation with the Child-Pugh Score. In conclusion, US is an essential tool for the diagnosis and treatment of patients with portal hypertension.
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Affiliation(s)
- Hisashi Hidaka
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan.
| | - Haruki Uojima
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
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Zaccherini G, Tufoni M, Iannone G, Caraceni P. Management of Ascites in Patients with Cirrhosis: An Update. J Clin Med 2021; 10:5226. [PMID: 34830508 PMCID: PMC8621554 DOI: 10.3390/jcm10225226] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/03/2021] [Accepted: 11/06/2021] [Indexed: 12/16/2022] Open
Abstract
Ascites represents a critical event in the natural history of liver cirrhosis. From a prognostic perspective, its occurrence marks the transition from the compensated to the decompensated stage of the disease, leading to an abrupt worsening of patients' life expectancy. Moreover, ascites heralds a turbulent clinical course, characterized by acute events and further complications, frequent hospitalizations, and eventually death. The pathophysiology of ascites classically relies on hemodynamic mechanisms, with effective hypovolemia as the pivotal event. Recent discoveries, however, integrated this hypothesis, proposing systemic inflammation and immune system dysregulation as key mechanisms. The mainstays of ascites treatment are represented by anti-mineralocorticoids and loop diuretics, and large volume paracentesis. When ascites reaches the stage of refractoriness, however, diuretics administration should be cautious due to the high risk of adverse events, and patients should be treated with periodic execution of paracentesis or with the placement of a trans-jugular intra-hepatic portosystemic shunt (TIPS). TIPS reduces portal hypertension, eases ascites control, and potentially modify the clinical course of the disease. Further studies are required to expand its indications and improve the management of complications. Long-term human albumin administration has been studied in two RCTs, with contradictory results, and remains a debated issue worldwide, despite a potential effectiveness both in ascites control and long-term survival. Other treatments (vaptans, vasoconstrictors, or implantable drainage systems) present some promising aspects but cannot be currently recommended outside clinical protocols or a case-by-case evaluation.
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Affiliation(s)
- Giacomo Zaccherini
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (G.Z.); (G.I.)
| | - Manuel Tufoni
- IRCCS AOU di Bologna—Policlinico di S. Orsola, 40138 Bologna, Italy;
| | - Giulia Iannone
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (G.Z.); (G.I.)
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (G.Z.); (G.I.)
- IRCCS AOU di Bologna—Policlinico di S. Orsola, 40138 Bologna, Italy;
- Center for Biomedical Applied Research, University of Bologna, 40126 Bologna, Italy
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7
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Alvaro D, Caporaso N, Giannini EG, Iacobellis A, Morelli M, Toniutto P, Violi F. Procedure-related bleeding risk in patients with cirrhosis and severe thrombocytopenia. Eur J Clin Invest 2021; 51:e13508. [PMID: 33539542 PMCID: PMC8244048 DOI: 10.1111/eci.13508] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/16/2020] [Accepted: 01/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gaps of knowledge still exist about the potential association between severe thrombocytopenia and increased risk of procedure-associated bleeding in patients with liver disease. METHODS In this narrative review, we aimed at examining the association between procedure-related bleeding risk and platelet count in patients with cirrhosis and severe thrombocytopenia in various settings. We updated to 2020 a previously conducted literature search using MEDLINE/PubMed and EMBASE. The search string included clinical studies, adult patients with chronic liver disease and thrombocytopenia undergoing invasive procedures, any interventions and comparators, and haemorrhagic events of any severity as outcome. RESULTS The literature search identified 1276 unique publications, and 15 studies met the inclusion criteria and were analysed together with those identified by the previous search. Most of the new studies included in our analysis did not assess the association between post-procedural bleeding risk and platelet count alone in patients with chronic liver disease. Furthermore, some results could have been biased by prophylactic platelet transfusions. A few studies found that severe thrombocytopenia may be predictive of bleeding following percutaneous liver biopsy, dental extractions, percutaneous ablation of liver tumours and endoscopic polypectomy. CONCLUSIONS Currently available literature cannot support definitive conclusions about the appropriate target platelet counts to improve the risk of bleeding in cirrhotic patients who underwent invasive procedures; moreover, it showed enormous variability in the use of prophylactic platelet transfusions.
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Affiliation(s)
- Domenico Alvaro
- Department of Translational and Precision MedicineSapienza University of RomeRomeItaly
| | - Nicola Caporaso
- Department of Clinical Medicine and SurgeryUniversity of Naples 'Federico II'NaplesItaly
| | - Edoardo Giovanni Giannini
- Gastroenterology UnitDepartment of Internal MedicineUniversity of Genoa, IRCCS‐Ospedale Policlinico San MartinoGenoaItaly
| | - Angelo Iacobellis
- Division of GastroenterologyFondazione IRCCS Casa Sollievo della SofferenzaFoggiaItaly
| | | | - Pierluigi Toniutto
- Hepatology and Liver Transplantation UnitAzienda Sanitaria Universitaria IntegrataAcademic HospitalUdineItaly
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8
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Madoff DC, Cornman-Homonoff J, Fortune BE, Gaba RC, Lipnik AJ, Yarmohammadi H, Ray CE. Management of Refractory Ascites Due to Portal Hypertension: Current Status. Radiology 2021; 298:493-504. [PMID: 33497318 DOI: 10.1148/radiol.2021201960] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Refractory ascites is a costly and debilitating condition that occurs most frequently in the setting of substantial cirrhotic portal hypertension, where it portends a poor prognosis. Many treatment options are available, among them medical management, serial large volume paracenteses, transjugular intrahepatic portosystemic shunts, and implanted drainage devices. Although the availability of multiple therapies ensures that most patients will achieve satisfactory results, it can be challenging for the provider to select the appropriate treatment for each specific patient. This article reviews the available therapeutic options for refractory ascites and incorporates available data and clinical experience to suggest a linear stepwise management approach to enhance patient outcomes.
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Affiliation(s)
- David C Madoff
- From the Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06520-8055 (D.C.M., J.C.); Department of Medicine, Division of Hepatology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY (B.E.F.); Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Ill (R.C.G., A.J.L., C.E.R.); and Department of Radiology, Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (H.Y.)
| | - Joshua Cornman-Homonoff
- From the Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06520-8055 (D.C.M., J.C.); Department of Medicine, Division of Hepatology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY (B.E.F.); Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Ill (R.C.G., A.J.L., C.E.R.); and Department of Radiology, Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (H.Y.)
| | - Brett E Fortune
- From the Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06520-8055 (D.C.M., J.C.); Department of Medicine, Division of Hepatology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY (B.E.F.); Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Ill (R.C.G., A.J.L., C.E.R.); and Department of Radiology, Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (H.Y.)
| | - Ron C Gaba
- From the Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06520-8055 (D.C.M., J.C.); Department of Medicine, Division of Hepatology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY (B.E.F.); Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Ill (R.C.G., A.J.L., C.E.R.); and Department of Radiology, Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (H.Y.)
| | - Andrew J Lipnik
- From the Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06520-8055 (D.C.M., J.C.); Department of Medicine, Division of Hepatology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY (B.E.F.); Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Ill (R.C.G., A.J.L., C.E.R.); and Department of Radiology, Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (H.Y.)
| | - Hooman Yarmohammadi
- From the Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06520-8055 (D.C.M., J.C.); Department of Medicine, Division of Hepatology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY (B.E.F.); Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Ill (R.C.G., A.J.L., C.E.R.); and Department of Radiology, Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (H.Y.)
| | - Charles E Ray
- From the Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06520-8055 (D.C.M., J.C.); Department of Medicine, Division of Hepatology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY (B.E.F.); Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Ill (R.C.G., A.J.L., C.E.R.); and Department of Radiology, Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (H.Y.)
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Abstract
Ascites occurs in up to 70% of patients during the natural history of cirrhosis. Management of uncomplicated ascites includes sodium restriction and diuretic therapy, whereas that for refractory ascites (RA) is regular large-volume paracentesis with transjugular intrahepatic portosystemic shunt being offered in appropriate patients. Renal impairment occurs in up to 50% of patients with RA with type 1 hepatorenal syndrome (HRS) being most severe. Liver transplant remains the definitive treatment of eligible candidates with HRS, whereas combined liver and kidney transplant should be considered in patients requiring dialysis for more than 4 to 6 weeks or those with underlying chronic kidney disease.
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Patel IJ, Rahim S, Davidson JC, Hanks SE, Tam AL, Walker TG, Wilkins LR, Sarode R, Weinberg I. Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions—Part II: Recommendations. J Vasc Interv Radiol 2019; 30:1168-1184.e1. [DOI: 10.1016/j.jvir.2019.04.017] [Citation(s) in RCA: 147] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 04/10/2019] [Accepted: 04/10/2019] [Indexed: 02/06/2023] Open
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Neong SF, Adebayo D, Wong F. An update on the pathogenesis and clinical management of cirrhosis with refractory ascites. Expert Rev Gastroenterol Hepatol 2019; 13:293-305. [PMID: 30791777 DOI: 10.1080/17474124.2018.1555469] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Ascites commonly complicates cirrhosis, becoming refractory to treatment with diuretics and sodium restriction in approximately 10% of patients. Pathogenesis of refractory ascites (RA) is multifactorial, the common final pathway being renal hypoperfusion and avid sodium retention. Refractory ascites has a negative prognostic implication in the natural history of cirrhosis. Management of RA include sodium restriction and regular large volume paracentesis (LVP) with albumin infusions, preventing paracentesis-induced circulatory dysfunction. In appropriate setting, transjugular intrahepatic porto-systemic shunt (TIPS) can be considered. Ascites clearance with TIPS can lead to nutritional improvement, avoiding sarcopenia. Liver transplantation (LT) remains the definitive treatment for eligible candidates. Areas covered: Our review summarizes current updates on pathogenesis and clinical management of RA including potential future therapeutic options such as the automated slow-flow ascites pump, chronic outpatient albumin infusion and cell-free and concentrated ascites reinfusion therapy. Expert commentary: Standard of care in patients with RA include LVP with albumin replacement and prompt referral for LT where indicated. Other novel therapeutic options on the horizon include automated low-flow ascites pump and cell-free, concentrated albumin reinfusion therapy.
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Affiliation(s)
- Shuet Fong Neong
- a Division of Gastroenterology, Department of Medicine, Toronto General Hospital , University of Toronto , Toronto , Ontario , Canada
| | - Danielle Adebayo
- a Division of Gastroenterology, Department of Medicine, Toronto General Hospital , University of Toronto , Toronto , Ontario , Canada
| | - Florence Wong
- a Division of Gastroenterology, Department of Medicine, Toronto General Hospital , University of Toronto , Toronto , Ontario , Canada
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Cho J, Jensen TP, Reierson K, Mathews BK, Bhagra A, Franco-Sadud R, Grikis L, Mader M, Dancel R, Lucas BP, 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; 14:E7-E15. [PMID: 30604780 PMCID: PMC8021127 DOI: 10.12788/jhm.3095] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
1. We recommend that ultrasound guidance should be used for paracentesis to reduce the risk of serious complications, the most common being bleeding. 2. We recommend that ultrasound guidance should be used to avoid attempting paracentesis in patients with an insufficient volume of intraperitoneal free fluid to drain. 3. We recommend that ultrasound guidance should be used with paracentesis to improve the success rates of the overall procedure. 4. We recommend that ultrasound should be used to assess the volume and location of intraperitoneal free fluid to guide clinical decision making of where paracentesis can be safely performed. 5. We recommend that ultrasound should be used to identify a needle insertion site based on size of the fluid collection, thickness of the abdominal wall, and proximity to abdominal organs. 6. We recommend that the needle insertion site should be evaluated using color flow Doppler ultrasound to identify and avoid abdominal wall blood vessels along the anticipated needle trajectory. 7. We recommend that a needle insertion site should be evaluated in multiple planes to ensure clearance from underlying abdominal organs and detect any abdominal wall blood vessels along the anticipated needle trajectory. 8. We recommend that a needle insertion site should be marked with ultrasound immediately before performing the procedure, and the patient should remain in the same position between marking the site and performing the procedure. 9. We recommend that using real-time ultrasound guidance for paracentesis should be considered when the fluid collection is small or difficult to access. 10. We recommend that dedicated training sessions, including didactics, supervised practice on patients, and simulation-based practice, should be used to teach novices how to perform ultrasound-guided paracentesis. 11. We recommend that simulation-based practice should be used, when available, to facilitate acquisition of the required knowledge and skills to perform ultrasoundguided paracentesis. 12. We recommend that competence in performing ultrasound-guided paracentesis should be demonstrated prior to independently performing the procedure on patients.
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Affiliation(s)
- Joel Cho
- Department of Hospital Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA.
| | - Trevor P Jensen
- Division of Hospital Medicine, University of California San Francisco Medical Center at Parnassus, San Francisco, California, USA
| | - Kreegan Reierson
- Department of Hospital Medicine, HealthPartners Medical Group, Regions Hospital, St. Paul, Minnesota, USA
| | - Benji K Mathews
- Department of Hospital Medicine, HealthPartners Medical Group, Regions Hospital, St. Paul, Minnesota, USA
- Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Anjali Bhagra
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ricardo Franco-Sadud
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Loretta Grikis
- White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Michael Mader
- Divisions of General and Hospital Medicine and Pulmonary and Critical Care Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Ria Dancel
- Division of Hospital Medicine, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Brian P Lucas
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont, USA
| | | | - Nilam J Soni
- Divisions of General and Hospital Medicine and Pulmonary and Critical Care Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas, USA
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13
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Abstract
Ascites, a common complication of liver cirrhosis, eventually becomes refractory to diuretic therapy and sodium restriction in ∼10% of patients. Multiple pathogenetic factors are involved in the development of refractory ascites, which ultimately lead to renal hypoperfusion and avid sodium retention. Therefore, renal dysfunction commonly accompanies refractory ascites. Management includes continuation of sodium restriction, which needs frequent reviews for adherence; and regular large volume paracentesis of 5 L or more with albumin infusions to prevent the development of paracentesis-induced circulatory dysfunction. In the appropriate patients with reasonable liver reserve, the insertion of a transjugular intrahepatic portosystemic stent shunt (TIPS) can be considered, especially if the patient is relatively young and has no previous hepatic encephalopathy or anatomical contraindications, and no past history of renal or cardiopulmonary disease. Response to TIPS with ascites clearance can lead to nutritional improvement. Devices such as an automated low-flow ascites pump may be available in the future for ascites treatment. Patients with refractory ascites and poor liver function and/or renal dysfunction, should be referred for liver transplant, as this will eliminate the portal hypertension and liver dysfunction. Renal dysfunction prior to liver transplant largely improves after transplant without affecting post-transplant survival.
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Affiliation(s)
- Danielle Adebayo
- Division of Gastroenterology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada. These authors contributed equally: Danielle Adebayo, Shuet Fong Neong
| | - Shuet Fong Neong
- Division of Gastroenterology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada. These authors contributed equally: Danielle Adebayo, Shuet Fong Neong
| | - Florence Wong
- Division of Gastroenterology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada. These authors contributed equally: Danielle Adebayo, Shuet Fong Neong
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14
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Fyson J, Chapman L, Tatton M, Raos Z. Abdominal paracentesis: use of a standardised procedure checklist and equipment kit improves procedural quality and reduces complications. Intern Med J 2018; 48:572-579. [PMID: 29345405 DOI: 10.1111/imj.13741] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 12/20/2017] [Accepted: 01/07/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Paracentesis is a common invasive procedure performed by junior doctors. Audit of procedure conduct at two New Zealand hospitals in 2012 revealed poor performance across a range of quality measures, including documentation of informed consent, excessive catheter dwell times and inappropriate albumin prescription. Complication rates were 12.7%, compared with published rates of around 9%. A local procedure protocol did not exist. AIM To evaluate the effect of a standardised procedure checklist (PC) and equipment kit (EK) on procedural quality and complication rates for abdominal paracentesis. METHODS After presenting the 2012 audit results to resident doctors, we reviewed the paracentesis literature and developed a local procedure protocol (PC and EK). These tools were made readily available after an education campaign. Paracenteses performed after the intervention were studied to determine the impact on procedural quality and safety. RESULTS Seventy-four paracenteses (14 diagnostic; 60 therapeutic) were performed in 10 months after the introduction of PC and EK. Significant improvements were observed with the use of PC including documentation of informed consent (97% vs 74%, P = <0.01) and aseptic technique (100% vs 62%, P = <0.01). Catheter dwell times <6 h improved (72% vs 48%, P = 0.02). Inappropriate albumin prescriptions were less frequent (21% vs 66%, P = <0.01). Complication rates decreased from 12.7% to 2.8% (P = <0.01). CONCLUSIONS The PC and EK improved rates of informed consent, appropriate documentation and protocol adherence. Significantly fewer procedure-related complications occurred after introduction of these tools.
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Affiliation(s)
- Jeremy Fyson
- Department of Medicine, North Shore Hospital, Auckland, New Zealand
| | - Laura Chapman
- Department of Medicine, North Shore Hospital, Auckland, New Zealand
| | - Michael Tatton
- Department of Medicine, North Shore Hospital, Auckland, New Zealand
| | - Zoë Raos
- Department of Gastroenterology, North Shore Hospital, Auckland, New Zealand
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15
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EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; 69:406-460. [PMID: 29653741 DOI: 10.1016/j.jhep.2018.03.024] [Citation(s) in RCA: 1551] [Impact Index Per Article: 258.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023]
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16
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Ryu SH, Kwon DI. Severe Intraperitoneal Hemorrhage from Pseudoaneurysm after a Large-volume Paracentesis, Successfully Treated with Microcoil Embolization. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2018; 71:162-167. [PMID: 29566477 DOI: 10.4166/kjg.2018.71.3.162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Large-volume paracentesis-induced intraperitoneal hemorrhage due to pseudoaneurysm formation is rarely reported. Here, we present a 56-year-old man with alcoholic liver cirrhosis admitted for massive ascites. Large-volume paracentesis was performed. Three days later, he became pale and complained of dyspnea and abdominal distention with hypotension. Percutaneous iliac angiography revealed contrast media leakage from a branch of the left circumflex iliac artery with pseudoaneurysm. He was successfully treated with microcoil embolization. Several days later, ascitic fluid increased and large-volume paracentesis was performed again. Two days later, his hemoglobin level suddenly decreased. An abdominal computed tomography scan showed new active bleeding at the left lower lateral peritoneal cavity, just anterior to the metalic coils. Percutaneous iliac angiography revealed contrast media extravasation from a branch of the left inferior epigastric artery with formation of collateral vessel. Percutaneous embolization was successfully performed again. After coil embolization, there were no further bleeding episodes.
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Affiliation(s)
- Soo Hyung Ryu
- Division of Gastroenterology, Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Dong Il Kwon
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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17
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MacIntosh T. Emergency Management of Spontaneous Bacterial Peritonitis - A Clinical Review. Cureus 2018; 10:e2253. [PMID: 29721399 PMCID: PMC5929973 DOI: 10.7759/cureus.2253] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 02/16/2018] [Indexed: 12/11/2022] Open
Abstract
Spontaneous bacterial peritonitis (SBP) has a high mortality rate; early antimicrobial therapy is essential for improving patient outcomes. Given that cirrhotic patients are often coagulopathic, the perceived risk of bleeding may prevent providers from performing a paracentesis and ruling out this potentially deadly disease. We examine the pathophysiology and risk factors for SBP, and current guidelines for its diagnosis and treatment. We then review the time-sensitive nature of performing a paracentesis, and the current controversies and contraindications for performing this procedure in patients at risk for SBP. Cirrhotic patients with ascites and clinical suspicion for SBP-abdominal pain or tenderness, fever or altered mental status-should have a diagnostic paracentesis. Although most patients with cirrhosis and liver dysfunction will have prolonged prothrombin time, paracentesis is not contraindicated. Limited data support platelet administration prior to paracentesis if <40,000-50,000/μL. Timely antimicrobial therapy includes a third-generation cephalosporin for community-acquired infection; nosocomial infections should be treated empirically with a carbapenem or with piperacillin-tazobactam, or based on local susceptibility testing. Patients with gastrointestinal (GI) hemorrhage should receive ceftriaxone prophylactically for GI hemorrhage. SBP has a high mortality rate. Early diagnosis and antimicrobial therapy are essential for improving patient outcomes. Cirrhotic patients with ascites with clinical suspicion for SBP, abdominal pain or tenderness, altered mental status or fever should have a diagnostic paracentesis performed prior to admission unless platelets <40,000-50,000/μL.
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18
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Wang J, Khan S, Wyer P, Vanderwilp J, Reynolds J, Bethancourt B, Ota KS. The Role of Ultrasound-Guided Therapeutic Paracentesis in an Outpatient Transitional Care Program: A Case Series. Am J Hosp Palliat Care 2018; 35:1256-1260. [DOI: 10.1177/1049909118755378] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background: Patients with ascites suffer from distressing symptoms and are at high risk for readmission after hospitalization. Timely paracentesis is an important palliative tool in managing this vulnerable population. At our institution, we have developed a multidisciplinary transitional care program for patients discharged from the hospital with a wide range of complex conditions including refractory ascites. Methods: We present a case series of 10 patients with symptomatic ascites who were enrolled in our transitional care program and treated with ultrasound-guided therapeutic paracentesis in our clinic. Patient medical records were retrospectively reviewed to collect procedure details, outcomes, and follow-up data on emergency department (ED) visits and readmissions. Cost data were obtained from the hospital financial system. Results: Over the span of 9 months (September 2016 to July 2017), 22 total therapeutic paracenteses were performed on 10 unique patients in the transitional care clinic. Median age of the patient cohort was 52.5 years (range: 27-71 years). All patients reported immediate relief of ascites-related discomfort following the procedure. We did not observe any major adverse effects due to the in-clinic procedure. Nine of the 10 patients did not have any ED visits or readmissions within 30 days of discharge. The cost of performing ultrasound-guided paracentesis in the transitional care clinic was US$546.77 compared to US$978.32 when performed in the hospital. Conclusion: Our experience suggests that outpatient paracentesis may be a safe, feasible, and cost-effective means of providing symptom management for patients with ascites during their transition from hospital to home.
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Affiliation(s)
- Jeffrey Wang
- Center for Transitional Care, St Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
- College of Arts and Sciences, Baylor University, Waco, TX, USA
| | - Shahida Khan
- Center for Transitional Care, St Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Paige Wyer
- Center for Transitional Care, St Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Jessica Vanderwilp
- Center for Transitional Care, St Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Justin Reynolds
- Center for Liver Disease and Transplantation, St Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Bruce Bethancourt
- Center for Transitional Care, St Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Ken S. Ota
- Center for Transitional Care, St Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
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19
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Barsuk JH, Rosen BT, Cohen ER, Feinglass J, Ault MJ. Vascular Ultrasonography: A Novel Method to Reduce Paracentesis Related Major Bleeding. J Hosp Med 2018; 13:30-33. [PMID: 29073312 DOI: 10.12788/jhm.2863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Paracentesis is a core competency for hospitalists. Using ultrasound for fluid localization is standard practice and involves a low-frequency probe. Experts recommend a "2-probe technique, " which incorporates a high-frequency ultrasound probe in addition to the low-frequency probe to identify blood vessels within the intended needle path. Evidence is currently lacking to support this 2-probe technique, so we performed a pre- to postintervention study to evaluate its effect on paracentesis-related bleeding complications. From February 2010 to August 2011, procedures were performed using only low-frequency probes (preintervention group), while the 2-probe technique was used from September 2011 to February 2016 (postintervention group). A total of 5777 procedures were performed. Paracentesis-related minor bleeding was similar between groups. Major bleeding was lower in the postintervention group (3 [0.3%], n = 1000 vs 4 [0.08%], n = 4777; P = 0.07). This clinically meaningful trend suggests that using the 2-probe technique might prevent paracentesis-related major bleeding.
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Affiliation(s)
- Jeffrey H Barsuk
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Bradley T Rosen
- Division of General Internal Medicine, Cedars- Sinai Medical Center, Los Angeles, California, USA
| | - Elaine R Cohen
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Joe Feinglass
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mark J Ault
- Division of General Internal Medicine, Cedars- Sinai Medical Center, Los Angeles, California, USA
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20
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Atwell TD, Wennberg PW, McMenomy BP, Murthy NS, Anderson JR, Kriegshauser JS, McKinney JM. Peri-procedural use of anticoagulants in radiology: an evidence-based review. Abdom Radiol (NY) 2017; 42:1556-1565. [PMID: 28070656 DOI: 10.1007/s00261-016-1027-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Peri-procedural anticoagulant management hinges on the balance of hemorrhagic and thrombotic complications. The radiologist is tasked with accurately assessing the hemorrhagic risk for patients undergoing procedures, taking into account procedural bleeding rates, underlying coagulopathy based on lab tests, and use of anticoagulants. The purpose of this article is to provide a contemporary review of commonly used anticoagulants and, incorporating published evidence, review their management related to image-guided procedures.
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21
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Hemostatic balance in patients with liver cirrhosis: Report of a consensus conference. Dig Liver Dis 2016; 48:455-467. [PMID: 27012444 DOI: 10.1016/j.dld.2016.02.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 02/18/2016] [Indexed: 12/11/2022]
Abstract
Patients with cirrhosis present with hemostatic alterations secondary to reduced availability of pro-coagulant and anti-coagulant factors. The net effect of these changes is a rebalanced hemostatic system. The Italian Association of the Study of the Liver (AISF) and the Italian Society of Internal Medicine (SIMI) promoted a consensus conference on the hemostatic balance in patients with cirrhosis. The consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Rome in December 2014. The statements were graded according to quality of evidence and strength of recommendations, and approved by an independent jury. The statements presented here highlight strengths and weaknesses of current laboratory tests to assess bleeding and thrombotic risk in cirrhotic patients, the pathophysiology of hemostatic perturbations in this condition, and outline the optimal management of bleeding and thrombosis in patients with liver cirrhosis.
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22
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Keil-Ríos D, Terrazas-Solís H, González-Garay A, Sánchez-Ávila JF, García-Juárez I. Pocket ultrasound device as a complement to physical examination for ascites evaluation and guided paracentesis. Intern Emerg Med 2016; 11:461-6. [PMID: 26895032 DOI: 10.1007/s11739-016-1406-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 02/04/2016] [Indexed: 12/14/2022]
Abstract
The pocket ultrasound device (PUD) is a new tool that may be of use in the early detection of ascites. Abdominal ultrasound-guided paracentesis has been reported to decrease the rate of complications due to the procedure, but must be performed in a healthcare setting; this new tool may be a useful on an ambulatory basis. The aim of this study was to determine the diagnostic usefulness of the PUD in the diagnosis of ascites and the safety of guided paracentesis. We conducted a retrospective study that included adult patients suspected of having ascites and in whom an evaluation was performed with the PUD to identify it. Concordance with abdominal ultrasound (AUS) was determined with the Kappa coefficient. Sensitivity (Se), specificity (Sp) and likelihood ratios (LR) were determined and compared with physical examination, AUS, computed tomography and procurement of fluid by paracentesis. Complications resulting from the guided paracentesis were analyzed. 89 participants were included and 40 underwent a paracentesis. The PUD for ascites detection had 95.8 % Se, 81.8 % Sp, 5.27 +LR and 0.05 -LR. It had a concordance with AUS of 0.781 (p < 0.001). Technical problems during the guided paracentesis were present in only two participants (5 %) and three patients (7.5 %) developed minor complications that required no further intervention. There were no severe complications or deaths. This study suggests that the PUD is a reliable tool for ascites detection as a complement to physical examination and appears to be a safe method to perform guided paracentesis.
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Affiliation(s)
- Daniel Keil-Ríos
- Department of Gastroenterology, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Vasco de Quiroga 15, Sección XVI, Tlalpan, 14000, Mexico City, Mexico
| | - Hiram Terrazas-Solís
- Department of Internal Medicine, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico
| | - Alejandro González-Garay
- Department of Research Methodology, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico
| | - Juan Francisco Sánchez-Ávila
- Department of Gastroenterology, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Vasco de Quiroga 15, Sección XVI, Tlalpan, 14000, Mexico City, Mexico
| | - Ignacio García-Juárez
- Department of Gastroenterology, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Vasco de Quiroga 15, Sección XVI, Tlalpan, 14000, Mexico City, Mexico.
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23
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Devarbhavi H, Murali AR. Safety of Ascitic Paracentesis in Patients with Budd-Chiari Syndrome on Oral Anticoagulation and Elevated International Normalized Ratio. J Clin Exp Hepatol 2015; 5:310-3. [PMID: 26900272 PMCID: PMC4723655 DOI: 10.1016/j.jceh.2015.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 08/24/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS Anticoagulation is the standard of care in patients with Budd-Chiari Syndrome (BCS). Ascites is a common symptom in patients with BCS. Often such patients require paracentesis while taking oral anticoagulation concurrently. It is unclear whether paracentesis leads to increased bleeding in such patients or whether anticoagulation has to be temporarily suspended. We describe our experience with paracentesis in patients with BCS taking oral anticoagulation. METHODS Our study subjects included consecutive patients with BCS with ascites on oral anticoagulation admitted between 2007 and 2011. The dose of oral anticoagulation was titrated to achieve international normalized ratio (INR) between 2 and 3. Routine hematological tests included Factor VIII (FVIII) levels. Paracentesis was undertaken without the prior administration of fresh frozen plasma and without the aid of ultrasonography. We looked for occurrences of bleeding at the puncture site or hemoperitoneum during and after the procedure. RESULTS Thirty-two of the 60 patients with BCS patients taking oral anticoagulation concurrently developed ascites. Thirty among 32 patients required paracentesis on one or more occasions. A total of 51 paracentesis procedures were performed (Median 1.6, Range 1-7). The mean INR was 3.1 (Range 1.4-7.9). No patient developed bleeding or hemoperitoneum. The mean FVIII measured was 138.8% of laboratory control and mean platelet level was 2.2 × 10(5)/ml. CONCLUSIONS Ascitic paracentesis in patients with BCS on anticoagulation is safe without an increased risk of abdominal wall bleeding or hemoperitoneum. Normal or high FVIII and platelet levels likely mitigate against bleeding risks.
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Affiliation(s)
- Harshad Devarbhavi
- Address for correspondence: Harshad Devarbhavi, Head, Department of Gastroenterology, St. John's Medical College Hospital, Bangalore, India. Tel.: +918022065134; fax: +91 8025520499.Head, Department of Gastroenterology, St. John's Medical College HospitalBangaloreIndia
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24
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Kurup AN, Lekah A, Reardon ST, Schmit GD, McDonald JS, Carter RE, Kamath PS, Callstrom MR, Atwell TD. Bleeding Rate for Ultrasound-Guided Paracentesis in Thrombocytopenic Patients. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:1833-1838. [PMID: 26362144 DOI: 10.7863/ultra.14.10034] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 01/21/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES The purpose of this study was to determine the rate of major bleeding complications for ultrasound-guided paracentesis performed in thrombocytopenic patients. METHODS We retrospectively reviewed the electronic medical records of patients with platelet counts of less than 50,000/μL who had ultrasound-guided paracenteses performed in the Department of Radiology without correcting preprocedural platelet transfusions between 2005 and 2011. Medical records were evaluated for evidence of major bleeding complications (grade 3 or higher as defined by the National Institutes of Health's Common Terminology Criteria for Adverse Events, version 4.03) and their clinical sequelae. Platelet count and bleeding complications were evaluated for an association, and a sensitivity analysis was performed to determine whether analysis of a control group of patients without thrombocytopenia would yield added confidence in this assessment. RESULTS Among 304 procedures in 205 thrombocytopenic patients (69% male; mean age ± SD, 56.6 ± 11.9 years), the mean platelet count was 38,400 ± 9300/μL (range, 9000-49,000/μL). Three major bleeding complications requiring red blood cell transfusion were observed in patients with platelet counts of 41,000 to 46,000/μL, for a complication rate of 0.99% (95% confidence interval, 0.3%-2.9%). No patient required an additional procedure or died because of the bleeding complication. There was no association of platelet count with bleeding complications. The sensitivity analysis showed that further evaluation of patients with normal platelet counts would not add to the conclusion. CONCLUSIONS The risk of major bleeding after ultrasound-guided paracentesis in thrombocytopenic patients is very low. In most patients, routine assessment of the preprocedural serum platelet concentration is not necessary, and correction of such an abnormal laboratory value is not indicated.
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Affiliation(s)
- A Nicholas Kurup
- Department of Radiology (A.N.K., A.L., G.D.S., J.S.M., M.R.C., T.D.A.), Division of Gastroenterology and Hepatology, Department of Internal Medicine (P.S.K.), and Department of Biomedical Statistics and Informatics (R.E.C.), Mayo Clinic, Rochester, Minnesota USA; and Department of Radiology, Essentia Health, Fargo, North Dakota USA (S.T.R.).
| | - Alexander Lekah
- Department of Radiology (A.N.K., A.L., G.D.S., J.S.M., M.R.C., T.D.A.), Division of Gastroenterology and Hepatology, Department of Internal Medicine (P.S.K.), and Department of Biomedical Statistics and Informatics (R.E.C.), Mayo Clinic, Rochester, Minnesota USA; and Department of Radiology, Essentia Health, Fargo, North Dakota USA (S.T.R.)
| | - Scott T Reardon
- Department of Radiology (A.N.K., A.L., G.D.S., J.S.M., M.R.C., T.D.A.), Division of Gastroenterology and Hepatology, Department of Internal Medicine (P.S.K.), and Department of Biomedical Statistics and Informatics (R.E.C.), Mayo Clinic, Rochester, Minnesota USA; and Department of Radiology, Essentia Health, Fargo, North Dakota USA (S.T.R.)
| | - Grant D Schmit
- Department of Radiology (A.N.K., A.L., G.D.S., J.S.M., M.R.C., T.D.A.), Division of Gastroenterology and Hepatology, Department of Internal Medicine (P.S.K.), and Department of Biomedical Statistics and Informatics (R.E.C.), Mayo Clinic, Rochester, Minnesota USA; and Department of Radiology, Essentia Health, Fargo, North Dakota USA (S.T.R.)
| | - Jennifer S McDonald
- Department of Radiology (A.N.K., A.L., G.D.S., J.S.M., M.R.C., T.D.A.), Division of Gastroenterology and Hepatology, Department of Internal Medicine (P.S.K.), and Department of Biomedical Statistics and Informatics (R.E.C.), Mayo Clinic, Rochester, Minnesota USA; and Department of Radiology, Essentia Health, Fargo, North Dakota USA (S.T.R.)
| | - Rickey E Carter
- Department of Radiology (A.N.K., A.L., G.D.S., J.S.M., M.R.C., T.D.A.), Division of Gastroenterology and Hepatology, Department of Internal Medicine (P.S.K.), and Department of Biomedical Statistics and Informatics (R.E.C.), Mayo Clinic, Rochester, Minnesota USA; and Department of Radiology, Essentia Health, Fargo, North Dakota USA (S.T.R.)
| | - Patrick S Kamath
- Department of Radiology (A.N.K., A.L., G.D.S., J.S.M., M.R.C., T.D.A.), Division of Gastroenterology and Hepatology, Department of Internal Medicine (P.S.K.), and Department of Biomedical Statistics and Informatics (R.E.C.), Mayo Clinic, Rochester, Minnesota USA; and Department of Radiology, Essentia Health, Fargo, North Dakota USA (S.T.R.)
| | - Matthew R Callstrom
- Department of Radiology (A.N.K., A.L., G.D.S., J.S.M., M.R.C., T.D.A.), Division of Gastroenterology and Hepatology, Department of Internal Medicine (P.S.K.), and Department of Biomedical Statistics and Informatics (R.E.C.), Mayo Clinic, Rochester, Minnesota USA; and Department of Radiology, Essentia Health, Fargo, North Dakota USA (S.T.R.)
| | - Thomas D Atwell
- Department of Radiology (A.N.K., A.L., G.D.S., J.S.M., M.R.C., T.D.A.), Division of Gastroenterology and Hepatology, Department of Internal Medicine (P.S.K.), and Department of Biomedical Statistics and Informatics (R.E.C.), Mayo Clinic, Rochester, Minnesota USA; and Department of Radiology, Essentia Health, Fargo, North Dakota USA (S.T.R.)
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25
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Boyer TD, Habib S. Big spleens and hypersplenism: fix it or forget it? Liver Int 2015; 35:1492-8. [PMID: 25312770 DOI: 10.1111/liv.12702] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 10/09/2014] [Indexed: 12/12/2022]
Abstract
Hypersplenism is a common manifestation of portal hypertension in the cirrhotic. More than half of cirrhotics will have low platelet counts, but neutropenia is much less common. Despite being common in the cirrhotic population, the presence of hypersplenism is of little clinical consequence. The presence of hypersplenism suggests more advanced liver disease and an increase in risk of complications, but there is no data showing that correcting the hypersplenism improves patient survival. In most series, the most common indications for treating the hypersplenism is to increase platelet and white blood cell counts to allow for use of drugs that suppress the bone marrow such as interferon alpha and chemotherapeutic agents. There are several approaches used to treat hypersplenism. Portosystemic shunts are of questionable benefit. Splenectomy, either open or laparoscopically, is the most effective but is associated with a significant risk of portal vein thrombosis. Partial splenic artery embolization and radiofrequency ablation are effective methods for treating hypersplenism, but counts tend to fall back to baseline long-term. Pharmacological agents are also effective in increasing platelet counts. Development of direct acting antivirals against hepatitis C will eliminate the most common indication for treatment. We lack controlled trials designed to determine if treating the hypersplenism has benefits other than raising the platelet and white blood cell counts. In the absence of such studies, hypersplenism in most patients should be considered a laboratory abnormality and not treated, in other words forget it.
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Affiliation(s)
- Thomas D Boyer
- Liver Research Institute and Department of Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
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Hemorrhagic complications of paracentesis: a systematic review of the literature. Gastroenterol Res Pract 2014; 2014:985141. [PMID: 25580114 PMCID: PMC4280650 DOI: 10.1155/2014/985141] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 11/11/2014] [Accepted: 11/11/2014] [Indexed: 11/18/2022] Open
Abstract
Introduction. Large volume paracentesis is considered a safe procedure carrying minimal risk of complications and rarely causing morbidity or mortality. The most common complications of the procedure are ascitic fluid leakage, hemorrhage, infection, and perforation. The purpose of this study was to evaluate all hemorrhagic complications and their outcomes and to identify any common variables. Methods. A literature search for all reported hemorrhagic complications following paracentesis was conducted. A total of 61 patients were identified. Data of interest were extracted and analyzed. The primary outcome of the study was 30-day mortality, with secondary endpoints being achievement of hemostasis after intervention and mortality based on type of intervention. Results. 90% of the patients undergoing paracentesis had underlying cirrhosis. Three types of hemorrhagic complications were identified: abdominal wall hematomas (52%), hemoperitoneum (41%), and pseudoaneurysm (7%). Forty percent of the patients underwent either a surgical (35%) or an IR guided intervention (65%). Patients undergoing a surgical intervention had a significantly higher rate of mortality at day 30 compared to those undergoing IR intervention. Conclusion. Abdominal wall hematomas and hemoperitoneum are the most common hemorrhagic complications of paracentesis. Transcatheter coiling and embolization appear to be superior to both open and laparoscopic surgery in treatment of these complications.
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Shah R, Haddad N, Vachharajani TJ, Asif A, Agarwal A. Thrombocytopenia in ESRD patients: epidemiology, mechanisms and interventional nephrology perspective. Semin Dial 2014; 27:618-25. [PMID: 24612107 DOI: 10.1111/sdi.12199] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
A well-functioning vascular access is essential for provision of life-sustaining dialysis treatment in patients with end-stage renal disease. Arteriovenous accesses are preferred form of vascular access. Although significant advances have been made in the field of dialysis access, arteriovenous access dysfunction remains the single most important cause of morbidity in ESRD patients. While thrombosis and stenosis of AV access are more frequently seen, hemorrhage from AV access can be life threatening with or without risk of permanent access loss. Aside from anticoagulation for comorbidities, qualitative and/or quantitative platelet abnormalities are often the predisposing factors. We describe an ESRD patient who developed new onset but severe thrombocytopenia due to metastatic small cell neuroendocrine carcinoma of lung. Given her persistent thrombocytopenia and presence of prolonged bleeding from the cannulation sites, a right internal jugular tunneled dialysis catheter was placed for continuation of maintenance dialysis. This review discusses the definition of thrombocytopenia, mechanisms of thrombocytopenia in patients with ESRD and with a special focus on implications of thrombocytopenia on dialysis access interventions. The review underscores the need for consensus with regard to cannulating AV access as well as guidelines specific to dialysis access-related endovascular intervention in the setting of thrombocytopenia and other coagulation abnormalities.
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Affiliation(s)
- Ravish Shah
- Divisions of Nephrology, The Ohio State University, Columbus, Ohio
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Abstract
Ultrasound guidance has become the standard of care for many bedside procedures, owing to its portability, ease of use, and significant reduction in complications. This article serves as an introduction to the use of ultrasonography in several advanced procedures, including pericardiocentesis, thoracentesis, paracentesis, lumbar puncture, regional anesthesia, and peritonsillar abscess drainage.
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Affiliation(s)
- Nicholas Hatch
- Department of Emergency Medicine, Maricopa Medical Center, 2601 East Roosevelt Street, Phoenix, AZ 85008, USA.
| | - Teresa S Wu
- EM Residency Program, Department of Emergency Medicine, Maricopa Medical Center, University of Arizona College of Medicine-Phoenix, 2601 East Roosevelt Street, Phoenix, AZ 85008, USA
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Harley KT, Wang MD, Amin A. Common procedures in internal medicine: improving knowledge and minimizing complications. Hosp Pract (1995) 2012; 37:121-7. [PMID: 20877180 DOI: 10.3810/hp.2009.12.265] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Internal medicine physicians have long been trained with the skills, knowledge, and attitudes to become proficient at certain medical procedures. Specifically, the lumbar puncture, paracentesis, thoracentesis, and central venous catheter placement are common medical procedures encountered during residency. Despite recent changes that no longer require documented competency in procedure performance, many residents and their attending supervisors continue to perform these procedures on a regular basis. In private practice many internists care for patients requiring these procedures. This review will summarize basic steps followed in these 4 medical procedures and highlight methods to minimize associated complications.
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Affiliation(s)
- Kevin T Harley
- University of California Irvine School of Medicine, Orange, CA 92868, USA
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30
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Ascites as the initial presentation of gastrointestinal carcinoma. J Emerg Med 2012; 44:e195-8. [PMID: 22766406 DOI: 10.1016/j.jemermed.2012.02.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Revised: 01/05/2012] [Accepted: 02/22/2012] [Indexed: 11/21/2022]
Abstract
BACKGROUND The rapid development of ascites in a patient without known liver disease is an uncommon occurrence in the Emergency Department. Initial stabilization may include therapeutic peritoneal lavage to reduce diaphragmatic pressure and halt the progression of respiratory compromise. In the absence of liver disease, the differential diagnosis should include a search for malignancy, which has been reported to account for up to 10% of all cases of newly diagnosed ascites. OBJECTIVES To discuss the differential diagnosis, evaluation, and treatment options associated with the development of acute malignant ascites. CASE REPORT We report the case of an 86-year-old woman who presented with the chief complaint of an enlarging abdomen and worsening shortness of breath of 1 week's duration. Bedside ultrasound rapidly revealed a large amount of intraperitoneal free fluid as a cause for her abdominal distension and respiratory compromise. Laboratory analysis of her blood along with computed tomography scan of her abdomen and pelvis were unremarkable. Diagnostic and therapeutic peritoneal lavage was done and the patient's symptoms improved. Pathologic examination of the peritoneal fluid revealed metastatic gastrointestinal carcinoma. CONCLUSION Rapidly progressing ascites may be the sole presenting symptom of metastatic gastrointestinal carcinoma.
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31
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Desborough M, Stanworth S. Plasma transfusion for bedside, radiologically guided, and operating room invasive procedures. Transfusion 2012; 52 Suppl 1:20S-9S. [DOI: 10.1111/j.1537-2995.2012.03691.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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32
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Jatoi A, Nieva JJ, Qin R, Loprinzi CL, Wos EJ, Novotny PJ, Moore DF, Mowat RB, Bechar N, Pajon ER, Hartmann LC. A pilot study of long-acting octreotide for symptomatic malignant ascites. Oncology 2012; 82:315-20. [PMID: 22572824 DOI: 10.1159/000337246] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 02/02/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Effective, non-invasive, palliative strategies for symptomatic malignant ascites are unavailable. This trial explored whether octreotide, an inhibitor of vascular endothelial growth factor, a putative mediator of ascites, prolongs the interval to next paracentesis. METHODS After a baseline paracentesis and a test of short-acting agent, patients with symptomatic ascites were randomly assigned to long-acting octreotide (Sandostatin LAR®) depot 30 mg intramuscularly every month versus 0.9% sodium chloride administered similarly. Patients were then monitored for recurrent, symptomatic ascites. RESULTS Thirty-three patients were enrolled: 16 assigned to the octreotide and 17 to the control arm. The median time to next paracentesis was 28 and 14 days in the octreotide and placebo arm, respectively (p = 0.17). After adjustment for extracted ascites volume and abdominal girth change, no statistically significant difference between the groups was observed (hazard ratio = 0.52, with a 95% confidence interval of 0.21-1.28; p = 0.15, per Cox model). Octreotide-treated patients described less of abdominal bloating (p = 0.01), abdominal discomfort (p = 0.02), and shortness of breath (p = 0.007) at one month, although other quality of life symptoms were comparable between the arms. Long-acting octreotide was reasonably well tolerated. CONCLUSION As prescribed in this trial, octreotide did not seem effective in prolonging the time to next paracentesis, although improvements in symptoms suggest that vascular endothelial growth factor inhibition merits further investigation.
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Affiliation(s)
- Aminah Jatoi
- Mayo Clinic Rochester, Rochester, MN 55905, USA.
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Patel IJ, Davidson JC, Nikolic B, Salazar GM, Schwartzberg MS, Walker TG, Saad WA. Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions. J Vasc Interv Radiol 2012; 23:727-36. [PMID: 22513394 DOI: 10.1016/j.jvir.2012.02.012] [Citation(s) in RCA: 419] [Impact Index Per Article: 34.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Revised: 02/22/2012] [Accepted: 02/22/2012] [Indexed: 12/12/2022] Open
Affiliation(s)
- Indravadan J Patel
- Department of Radiology, University Hospitals Case Medical Center, Cleveland, OH, USA
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Zama IN, Edgar M. Management of Symptomatic Ascites in Hospice Patients With Paracentesis. Am J Hosp Palliat Care 2011; 29:405-8. [DOI: 10.1177/1049909111420130] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Refractory ascites causes significant distress to patients and can be managed in various ways. In hospice patients where the goal of care is to preserve comfort and foster better quality of life, diuretics should be tried first; however, in resistant cases, home-based paracentesis should be entertained. Home-based paracentesis is a safe and simple procedure that can be done blindly, if done under standard precautions there is minimal associated risk of bleeding, infection or perforation and no need for pre or post-laboratory testing or the correction of high international normalization ratio or thrombocytopenia. Home-based paracentesis is cost effective, provides immediate symptomatic relief, good patient and caregiver satisfaction and obviates the associated distress to the patient and family of transporting the patient for either outpatient or inpatient paracentesis.
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Affiliation(s)
- Ivan N. Zama
- Capital Caring and Capital Palliative Care Consultants, Largo, Maryland
- The George Washington University School of Medicine, Washington, DC
| | - Millicent Edgar
- Capital Caring and Capital Palliative Care Consultants, Largo, Maryland
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Abnormal preprocedural international normalized ratio and platelet counts are not associated with increased bleeding complications after ultrasound-guided thoracentesis. AJR Am J Roentgenol 2011; 197:W164-8. [PMID: 21700980 DOI: 10.2214/ajr.10.5589] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of our study was to identify differences in hemorrhagic complications after ultrasound-guided thoracentesis on the basis of patient coagulation parameters. MATERIALS AND METHODS The records of consecutive patients who underwent ultrasound-guided thoracentesis between January 1, 2008 and April 30, 2010 were reviewed to document the international normalized ratio (INR) and platelet count obtained within 72 hours before thoracentesis and to identify bleeding complications that occurred after the procedure. The observed complication rates and 95% CIs for differences in complication rates were calculated. RESULTS There were 1076 procedures performed during the study period with no hemorrhagic complications identified (0% complication rate; 95% CI, 0.00-0.34%). INR values before thoracentesis were available for 822 procedures: INR exceeded 2.0 in 139 cases (17%), 2.5 in 59 cases (7%), and 3.0 in 32 cases (4%). The 95% CI for the 0% difference in complications observed between two groups of patients determined by specific INR values was -0.008 to 0.014 (INR, 1.5), -0.007 to 0.026 (INR, 2.0), -0.007 to 0.061 (INR, 2.5), and -0.009 to 0.11 (INR, 3.0). Platelet values before thoracentesis were available for 953 procedures; the platelet count was less than 100,000/μL for 148 procedures (16%), less than 50,000/μL for 58 procedures (6%), and less than 25,000/μL for 12 procedures (1%). The 95% CI for the 0% difference in complications between two groups of patients determined by a platelet count threshold of 50,000/μL was -0.007 to 0.062. CONCLUSION The risk of bleeding after ultrasound-guided thoracentesis performed by radiologists is low even if the preprocedural INR and platelet count are abnormal. An approach in which no coagulation testing or correction is performed before thoracentesis may be justified.
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EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol 2010; 53:397-417. [PMID: 20633946 DOI: 10.1016/j.jhep.2010.05.004] [Citation(s) in RCA: 1093] [Impact Index Per Article: 78.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Accepted: 05/25/2010] [Indexed: 02/07/2023]
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Abstract
OBJECTIVE Since the previous comprehensive radiology review on coagulation concepts that was done in 1990, many studies have been published in the medical and surgical literature that can guide the approach of a radiology practice. The purpose of this article is to provide an analysis of these works, updating the radiologist on proper use and interpretation of coagulation assessment tools, medications that modify the hemostatic system, and the use of transfusions prior to interventions. CONCLUSION The basic tools for coagulation assessment have not changed; however, results from subspecialty research have suggested ways in which the use of these tools can be modified and streamlined to safely reduce time and expense for the patient and the health care system.
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Yalamanchili S, Harvey SM, Friedman A, Shams JN, Silberzweig JE. Transarterial embolization for inferior epigastric artery injury. Vasc Endovascular Surg 2009; 42:489-93. [PMID: 19000984 DOI: 10.1177/1538574408316144] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The inferior epigastric artery represents a potentially overlooked source of pelvic arterial hemorrhage. The authors describe 3 patients with massive inferior epigastric artery bleeding following cesarean section, paracentesis, and blunt trauma that were successfully treated with transarterial embolization. The inferior epigastric artery should be considered as a possible source of arterial hemorrhage if arteriography of internal iliac artery branches does not yield a bleeding source.
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Sobkin PR, Bloom AI, Wilson MW, LaBerge JM, Hastings GS, Gordon RL, Brody LA, Sawhney R, Kerlan RK. Massive abdominal wall hemorrhage from injury to the inferior epigastric artery: a retrospective review. J Vasc Interv Radiol 2008; 19:327-32. [PMID: 18295690 DOI: 10.1016/j.jvir.2007.11.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2007] [Revised: 10/28/2007] [Accepted: 11/01/2007] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To identify the etiology of inferior epigastric artery injury (IEAI) in patients referred to the interventional radiology service and determine the efficacy of diagnostic imaging and embolization in these patients. MATERIALS AND METHODS A retrospective review of patients referred to the interventional radiology departments at three university-affiliated hospitals from 1995 through 2007 was performed. Patients were identified and data were extracted from case log books and the electronic medical record. RESULTS Twenty IEAIs were identified in 19 patients. The etiology of arterial injury was paracentesis in eight (40%), surgical trauma in three (15%), percutaneous drain placement in three (15%), blunt trauma in two (10%), subcutaneous injection in one (5%), stabbing in one (5%), and unknown in two (10%). Fifteen of 19 patients (79%) had an underlying coagulopathy. The diagnosis was confirmed by contrast medium-enhanced computed tomography (CT) in 14 (70%), tagged red blood cell scan in two (10%), and noncontrast CT in one (5%). Three patients (15%) had no diagnostic imaging. Contrast medium-enhanced CT showed active extravasation in nine of 14 patients (64%) and 13 of 14 exhibited active extravasation on subsequent arteriography. The sensitivity and specificity of contrast medium-enhanced CT for demonstrating active arterial bleeding were 70% and 100%, respectively. All 20 IEAIs were treated with transcatheter embolization, with an overall success rate of 90% and no complications. CONCLUSIONS IEAI is most often an iatrogenic injury in a coagulopathic patient. Contrast medium-enhanced CT can be diagnostic for active bleeding, but in the setting of ongoing hemorrhage a negative study result should not preclude arteriography. Embolization is an effective means to control hemorrhage.
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Affiliation(s)
- Paul R Sobkin
- Department of Radiology, Section of Interventional Radiology, University of California San Francisco, California, USA
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40
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Abstract
BACKGROUND Thrombocytopenia is a common finding in advanced liver disease. It is predominantly a result of portal hypertension and platelet sequestration in the enlarged spleen, but other mechanisms may contribute. The liver is the site of thrombopoietin (TPO) synthesis, a hormone that leads to proliferation and differentiation of megakaryocytes and platelet formation. Reduced TPO production further reduces measurable serum platelet counts. AIM This paper describes the scope of thrombocytopenia in chronic liver disease and assesses the clinical impact in this patient population. METHODS A medline review of the literature was performed pertaining to thrombocytopenia and advanced liver disease. This data is compiled into a review of the impact of low platelets in liver disease. RESULTS The incidence of thrombocytopenia, its impact on clinical decision making and the use of platelet transfusions are addressed. Emerging novel therapeutics for thrombocytopenia is also discussed. CONCLUSIONS Thrombocytopenia is a common and challenging clinical disorder in patients with chronic liver disease. New therapeutic options are needed to safely increase platelet counts prior to invasive medical procedures as well as to counteract therapies that further exacerbate low platelets, such as interferon. An ideal compound would be orally available and safe, with rapid onset of action.
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Affiliation(s)
- F Poordad
- Cedars-Sinai Medical Center, Center for Liver Disease and Transplantation, Los Angeles, CA 90048, USA.
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41
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Abstract
PURPOSE OF REVIEW Plasma transfusion to correct abnormal coagulation test results prior to an invasive procedure is a common clinical practice; however, there are no evidence-based guidelines. This review aims to analyze the most recent publications to either support or disprove such practice. RECENT FINDINGS Due to heightened awareness of transfusion-related acute lung injury and volume overload in susceptible patients, clinicians are increasingly questioning the validity of prophylactic plasma transfusion. Recently, several articles, reviews and clinical studies (although small and poorly designed) have shown no benefit of prophylactic plasma transfusion in either correcting abnormal coagulation tests or reducing perceived risk of hemorrhage. SUMMARY The use of sensitive reagents (especially for prothrombin time) has resulted in increased incidence of abnormal preprocedure coagulation screening test results - tests that are not designed to assess risk of bleeding in patients without a history of bleeding. Transfusion of plasma prior to an invasive procedure to correct mild to moderate abnormal test results neither corrects the abnormality nor reduces the perceived bleeding risk.
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Affiliation(s)
- Lorne Holland
- Department of Pathology, The University of Texas Southwestern Medical Center, Dallas, Texas 75390-9073, USA
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