Early Paracentesis-Induced Thrombocytopenia (EPIT): A Retrospective Study With Novel Insights Regarding Splenic Hemodynamics

Abstract

Introduction: Thrombocytopenia is commonly observed in patients with advanced liver disease. The occurrence of a temporary reduction in platelet count after paracentesis has not been described in the literature. An acute drop in platelet count after paracentesis often leads to unnecessary tests to search for causes such as heparin-induced thrombocytopenia (HIT). The primary purpose of this study is to document this phenomenon occurring in the early post-paracentesis period and test the hypothesis that this is related to a temporary reduction in intra-abdominal pressure and increase in splenic arterial flow leading to splenic congestion and increased splenic sequestration of platelets. Methods: A retrospective review of patients who underwent inpatient paracentesis was performed. The primary outcome was an acute reduction in platelet count post-paracentesis. The secondary outcome was a concomitant drop in WBC and RBC counts. Using multiple regressions, we examined variables including etiology of the liver disease, amount of ascitic fluid removed, presence of infection, splenomegaly, use of antibiotics, intravenous fluids (IVF), steroid use, and venous thromboembolism prophylaxis that may independently predict changes in platelet, WBC and RBC counts after paracentesis. Results: Out of 220 patients who underwent inpatient paracentesis, 190 (86.4%) patients had a reduction in platelet count (p < .001). Reductions in Platelet, WBC and RBC after paracentesis were 14.5% (p < .001), 14.2% (p < .001) and 5.9%, respectively (p < .001). Among multiple predictors of a drop in platelet count in the early post-paracentesis period, only the amount of fluid removed was a significant predictor (p < .001). Conclusion: We coined this phenomenon of acute drop in platelet count after paracentesis - Early paracentesis induced thrombocytopenia (EPIT) - that represents an absolutely new mechanism of thrombocytopenia in patients with advanced liver disease. This phenomenon is related temporary mechanical alteration in splenic hemodynamics due to reduction in intra-abdominal pressure (IAP) post-paracentesis and increase in cardiac output with subsequent increase in splenic congestion and platelet sequestration. Physicians and other practitioners caring for patients with chronic liver disease need to be aware of this condition and pathophysiological phenomenon to reduce unnecessary testing, patient aggravation, and reduce healthcare costs.915_A Figure 1. Platelet counts pre- and post-paracentesis.915_B Figure 2. Patient Characteristics:915_C Figure 3. Variable affecting change in Platelet count.