Guided Ascites Drainage (Paracentesis)

Background and indications

Ultrasound-guided paracentesis is an evacuative puncture of ascites (intraperitoneal fluid), performed under imaging guidance to minimize organ puncture risk. It is indicated for refractory ascites (advanced hepatic cirrhosis), tense ascites (respiratory distress, pain), neoplastic ascites, and for diagnostic purposes (first-time ascites, suspected infection).

Pre-procedure assessment

Assessment includes abdominal ultrasound (ascites confirmation and quantification, optimal puncture site identification), coagulation panel (PT, platelets — paracentesis is feasible even with moderate coagulopathy), and serum albumin level (to plan compensatory albumin infusion).

Procedure

Under local anesthesia and ultrasound guidance, an 18G needle or small-bore pigtail catheter (6-8F) is inserted into the peritoneal cavity, typically in the left iliac fossa. Fluid is evacuated by gravity or gentle aspiration. For large-volume paracentesis (> 5 liters), albumin infusion (6-8 g per liter removed) is administered to prevent post-paracentesis circulatory dysfunction syndrome. The procedure takes 30-60 minutes.

Results and scientific evidence

Large-volume paracentesis is safe and effective with immediate symptom relief. Replacement albumin use reduces post-paracentesis circulatory dysfunction risk (EASL 2018 guidelines). For refractory ascites requiring frequent punctures (> 2/month), TIPS placement or tunneled drain (peritoneal PleurX) should be discussed.

Risks and complications

Persistent fluid leak at puncture site (5-10%), wall hematoma (1-3%), intestinal perforation (< 0.5%, minimized by ultrasound guidance), bacterial peritonitis (< 1%). Hemorrhagic risk is low even in cirrhotic patients with coagulopathy.

Recovery

Same-day discharge. Blood pressure and renal function monitoring post-procedure. Immediate activity resumption.

Practical information

The procedure is performed as an outpatient or short inpatient stay depending on the case. It is performed by an interventional radiologist, in coordination with the hepatologist or oncologist.