Therapeutic Paracentesis Research Articles

#1125 CAPD in ESRD and CLD patients with refractory ascites: a 12-month follow-up study

Abstract Background and Aims Refractory ascites secondary to chronic liver disease among ESRD patients are a major source of morbidity and mortality. Hemodialysis is frequently interrupted due to intradialytic hypotension and other complications which make ultrafiltration removal among CLD patients, a big challenge. This results in sub-optimal clearance which translates into poor quality of life along with recurrent admissions. CAPD in these patients is effective in providing a good clearance as well as removal of ascites with adequate ultrafiltration removal. There is a lack of data regarding the feasibility, safety, and clinical outcomes of CAPD among CLD patients with ascites. We conducted a study with objectives to evaluate serum albumin levels at baseline and 12 months, and to determine peritonitis rates and dialysis modality suitability in CLD patients. Method Study Design A retrospective cohort study. Study Population All hemodialysis patients with refractory ascites due to CLD. Refractory ascites was defined as the need for >5 therapeutic paracentesis in the last 3 months after optimal clinical, dietary and fluid management. All CLD patients were extensively counselled regarding high protein intake. Each patient visited either the Nephrologist or PD Nurse, renal dietician at least once in 4-6 weeks. Results Over a period of five years, 34 patients were included in the analysis to assess the efficacy of Continuous Ambulatory Peritoneal Dialysis (CAPD) for ascites management in chronic liver disease. Baseline characteristics are presented in Table 1. The frequency of ascites drainage prior to CAPD was every 3.4 weeks. Open catheter insertion was performed in 31 out of 34 patients. Serum albumin levels increased from 2.98 ± 0.4 g/dL at baseline to 3.1 ± 0.28 g/dL at 12 months (p = 0.21) (Fig. 1). Child-Pugh Score and MELD score remained stable. Bacterial peritonitis episodes were higher at 12 months (3 vs 9; p = 0.04). PD-related complications at one year included one omental wrap, three pericatheter leaks, and one umbilical hernia. At the 12-month follow-up, 32 patients survived. One patient died from myocardial infarction, and another experienced severe hepatic encephalopathy and aspiration pneumonia. Conclusion PD was well tolerated in patients with refractory ascites, presenting no additional hypoalbuminemia risk. Continuous multidisciplinary monitoring for malnutrition remains critical. Peritonitis risk was elevated relative to SBP in HD patients yet was on par with typical PD rates, without an increase in hospital admissions.

Assessment of the 2021 AASLD Practice Guidance for Albumin Infusion in Elective Therapeutic Paracentesis: A Regression Discontinuity Design.

The 2021 American Association for the Study of Liver Disease (AASLD) Practice Guidance recommends albumin infusion when removing ≥5 L of ascites to prevent post-paracentesis circulatory dysfunction. However, the optimal criteria and scenarios for initiating albumin infusion subsequent to therapeutic paracentesis (TP) have been subject to limited scientific inquiry. We conducted a retrospective cohort study at a US academic healthcare center. Participants received elective, outpatient TP between July 2019 and December 2022. Patients with spontaneous bacterial peritonitis, post-TP clinical adjustments, and/or hospitalization were excluded. The institution strictly followed the AASLD Guidance. We used a sharp regression discontinuity (RD) design to estimate the effect of albumin infusion at the AASLD Guidance-recommended cutoff of 5 L on serum creatinine and sodium trajectory after TP. Over the study period, 1,457 elective TPs were performed on 235 unique patients. Albumin infusion at the threshold of 5 L of ascites removal reduced serum creatinine levels by 0.046 mg/dL/d (95% confidence interval 0.003-0.116, P = 0.037) and increased serum sodium levels by 0.35 mEq/L/d (95% confidence interval 0.15-0.55, P = 0.001) compared with those who did not receive albumin infusion. The RD plots indicated worsened serum creatine/sodium levels after draining 3 L of fluid, approaching levels similar to or worse than with albumin infusion at 5 L or more. Our RD models supported the 2021 AASLD Guidance with robust estimation of causal effect sizes at the cutoff level of 5 L. Nevertheless, the findings also highlight the need to further evaluate the efficacy of albumin infusion in patients who undergo elective TP and have 3-5 L of ascites removed.

Midodrine reduces new-onset acute kidney injury and hyponatremia in children with cirrhosis and ascites awaiting liver transplantation: Results from an open-label RCT.

Midodrine, an oral α-1-adrenergic receptor agonist, counters arterial hypovolemia and reduces complications in adult patients with cirrhosis. This randomized controlled trial (RCT) aimed to assess the efficacy and safety of midodrine in preventing complications and improving survival in children with cirrhosis and ascites who are awaiting liver transplantation (LT). This open-label RCT conducted from January 2022 to May 2023 included children under 18 years with cirrhosis and ascites. Patients were randomized to receive either midodrine plus standard medical therapies (SMTs) or SMT alone. The primary outcome measure was the incidence of cirrhosis-related complications within 6 months. Thirty-five subjects were enrolled and randomized. Patients in the midodrine arm had a lower incidence of new-onset acute kidney injury (AKI) compared with the SMT arm (11.1% vs. 41.2%). Patients in the midodrine arm showed a decline in serum creatinine and improvement in glomerular filtration rate, whereas no changes were observed in the SMT arm. There was a lower incidence of new-onset hyponatremia in the midodrine arm (20% vs. 56%). Midodrine led to reduction in plasma rennin activity (PRA) and improvement in systemic hemodynamics. There was no difference in the rate of resolution of ascites, recurrence of ascites, requirement of therapeutic paracentesis, cumulative albumin infusion requirement, episodes of spontaneous bacterial peritonitis, and hepatic encephalopathy between the two arms. Midodrine, when added to SMT, was effective in reducing the incidence of new-onset AKI and hyponatremia in pediatric cirrhotics awaiting LT. It also improved systemic hemodynamics and showed a trend towards reducing PRA.

S1365 Skin Glue for Prevention of Fluid Leaks Following Therapeutic Paracentesis: A Randomized Trial

S1365 Skin Glue for Prevention of Fluid Leaks Following Therapeutic Paracentesis: A Randomized Trial

PRO: Ascitic fluid cell count should be routinely sent with every therapeutic paracentesis to assess for spontaneous bacterial peritonitis.

PRO: Ascitic fluid cell count should be routinely sent with every therapeutic paracentesis to assess for spontaneous bacterial peritonitis.

CON: Ascitic fluid cell count should not be routinely sent with every therapeutic paracentesis to assess for spontaneous bacterial peritonitis.

CON: Ascitic fluid cell count should not be routinely sent with every therapeutic paracentesis to assess for spontaneous bacterial peritonitis.

Continuous passive paracentesis versus large-volume paracentesis in the prevention and treatment of intra-abdominal hypertension in the critically ill cirrhotic patient with ascites (COPPTRIAHL): study protocol for a randomized controlled trial

BackgroundCritically ill patients with cirrhosis and ascites are at high risk for intra-abdominal hypertension (IAH) which increases mortality. Clinical guidelines recommend maintaining intra-abdominal pressure (IAP) below 16 mmHg; nonetheless, more than three quarters of critically ill patients with cirrhosis develop IAH during their first week of ICU stay. Standard-of-care intermittent large-volume paracentesis (LVP) relieves abdominal wall tension, reduces IAP, optimizes abdominal perfusion pressure, and is associated with short-term improvement in renal and pulmonary dysfunction. However, there is no evidence of the superiority of different paracentesis strategies in the prevention and treatment of IAH in critically ill patients with cirrhosis.This trial aims to compare the outcomes of continuous passive paracentesis versus LVP in the prevention and treatment of IAH in patients with cirrhosis and ascites.MethodsAn investigator-initiated, open label, randomized controlled trial, set in a general ICU specialized in liver disease, was initiated in August 2022, with an expected duration of 36 months. Seventy patients with cirrhosis and ascites will be randomly assigned, in a 1:1 ratio, to receive one of two methods of therapeutic paracentesis. A stratified randomization method, with maximum creatinine and IAP values as strata, will homogenize patient baseline characteristics before trial group allocation, within 24 h of admission.In the control group, LVP will be performed intermittently according to clinical practice, with a maximum duration of 8 h, while, in the intervention group, continuous passive paracentesis will drain ascitic fluid for up to 7 days.The primary endpoint is serum creatinine concentration, and secondary endpoints include IAP, measured creatinine clearance, daily urine output, stage 3 acute kidney injury and multiorgan dysfunction assessed at day 7 after enrollment, as well as 28-day mortality rate and renal replacement therapy-free days, and length-of-stay. Prespecified values will be used in case of renal replacement therapy or, beforehand ICU discharge, liver transplant and death. Safety analysis will include paracentesis-related complication rate and harm. Data will be analyzed with an intention-to-treat approach.DiscussionThis is the first trial to compare the impact of different therapeutic paracentesis strategies on organ dysfunction and outcomes in the prevention and treatment of IAH in critically ill patients with cirrhosis and ascites.Trial registrationClinicalTrials.gov NCT04322201. Registered on 20 December 2019

Pulmonary function testing in patients with liver cirrhosis (Review).

Liver cirrhosis is a common long-term outcome of chronic hepatic inflammation. Patients with liver cirrhosis may also have pulmonary complications. There are several reasons for pulmonary dysfunction in liver cirrhosis, including intrinsic cardiopulmonary dysfunction unrelated to liver disease and specific disorders related to the presence of liver cirrhosis and/or portal hypertension. The most prevalent and clinically significant pulmonary complications are hepatic hydrothorax, hepatopulmonary syndrome, spontaneous pulmonary empyema and portopulmonary hypertension. Pulmonary function tests (PFTs) have traditionally been used to assess the lung function of patients with liver cirrhosis. To the best of our knowledge, the present review is the first to detail all types of PFTs performed in patients with liver cirrhosis and discuss their clinical significance. Patients with liver cirrhosis have reduced values of spirometric parameters, diffusion capacity for carbon monoxide (DLCO), lung volumes, maximal inspiratory pressure and maximal expiratory pressure. Furthermore, they have a higher closing volume, a greater airway occlusion pressure 0.1 sec after the onset of inspiratory flow and greater exhaled nitric oxide values. In order to improve pulmonary function, patients with ascites may require therapeutic paracentesis. Such findings should be considered when evaluating individuals with liver disease, particularly those who may require surgery. Poor lung function, particularly restrictive lung disease, can have an impact on post-transplant outcomes, such as ventilator time, length of hospital duration and post-operative pulmonary complications; thus, the transplant care team needs to be aware of its prevalence and relevance.

Neonatal Haemorrhagic Ascites: A Rare Case Report

Haemorrhagic ascites in the newborn is rare. Ascites is the pathological accumulation of fluid within the peritoneal cavity. Various causes of ascites have been described in different age groups. Abdominal paracentesis does provide symptomatic relief and can be used as a diagnostic tool to find the cause of ascites. Here we report one such case of haemorrhagic neonatal ascites in a 37week neonate, where therapeutic paracentesis was done for the gross ascites. Close follow-up is recommended for signs of frozen abdomen and intestinal obstruction.

The Predictors of Hepatorenal Syndrome Development in HCV Cirrhotic Ascitic Egyptian Patients with Spontaneous Bacterial Peritonitis.

Spontaneous bacterial peritonitis is considered a precipitating factor for renal impairment in patients with liver cirrhosis. No specific study addressing this problem has been reported. This study aimed to detect the incidence and predictive factors of hepatorenal syndrome in these patients. This study enrolled 121 hepatic cirrhotic patients with spontaneous bacterial peritonitis. History taking, clinical examination, and laboratory investigations including ascitic fluid analysis were carried out. Kidney function tests were repeated 3 days after the initiation of treatment. Patients were divided into 2 groups after one week of treatment during the follow-up period: Group I: patients without hepatorenal syndrome, and Group II: patients with hepatorenal syndrome. Multivariate analysis was performed to determine independent predictors of hepatorenal syndrome development. A total of 30 patients (24.8%) developed hepatorenal syndrome. Patients with hepatorenal syndrome had significantly lower sodium and albumin levels as well as higher creatinine, bilirubin, Child-Turcotte-Pugh score, portal vein diameter, Model for End-Stage Liver Disease score. Higher percentage of them had a history of recurrent spontaneous bacterial peritonitis and multiple therapeutic paracentesis of ascites. Multivariate analysis detected that serum bilirubin, Model for End-Stage Liver Disease-Sodium, and portal vein diameter were significant predictors of hepatorenal syndrome. Cutoff values were determined as 3.3 mg/dl for bilirubin, 15.9 mm for portal vein diameter, and 26 for Model for End-Stage Liver Disease-Sodium. Hepatorenal syndrome is a common complication of spontaneous bacterial peritonitis. In our study, high serum bilirubin, Model for End-Stage Liver Disease-Sodium, and portal vein diameter are predictors of the development of hepatorenal syndrome in patients with spontaneous bacterial peritonitis.

Umbilical hernia in a patient with ascites. Clinical case

INTRODUCTION. Since 1808, umbilical hernias were registered based on existing data, in such a way that 4716 scientific articles were registered in the last two centuries. About 6 to 14% of all abdominal wall hernias in adults are umbilical hernias with a prevalence of 2%. CLINICAL CASE. A 47-year-old male came to the emergency room presenting with a giant umbilical hernia, liver cirrhosis and increased abdominal girth, fluid retention (ascites) to perform paracentesis of approximately 5 Liters, presenting confusion, asterixis, dyslalia, aphasia, upon admission. no coordination of walking. On physical examination, she was found to be hemodynamically unstable with the presence of ascitic fluid leakage through an ulcer caused by tension in the umbilical region; feverish peaks, for which reason a liquid sample was taken by puncture in the left iliac fossa, yellow in color and cloudy in appearance with glucose 106 mg/dL, LDH 239 mg/ml, presence of Hb (+++), and leukocytosis. He was evaluated for general surgery. Where a non-reducible incarcerated umbilical hernia was observed, it was decided to treat the complicated hernia, partial omentectomy plus ventral plasty with the Rives-Stoppa technique plus omphaloplasty with Drenovac-type closed drainage was performed without complications. DISCUSSION. Cirrhotic patients who do not respond to medical treatments for ascites will require treatment such as serial therapeutic paracentesis. Large volume paracentesis (LVP), defined as the removal of more than 5 L of ascitic fluid, is an effective therapy for patients with tense ascites.

Midodrine and albumin as a possible "winning pair" in managing paracentesis-induced circulatory dysfunction: a clinical case report.

Paracentesis-induced circulatory dysfunction (PICD) is a "silent killer syndrome" occurring after large volume paracenteses (LVPs). We here report an unusual case of PICD induced by right heart failure recognized and managed successfully. A 60-year-old woman was admitted to our Emergency Department for worsening dyspnea and hypoxia. Her medical history enclosed a chronic heart failure with reduced ejection fraction and post-stroke dysarthria associated to right hemiplegia. Clinical and laboratory examination defined a severe right-heart failure unresponsive to high-dose diuretic therapy. Diagnostic and therapeutic paracentesis was thus performed determining, initially, a progressive normalization of the abdominal volume, followed, subsequently, by a severe hypotension associated with an acute kidney injury (AKI) combined with severe hyponatremia associated with a normal cardiac output. In the hypothesis of a PICD, abdominal drainage and diuretic therapy were interrupted, reninemia sampling was performed, resulting in diagnostic, and treatment with albumin and norepinephrine was started. The latter was tapered and then replaced with Midodrine that conferred the possibility to reach clinical and laboratory stability, allowing relocation in a cardiological rehabilitation. PICD represents an independent predictor of mortality. Midodrine's prophylactic use in PICD has been suggested as a cheaper alternative to albumin, as it appears to improve renal perfusion and reduce ascites with better clinical handling, as demonstrated in our patient. Our clinical case wants to show how not all PICDs are secondary to hepatic dysfunctions with Midodrine playing a possible therapeutic role by counteracting the pathophysiological mechanism in a rapid and non-invasive way, representing a valid therapeutic option in adjunction to albumin.

Abstract 15561: A Rare Case of Air Embolus in the Presence of Bilateral Pulmonary Emboli

Case Presentation: A 70-year-old male with cardiac risk factors, cirrhosis, stage II cholangiocarcinoma, and a right internal jugular port-a-catheter, presented to the hospital following an unwitnessed syncopal episode one day after undergoing a therapeutic paracentesis. On presentation he was hemodynamically unstable and endorsed severe substernal chest pain. Diagnostic work-up revealed large bilateral pulmonary emboli, and large amounts of intravascular gas in the right brachial vein, superior vena cava (SVC), right atrium and ventricle (Figure A). He was immediately placed on supplemental oxygen, given intravenous fluids, and started on vasopressors. He was a poor candidate for mechanical thrombectomy thus tissue plasminogen activator (tPA) was administered, and he was admitted to the medical intensive care unit for further management. Discussion: Venous air emboli occur as rare complications of trauma or intravascular procedures when air or gas enters the vasculature. Symptoms are generally non-specific making them difficult to recognize. In this patient, a central port-a-catheter had been placed two months prior for chemotherapy administration. A central line provides a direct connection between the air and the vasculature. The sub-atmospheric pressures in the SVC, where these lines often terminate, create a pressure gradient conducive to the development of air emboli. Hypovolemic states as seen in cirrhosis and pulmonary emboli) can further magnify this gradient. Interestingly, the presence of a large venous air embolism and concurrent massive bilateral pulmonary emboli, has rarely been previously reported. Caution should be taken in prevention, early detection, and treatment to avoid potentially fatal complications.

Post-paracentesis Ascitic Fluid Leak in Patients with Cirrhosis of Liver and its Management: A Prospective Study

Ascites is the most common complication of decompensated cirrhosis of liver requiring paracentesis for diagnostic and therapeutic purposes. The ascitic fluid leak can develop after paracentesis in patients with cirrhosis leading to significant morbidity if persistent. We aimed to study the incidence and predictors of post-paracentesis leak in patients with ascites. In this prospective study, patients with cirrhosis undergoing therapeutic paracentesis were followed up, and those patients who developed persistent leak were included as cases. Controls were randomly selected in a 2:1 ratio from the group of patients who did not develop leak. Clinical and laboratory parameters were compared between the two groups. A total of 256 patients underwent 1126 sessions of therapeutic abdominal paracentesis over a period of 14 months. Post-paracentesis leak was seen in 55 (4.8%) patients while only 20 (1.7%) patients had persistent leak. The management of leak was in a stepwise manner initially with tincture benzoin with tight dressing followed by topical cyanoacrylate adhesive and followed by autologous blood patch in those not responding. The persistent leak group had higher proportion of patients with parietal edema, higher PT-INR and Child-Pugh score, lower mid-upper arm circumference, short physical performance battery score, and handgrip strength. On multivariate analysis, only the presence of parietal edema was an independent predictor of post-paracentesis persistent leak (odds ratio 10.35, 95% confidence interval 1.61-66.54, P=0.014). Persistent leak after paracentesis develops in a minority of patients with cirrhosis. The presence of parietal edema is a risk factor for persistent leak. The majority of these patients can be managed in a stepwise approach.

S3163 Skull Metastasis in a Patient With HCC

Introduction: Hepatocellular carcinoma (HCC) rarely metastasizes to the skull. The prevalence of skull metastasis in HCC has been described to be 6.1%. Cranial nerve deficits are seen in more than a third of patients presenting with skull metastasis. We present a patient with a diagnosis of HCC with a concomitant soft tissue mass at the clivus concerning metastatic HCC. Case Description/Methods: A 62-year-old male with a medical history of cirrhosis secondary to hepatitis C, arterial hypertension and type 2 diabetes mellitus who arrived to our institution due to 5-day history of progressive abdominal swelling and distension. In addition, he referred to having intense left-sided headache and visual disturbances, described as "double vision," three months before arrival. The physical exam showed an uncomfortable, acutely ill, with a temporal wasting patient. HEENT exam revealed the inability to abduct his left eye—suggestive of cranial nerve VI palsy—and tongue deviation to the right side. Also, the abdominal exam showed a soft and depressible abdomen, with flank dullness and mild abdominal tenderness to palpation. Imaging workup included a brain MRI which showed a soft tissue mass at the clivus extending superiorly to the suprasellar region invading the sphenoid sinuses. Additional abdominopelvic CT scan revealed a cirrhotic liver with associated portal hypertension, a large infiltrative right liver lobe LT-TIV observation due to hepatocellular carcinoma (HCC), and celiac lymph node findings concerning for metastatic disease. Management strategies include performing a diagnostic and therapeutic paracentesis which yielded results concerning portal hypertension. Neurosurgery service evaluated the patient and recommended radiotherapy without further neurosurgery management. The patient was eventually discharged home with multidisciplinary follow-up. Discussion: Skull metastasis from HCC is uncommon; but it is notorious for affecting the patient's prognosis and quality of life. Therefore, it is important to make an early diagnosis and properly manage skull metastasis from HCC. This case exhibits the importance of considering the skull and brain metastases of a hepatocellular when evaluating a patient with HCC with neurological symptoms.

S3400 Elevated Ascitic Fluid Amylase? Think Twice It Could Be a Foreshadowing of Intestinal Perforation

Introduction: Elevated ascitic fluid amylase concentration is characteristic of pancreatic ascites. Nevertheless, ascitic amylase values greater than 2000 u/L can also be seen in intestinal perforation. We present a case of a patient without evident risk factors for fungal peritonitis whose ascitic fluid was notable for yeast and elevated amylase with a final diagnosis of intestinal perforation. Case Description/Methods: A 54-year-old female with a medical history of metastasized transitional cell urethral cancer arrived at our institution due to persistent non-bloody vomiting, diffuse abdominal pain, and worsening abdominal distension for a month. Initial evaluation was a remarkable food distended, tense abdomen with normoactive bowel sounds and positive fluid wave. Images were remarkable for large amounts of ascites, with a faint enhancement of the peritoneal surface consistent with acute peritonitis and findings concerning partial small bowel obstruction with free retroperitoneal air of unknown origin. The patient was started on intermittent suction via a nasogastric tube. Diagnostic and therapeutic paracentesis was performed. CT urogram was performed due to concern of bladder perforation, which was remarkable for diverticular microperforation. Ascitic fluid analysis was consistent with secondary peritonitis, with yeast species and markedly elevated ascitic amylase at >7,500 u/L in the setting of normal pancreatic enzymes. Empiric coverage for fungal peritonitis was started with caspofungin. Hospitalization was complicated by shock and acute abdomen. Emergent imaging revealed duodenal jejunal mesenteric ischemia with perforation of the proximal jejunum and peritonitis. The patient underwent exploratory laparotomy with palliative gastrostomy, lysis of adhesions, and peritoneal lavage. After the intervention, blood cultures came back positive for candida glabrata. The patient completed therapy for fungemia and was discharged to hospice care. Discussion: Candida peritonitis is most seen as secondary peritonitis. It generally occurs as a result of translocation of micro-organisms across the bowel wall, perforation of a hollow viscus, or instrumentation of the gastrointestinal tract. It is associated with high morbidity and mortality. This case raises awareness of careful evaluation of elevated ascitic amylase with concomitant yeast species in ascitic fluid gram stain, as they can both be indicators of intestinal perforation where a surgical approach can be lifesaving.

S3216 When to Start Anticoagulation? A Case of Portal Vein Thrombosis in a Post-Partum Cirrhosis Patient With Variceal Bleeding

Introduction: While portal vein thrombosis (PVT) is a relatively rare disease in the general population, the prevalence of PVT in cirrhosis increases in parallel with the severity of cirrhosis. The pathogenesis of PVT in cirrhosis is thought to be multifactorial resulting mainly from alterations in the different components of Virchow’s triad. Case Description/Methods: Here we report a case of a 36-year-old woman with history of alcoholic cirrhosis who presented 2 weeks status post c-section complaining of acute onset abdominal pain, bloating, and nausea with two episodes of hematemesis. Her initial vital signs were unremarkable and hemoglobin was 7.4 gm/dL. Her model for end-stage liver disease (MELD) score was 16. She underwent upper endoscopy (EGD) with successful banding of 3 columns of large varices which showed stigmata of recent bleeding. Patient also underwent diagnostic and therapeutic paracentesis which did not show signs of spontaneous bacterial peritonitis (SBP). However, she did have history of wound dehiscence of her cesarean incision with persistent leakage of serous fluid despite prior negative pressure wound therapy. Therefore, CT abdomen/pelvis was obtained which demonstrated nonocclusive thrombus in the main portal vein extending into both the right and left branches. Due to finding of PVT, MRI was also obtained which showed no evidence of malignancy. As her hemoglobin remained stable ( >7 gm/dL) during hospitalization, she was started on therapeutic low molecular weight heparin (LMWH). Unfortunately, patient was re-admitted five days later for hematemesis and drop in her hemoglobin to 5.6 gm/dL. She received blood products, and repeat EGD showed cratered and superficial esophageal ulcers at the site of prior variceal treatment. Ultimately LMWH was held and resumed after hemoglobin stabilized. Discussion: This case demonstrates the conundrum of if/when to treat PVT in patients with cirrhosis. Current guidelines recommend anticoagulation as the mainstay of PVT treatment. However, this is can be complicated by other sequelae of decompensated cirrhosis such as variceal bleeding. Consequences of non-treatment include further increase in resistance to portal blood thus worsening portal hypertension. In this case, patient’s post-partum status also favors anticoagulation as other society guidelines have recommended anticoagulation with LMWH for postpartum patients with vascular disease of the liver. Therefore, individualized treatment algorithms should be developed and used to guide management.

S1484 Paracentesis Team: An EPIC Chat Opt-In Group for Hospital Procedures

Introduction: At our institution, a lack of certified providers able to perform a bedside paracentesis has led to increased utilization of interventional radiology for both diagnostic and therapeutic paracenteses. With increased turnover of providers and low numbers of hospitalists able to perform the procedure, minimal supervision existed to train and certify new providers in paracenteses. Through a hospital initiative, a paracentesis team was formed, led by both hospitalists and certified residents, to increase the number of certified providers able to perform this procedure. Methods: To pair providers together for training as well as to expedite patient care through timely paracenteses, an EPIC Chat Opt-In group was created in September 2021 titled “Medicine Paracentesis Priority List.” Any provider in the hospital could message the group requesting a paracentesis be completed. Providers in the chat could then offer to perform or to supervise another provider. Patient charts were saved for data collection. Requests to interventional radiology first were directed to the paracentesis team instead. Results: Prior to the intervention, there were only 3 hospitalists and 3 certified residents available to supervise the procedure. Over the course of the 8 months, around 70 paracenteses were performed through chat request, and 10 new providers completed the minimum 5 paracentesis to become certified. A total of 30 different providers performed the procedure. Less than 10 needed to be referred to interventional radiology due to unsafe bedside paracentesis. There were 30 inpatient IR paracentesis in the 6 months prior to intervention, and 33 in the 6 months after start (Figure 1). However, March (month 7 after intervention) saw 0 paracenteses completed by IR, with only 5 in the past 3 months (months 5-7). Conclusion: The creation of a paracentesis team accessible through an EPIC Chat Opt-In group has increased certification of hospital providers and led to multiple beneficial outcomes for the hospital. Total numbers of Interventional Radiology paracenteses have stayed the same, followed by a sharp decrease over months 5-7, suggesting a lag period. Additional outcomes were centralized collection of paracentesis materials and standardized policies for performing the procedure and escalating care to IR. With our hospital support and continued growth of certified providers, we expect this intervention to lead to improved hospital outcomes and many more certified providers.Figure 1.: Interventional Radiology and Internal Medicine inpatient paracentesis numbers from our intervention starting September 2021.

Lymphatic Malformation Presenting as Recurrent Pleural Effusion and Ascites

Background: Chylothorax is defined as the accumulation of chyle in the pleural space and is characterized by elevated triglyceride content in pleural fluid >110 mg/dl. Chylous ascites is the accumulation of chyle in peritoneal fluid characterized by triglyceride levels >200 mg/dL. Causes can be traumatic or nontraumatic; portal or nonportal; and congenital or acquired (inflammatory, postoperative, malignant, or infectious). Lymph duct abnormalities are a rare cause of concurrent occurrence of chylothorax with chylous ascites. Clinical Description: We report a 4½-year-old girl who initially presented a fever and was diagnosed to have right-sided pleural effusion. Since no other focus was identified, she was treated as a case of tubercular pleural effusion, following which her symptoms settled transiently. She thereafter had a recurrence of her symptoms in association with ascites and was managed as a case of relapse of tuberculosis (TB) with category 2 anti-tubercular therapy. Since her symptoms did not resolve, she was referred to our hospital for further management. Management: Clinical reasoning based on history and examination coupled with investigations ruled out cardiac, renal, hepatic, malabsorption, or nutritional pathologies of recurrent effusions. TB was ruled out. A lymphatic malformation was suspected. Therapeutic cum diagnostic paracentesis was done in a fed state, which indicated a chylous nature by the milky appearance and suggestive cytology and biochemistry. Lymphoscintigraphy confirmed the presence of a lymphatic duct abnormality. The child was managed with diet modifications, following which she improved within a week. Conclusions: The approach to recurrent effusions without any focus should be logical and sequential, as described above, to exclude the aforementioned common conditions. If workup for TB is repeatedly negative other less likely causes should be considered.

S1835 Silent Hemoperitoneum and MRSA Bacterascites: An Unusual Presentation of Gallbladder Perforation

Introduction: Gallbladder perforation (GBP) is an uncommon, life-threatening event, most often seen as a complication of acute cholecystitis. Occurrence of GBP in the absence of cholecystitis is exceedingly rare, but may occur in those with cholelithiasis. We report a case of spontaneous GBP without cholecystitis presenting as painless hemoperitoneum and methicillin-resistant Staphylococcal aureus (MRSA) bacterascites in a patient with decompensated cirrhosis. Case Description/Methods: A 63 year old female with past history of NASH cirrhosis (MELD 27, Child-Pugh C), esophageal varices, and ascites requiring weekly therapeutic paracentesis presented with encephalopathy. A paracentesis on admission was negative for spontaneous bacterial peritonitis by cell count and culture. CT imaging on admission revealed a partial small bowel obstruction (pSBO) and cholelithiasis with an otherwise normal gallbladder and biliary tree. The pSBO resolved with conservative management. One week into the hospitalization, her ascites worsened. A second paracentesis showed 253,290 RBC/mm3, with a corrected ANC of -54 cells/mm3. A 3 gram serum hemoglobin drop was also noted. A repeat abdominal CT scan showed a non-inflamed gallbladder with her known gallstones now layering in the pelvis, suggestive of GBP (Figure). She was initially started on piperacillin-tazobactam, but her ascitic fluid culture later grew MRSA. Based on her surgical risk and overall clinical stability, she was managed non-operatively. She was transitioned to indefinite therapy with amoxicillin-clavulanate and doxycycline, and later discharged home. Discussion: Most GBPs are due to severe inflammation or trauma. Risk factors for spontaneous GBP include cholelithiasis, congenital obstruction, and anticoagulant therapy. Although rare, patients with cirrhosis may have a higher risk for GBP due to venous congestion from portal hypertension and their propensity for cholelithiasis. Her MRSA bacterascites may have been from iatrogenic seeding during the first paracentesis, but the timeline to discovery raised concerns that it originated from the GBP. MRSA is rarely a biliary pathogen, but may result from bacteremia that seeds the gallbladder. Regardless, the patient began indefinite antibiotic therapy, as her gallstones posed as persistent nidi for infection. This case highlights the rare possibility of silent GBP as a cause for worsening ascites, as well as the therapeutic dilemma of retained peritoneal gallstones in a poor surgical candidate.Figure 1.: Gallstones residing in intact gallbladder on left, compared to subsequent scan on the right demonstrating gallstones in patient's pelvis.