Ascites Tap Procedure - Site, Indications, Complications, Result

An ascitic tap or paracentesis is a medical procedure with both therapeutic and diagnostic value. In this procedure, a needle or a catheter is inserted into the abdominal cavity to drain the excess amount of fluid accumulated in the peritoneal cavity (abdominal cavity).

The needle is inserted in the anterior surface of the abdomen. A small amount of fluid is drained to diagnose certain conditions, such as liver cancer. In contrast, a large amount of fluid is drained to treat conditions like ascites.

An ascites tap is conveniently performed at the doctor's clinic or an outpatient department. It does not require any hospitalisation.

​​​​​​​Anatomy and Physiology of Peritoneal Cavity

1. An ascitic tap is done to remove excessive fluid from the abdominal/ peritoneal cavity. The peritoneal cavity is the space between the anterior wall of the abdomen and the spine that is located posteriorly.
2. The space surrounds all the internal organs, such as the liver, kidney, stomach, intestines, etc., of the body.
3. Usually, the peritoneal cavity has little or no fluid. But in certain conditions such as ascites, there is an abnormal collection of excess fluid in the peritoneal cavity.
4. The extra fluid compresses and damages other internal organs when there is a fluid buildup in the peritoneal cavity. Hence, performing a tap at the ascites tapping site becomes essential.
5. Ascitic tap is done by making the patient lie on the side or back. The anterior wall of the abdomen is the ascites tapping site. In the anterior abdominal wall, the ascites tapping site is present lateral to the lateral rectus muscle in the lower half of the abdomen.
6. To be precise, it is 2 to 4 cm medial and above the anterior superior iliac spine, which is the bony prominence one can feel in the lower belly on both sides of the abdomen. This tapping site avoids injury to the inferior epigastric blood vessels.
7. Some doctors may also perform paracentesis in the midline of the abdomen, which consists of a fibrous band of tissue that runs straight from the xiphoid process of the chest bone to the pubic (hip) bone. 

Ascitic tap can be used as a diagnostic or a therapeutic procedure.

Therapeutic indications of an ascitic tap

1. Ascites is a characteristic feature of a condition called portal hypertension. It is a severe condition that can turn fatal if not treated in time.
2. As the name suggests, Ascites tap is mainly done to relieve the harmful effects of ascites such as abdominal pain and trouble breathing due to increased pressure in the abdomen that pushes the diaphragm upwards, i.e., abdominal compartment syndrome. 
3. Ascitic tap is also performed in refractory ascites, wherein ascites keep developing repeatedly.

Diagnostic indications of an Ascitic tap 

Apart from ascites, ascites tap or paracentesis can be used to diagnose:

1. New onset ascites (ascites that have developed without any pre-existing condition)
2. Rule out bacterial infections of the peritoneum (peritonitis) in those with pre-existing ascites 
3. Find the cause behind unexplained ascites

Before performing an ascitic tap, it is crucial to choose the right candidate. The doctor will ensure the following things before performing an ascitic tap procedure:

1. Patients with a healthy and functioning liver are chosen for ascites tap.
2. The patient is not suffering from any coagulation disorders such as thrombocytopenia.
3. The platelet count of the patient is normal.

Ascites tap is performed in the following steps:

1. The patient is prepared by cleaning the ascitic fluid tapping location with the help of antiseptic solutions.
2. The doctor percusses the fluid in the abdomen or taps the areas on the abdomen with the help of his fingers and figures out the location of the fluid. 
3. Then the area of the ascitic fluid tapping location is numbed with the help of anaesthesia.
4. One may feel a stinging feeling after anaesthesia.
5. The patient is advised to lie down in the right or left lateral position so that the fluid is collected on one side of the abdomen.
6. The diagnostic ascitic tap is performed with a 10-20mL syringe and an 18-gauge needle.
7. The therapeutic tap is performed with a needle or an intravenous catheter.
8. It is inserted about 15 cm away from the navel on the right or left side of the abdomen or 2 cm to 5 cm medial and above from the anterior superior iliac spine.
9. It can also be inserted with the help of ultrasound to locate the presence of ascitic fluid better.
10. The doctor may or may not use imaging techniques while performing the ascitic tap procedure.
11. The needle is inserted at an angle of 45 degrees or using a Z-track technique. This technique minimises the risk of any fluid leakage from the ascites fluid tapping site.
12. One may feel pressure when the needle is inserted.
13. Sometimes the doctor may make a small cut in the skin if a large amount of fluid is to be drained.
14. The required amount of fluid is collected. It is small in quantity in case of diagnosing diseases, whereas large, up to 1-2 litres, while removing abdominal fluid buildup, such as while treating ascites.
15. The needle is removed, and pressure is applied at the ascitic fluid tapping site to prevent bleeding.
16. The dressing is done at the ascites fluid tapping location to prevent any risk of infections.
17. Stitches are used to close the wound if a cut is made.

Ascites tap is a simple procedure that can be performed in a clinic or at the OPD. The patient needs to be correctly diagnosed and prepared before the ascites tap. 

Before Ascites Tap Procedure

The doctor proceeds as follows:

1. Takes a proper medical history of the patient before making a diagnosis and performing the procedure. 
2. Advises specific tests and imaging procedures to confirm the diagnosis. In case of previously diagnosed and evaluated conditions, the doctor schedules the patient for the procedure after ruling out possible risks and complications. 
3. Explains the risks and benefits of the procedure and takes due consent beforehand. 
4. The doctor may run some tests before the ascites tap procedure to properly assess the nature of fluid accumulated in the peritoneal cavity. These include 
5. A CT or ultrasound is done to evaluate the amount of fluid before the procedure.
6. Tests to determine the patient's coagulation profile are done to rule out any bleeding disorders.
7. The informed consent of the patient is taken before the procedure.

One must inform the doctor about:

1. Any medications they are currently on, including herbal medicines
2. Any history of allergies to anaesthetic medications
3. Bleeding disorders
4. Pregnancy status 

On the day of Ascites Tap

The course of events on the day of the ascites tap are as follows:

1. The patient may be advised to change into a gown and go to the treatment room.
2. The patient will be asked to empty the bowel and bladder before performing the procedure.
3. The skin at the ascitic fluid tapping location is shaved, if necessary, and cleansed with the help of antiseptic solutions before the procedure.
4. Bedside ultrasound is kept ready that guides the needle insertion and prevents rupture or damage to the internal organs.
5. The paracentesis kit is kept ready for use. It includes all the equipment that is required to perform the ascites tap. Some doctors may perform the tap without the kit as well.

1. Ascites tap does not require any hospitalisation, so the patient usually goes home on the same day if there are no complications.
2. The patient's blood pressure is monitored for two to four hours after the procedure, after which the patient is allowed to go home. 
3. Ascites tap is a safe procedure without any significant risks or side effects. The patient is advised to take care of the wound and change the dressing till the ascitic fluid tapping site has healed.

After the ascites tap, the fluid may be sent for the following tests, depending upon the condition and requirement: 

1. Staining of bacteria
2. White blood cell count
3. Albumin levels
4. pH
5. Level of enzymes such as lactate dehydrogenase, amylase, etc.
6. Glucose levels

These are essential in diagnosing various conditions such as:

1. Infections
2. Liver cirrhosis
3. Metastasised cancer 
4. Diseases of the heart, kidney, or pancreas
5. Bowel damage

Improvements are seen almost instantly when performed for therapeutic reasons, such as in ascites to drain large amounts of fluid. 

It is common to feel dizzy or lightheaded after an ascites tap when large amounts of abdominal fluid are removed. Hence, continuous monitoring by the nurses is done for a few hours after the procedure to avoid any risk of low blood pressure.

One must contact a doctor if the dizziness persists after going home or gets serious.

Ascites tap is an essential procedure which has played an immense role in diagnosing and treating some serious conditions. It has several benefits, such as: 

1. Safe
2. Easy to perform
3. Does not take much time to perform 
4. Provides quick relief 
5. Low risks and complications
6. Highly accurate in diagnosing conditions like bacterial peritonitis
7. Very effective in treating conditions such as ascites

Just like any other medical procedure, ascitic tap procedure also has its own risks and complications:

1. While inserting the needle, an injury to the abdominal organs can occur, leading to conditions like bowel perforation. 
2. Ascitic leak, where the ascitic fluid leaks from the tapping site.
3. Blood vessels can also get injured and result in internal bleeding.
4. Risk of infections
5. Low blood pressure due to excessive removal of ascitic fluid
6. Hepatorenal syndrome (syndrome involving abnormal functioning of both liver and kidney)
7. An excessive drop in blood pressure can even lead to shock, which is a dangerous condition 

The cost of ascites tap in India depends upon a lot of factors, such as the doctor's fees based on his experience and expertise, the hospital charges, the hospital locality, whether the tap is diagnostic or therapeutic, and many other factors. The cost of ascites tap is on the higher end, which is its only downfall. It ranges anywhere from INR 25,000 and can go up to INR 1 to 2 lakhs.

Although it's an expensive procedure, it is lifesaving and a must to protect patients from the harmful effects of ascites. It is a safe procedure that involves few risks and side effects when performed by well-trained and experienced doctors. 

If you are looking for a doctor to perform an ascitic tap, look no further! Our team of experts at HexaHealth can help you get a successful ascites tap at an affordable cost. If this is going to be your first meeting with us, you can even avail a free consultation call with us! Contact us right