Krystian Sporysz

LEARNING OBJECTIVE

This case report shows us how important ultrasound is during any kind of interventions like paracentesis.

It is not obligatory, but I think it should be necessary; because of patients’ safety.

In this case not using an ultrasound could have caused puncture to the bowel.

AIM

The aim of this study is to show how important is to use ultrasound for the paracentesis.

Peritoneal fluid is the common complication of  the liver failure. Paracentesis with fluid sample taken should be done to every patient with newly recognised ascites.

Bedside ultrasound examination is an easy and quick method to confirm the presence of a fluid, even small amount, but also it can be very useful to establish the cause of the fluid.

Paracentesis as an invasive diagnostic procedure can cause some dangerous complications such as bowel, liver or vessels puncture. Most of them could be avoided while using ultrasound.

METHODS

Ultrasound guided paracentesis was done on a 61-year-old patient from emergency department with abdominal pain and no history of chronic diseases.

Laparoscopic surgery for ovaries removal was done 6 months before. Patient had complained of an abdominal pain for one week before admission. Bedside ultrasound examination was performed.

RESULTS

Abdominal ultrasound examination had shown features of liver cirrhosis, lots of free fluid in peritoneal cavity and dilated of a small bowel loops with some adhesions.

Under the control of the ultrasound paracentesis was performed. Omitting the bowel and adhesions save puncture was done.

Picture 1. Free fluid in the peritoneal cavity. Dilated small bowel loops with adhesion to the anterior abdominal wall (white arrow).

Picture 2. Free fluid in the peritoneal cavity. The only safe place for inserting the needle, over 6 cm away from the right lobe of the liver.

CONCLUSIONS

The actual guidelines for management of patient with ascites says that the optimal place to insert the needle is the left lower quadrant, 2 finger breadths (3 cm) cephalad and 2 finger breadths medial to the anterior superior iliac spine.

However, in this case typical places for inserting the needle were impossible to perform a safety puncture. Patient had small bowel loops and adhesions near to the anterior abdominal wall.

But with assist of ultrasound we were able to find an appropriate place for the procedure without causing any complications.

That is why ultrasound examination should be performed before every invasive procedure, because patients’ safety is our highest priority.