Risks and Benefits of Large Volume Paracentesis in Spontaneous Bacterial Peritonitis With Tense Ascites: Where is the Clinical Evidence?

Abstract

Introduction: Spontaneous bacterial peritonitis (SBP) is the most common bacterial infection in cirrhosis with high mortality. Antibiotics are the mainstay of treatment. Moreover, albumin infusion in SBP improves survival by 60% and decreases the risk of acute renal impairment. Large volume paracentesis (LVP) is the standard treatment for tense ascites. LVP is historically avoided in patients with SBP due to the potential risk of circulatory dysfunction. These are based on presumed physiologic mechanisms and have not been adequately studied with robust clinical outcomes. We decided to determine whether or not LVP can be safely used in SBP patients, especially in the era where albumin infusion, regardless of performing LVP or not, is part of SBP management. Potential benefits of LVP in SBP include: improved patients’ abdominal discomfort, decreased ascites microbial load, decreased intra-abdominal pro-inflammatory cytokines, and bacterial vasoactive peptides. Methods: We conducted a systematic review of randomized controlled clinical trials (RCTs). We searched Medline, EMBASE, Cochrane CENTRAL, and Clinicaltrials.gov databases using controlled vocabularies (MeSH, EMTREE), and key word searching for large volume/therapeutic paracentesis, spontaneous bacterial peritonitis, and refractory/tense ascites. We also screened all SBP trials as well as all LVP trials. We also performed hand searching and cross referencing of clinical guidelines and major reviews. Results: Our comprehensive search retrieved 189 trials in Medline, 147 in Cochrane CENTRAL, 91 in EMBASE, and 28 in Clinicaltrials.gov in English. After removing the duplicates there was only randomized controlled clinical trial that studied LVP in SBP patients. All other LVP trials had excluded SBP patients from their studies. Similarly, all SBP trials did not include LVP in their management. The AASLD clinical guidelines did not provide recommendations regarding whether or not LVP can be considered in SBP. The only available RCT of LVP in SBP randomized 42 SBP patients to receive LVP (group 1) vs. no LVP (group 2). Twelve months survival was not statistically significantly different between 2 groups (11.1% vs. 14.3%; p>0.05), however symptoms resolved faster with LVP (p=NS) but with slightly higher rate of renal impairment (p=NS ). Conclusion: There is an extreme paucity of evidence with regard to role and safety of LVP in tense ascites in SBP. The current clinical guidelines do not provide recommendations on whether or not LVP can be considered in SBP. The only retrieved small RCT showed no worse outcomes with LVP, whereas LVP may cause faster symptom relief. Further investigations are warranted to delineate clinical risks and benefits of LVP in SBP.