HPI: This is a 72-year-old male with a PMH of cirrhosis and multiple other medical comorbidities who presented from his nursing home with vomiting and abdominal pain and distention.
POCUS revealed loculated ascites, which was confirmed on CT abdomen.
The patient underwent diagnostic paracentesis under dynamic ultrasound guidance, which yielded 50mL of serosanguinous fluid.
Ascites on Ultrasound
Ultrasound is a useful tool for diagnosing ascites because it can detect small amounts of abdominal free fluid not otherwise felt on physical exam and help estimate volume
It can guide safe paracentesis by helping visualize bowel and other organs to avoid
Simple ascites appears anechoic while hemorrhagic or exudative ascites will often contain floating debris
Septations (aka loculations) suggest an inflammatory or neoplastic cause
Clip 1 shows complex abdominal free fluid with loops of bowel floating within it.
Clip 2 shows an ultrasound-guided paracentesis. Note the needle being introduced into the ascitic fluid from the right side of the screen. The linear probe is used for better resolution of the superficial structures. Color flow can be used to identify the inferior epigastric artery and other vasculature to avoid puncturing in the abdominal wall.
This Core Ultrasound video gives a helpful rundown on how to perform an ultrasound-guided paracentesis.
Case conclusion: Spontaneous bacterial peritonitis was diagnosed based on the ascitic fluid containing >8000 neutrophils, and antibiotics were initiated. The patient was admitted. His hospital course was complicated by acute renal failure and an acute duodenal ulcer bleed, and he remains admitted 1 month later.
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