Paracentesis Question

[TAbrown]

I am a Medicine Resident and have an 83 y.o patient with a long-standing hx of uncontrolled DM2 and now with NASH, leading to ESLD (last 2 were newly dx within the last 3 months during an unrelated hospitalization).

She was transferred to me from an outside hospital because of c. diff refractory to flagyl and I now have her on vanc with improvement in diarrhea.

She has symptomatic ascites (she's on xalatan and aldactone) - desats when in the supine position, has difficulty tolerating PO 2/2 ascites, and is otherwise uncomfortable.

I consulted GI who did not provide much useful information. I asked him about the utility of doing a therapeutic paracentesis, but he quickly shot that down, saying that too many "good serum components" would be removed.

If any GI fellows or attendings are reading this, please give me your input on whether this is the right decision.

Thanks
-TB

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[Gastrapathy]

It depends on how symptomatic she is. Based on your presentation, she probably needs a tap. Now, you got that answer because you consulted GI to do a core IM procedure and the fellow or staff was annoyed. If you think she needs a para, do one. If you don't know how, call that fellow back and say, "she's too symptomatic and she needs a para. I'm not signed off so would you mind giving me a hand once I'm set up." Tense ascites doesn't require US. Find a Caldwell needle, watch the video on the nejm site, wait for the fellow.

Or, be lazy and have IR do the tap. (Institution dependent)

Also, hopefully you meant lasix and aldactone vice xalatan and aldactone. You can really push the doses of the diuretics and she probably just needs more.

What help would you like your consultant to provide? What was your question for your consultant? Usually a "not very helpful" consult is the result of a not very clear question. A consult for "liver no work good" is going to get you a lot less than "I have an 83 yo NASH cirrhotic with refractory ascites. She needs a therapeutic tap that I would like help with and I would like recommendations about how hard to push her diuretics."

 

[TAbrown]

Thanks Gastrapathy,

I appreciate your input.

I did mean lasix not xalatan.

It's always difficult to go against an attending, but I do think a paracentesis would be beneficial in this situation.

Further discussion with my Medicine attending will be done tomorrow regarding this.