A 50 year old patient with HIV, HCV cirrhosis presents to the emergency room with subjective fevers and generalized abdominal pain with tenderness. As part of your workup, you plan for a diagnostic paracentesis. On ultrasound imaging, the patient has a large amount of easily tapped ascites. His INR, however, returns at 2.9. Should you proceed with your procedure?
Answer: Yes. If you suspect SBP (spontaneous bacterial peritonitis), your patient deserves a prompt diagnostic paracentesis. Coagulopathy is common in patients with cirrhosis and is not an absolute contraindication.
Multiple studies support this perspective:
- A retrospective study of 608 patients showed no increased bleeding in patients with mild to moderate coagulopathy (defined as plts 50-99 or PT twice “normal”).
- In a study of 1,100 LVPs, in which the INR ranged from 0.9-8.7 (interquartile range, 1.4-2.2), there were no significant post-procedure complications.
- A chart review of 4,729 paracentesis procedures revealed only nine episodes of severe hemorrhage, but found no correlation between these episodes and elevated INR, thrombocytopenia, or operator experience.
Sources:
- McVay PA, Toy PT. Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion. 1991 Feb;31(2):164-71.
- Grabau CM, Crago SF, Hoff LK, Simon JA, Melton CA, Ott BJ, Kamath PS. Performance standards for therapeutic abdominal paracentesis. Hepatology. 2004 Aug;40(2):484-8.
- Pache I, Bilodeau M. Severe haemorrhage following abdominal paracentesis for ascites in patients with liver disease. Aliment Pharmacol Ther. 2005 Mar 1;21(5):525-9.
