Ascites (also called abdominal or peritoneal dropsy, hydroperitonia,
and hydrops abdominis) is defined as an abnormal accumulation of
fluid in the abdominal cavity. The word ascites is
derived from the Greek askos, meaning “bag” or “sac.” The
presence of ascites has important implications diagnostically, therapeutically,
and prognostically. Cirrhosis of the liver is usually related to
alcoholism, which accounts for 75 percent of cases of ascites; malignancy
accounts for an additional 10 to 12 percent, and cardiac failure
for another 5 percent. The remaining cases have a variety of etiologies.1 Unfortunately,
the physical examination is not very reliable when it comes to detecting
ascites, making paracentesis an important clinical tool.2
Peritoneal aspiration of ascitic fluid or paracentesis was first
described by Saloman in the early twentieth century.3 With
the introduction of diuretics as well as a fear of procedure-related
complications, paracentesis fell out of favor in the 1950s, being
replaced by medical management. At that time, large-bore needles
were being used and complication rates were significant. Clinical
studies published in the late 1980s demonstrated that performing
a paracentesis was, in fact, a safe procedure.4,5 Nowadays,
the procedure is commonplace in Emergency Departments.
Paracentesis is an important diagnostic tool for patients with
new-onset ascites to determine its etiology and in those patients
with long-standing ascites to detect the presence of infection.
Spontaneous bacterial peritonitis can be a very subtle disease.
It is well known that some patients with spontaneous bacterial peritonitis
are asymptomatic, making peritoneal fluid aspiration and cultures
imperative.6 In addition to the diagnostic usefulness of
paracentesis, large volumes of ascitic fluid can be removed therapeutically
by this procedure in order to improve a patient’s respiratory
status and comfort level from tense ascites. This often occurs in
patients with end-stage liver disease as well as in some cases of
malignancy. Malignant ascites may occur with carcinoma of the ovary,
pancreas, stomach, colon, breast, testes, and a variety of sarcomas
The gross anatomy of the abdomen is well known to practitioners
and is important to review in preparing for a paracentesis. The
abdominal cavity is lined by the peritoneum and is protected from
the environment by the abdominal wall musculature, fat, and skin.
The right and left rectus muscles, which are nourished by the epigastric
vessels, meet in the midline at the avascular linea alba. The umbilicus
is located along the lower portion of the linea alba. The layers
of the anterior abdominal wall structures vary above and below the
level of the anterosuperior iliac spine (Figure 54-1).
The layers of the anterior abdominal wall vary above
(A) and below (B)
the level of the anterosuperior iliac spine.
The liver sits in the upper right quadrant; when enlarged, it
can be palpated in the ...