Ahmed Mustajab, Islam Masuma, Gogokhia Lasha, Borz-Baba Carolina, Wakefield Dorothy, Jakab Sofia S
Internal Medicine, Saint Mary's Hospital, Waterbury, USA.
Gastroenterology and Hepatology, NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, USA.
Cureus. 2023 Dec 31;15(12):e51397. doi: 10.7759/cureus.51397. eCollection 2023 Dec.
Paracentesis is currently performed by interventional radiologists (IR) rather than gastroenterologists/hepatologists or internists. In this model of care, there is usually no evaluation of patients' renal function or adjustment of their medications at the time of paracentesis. The objectives of this study were to analyze hospital utilization and cirrhosis complications within six months of index outpatient paracentesis by IR and to identify potential areas of improvement in care.
This is a retrospective study of patients with cirrhosis and ascites who underwent outpatient paracentesis by IR between October 15, 2015, and October 15, 2018, at a tertiary academic medical center. We collected demographics, data on cirrhosis etiology/complications, laboratory tests, provider notes, outpatient paracentesis dates, emergency department (ED) visits, hospitalizations, and ICU admissions within the following six months post index paracentesis. Associations between categorical predictors and clinical outcomes were analyzed using the chi-square test. Associations between quantitative predictors and clinical outcomes were analyzed using the Wilcoxon rank sum test.
Our study included 69 unique patients who had at least one outpatient encounter for paracentesis by IR in the study period. Most patients were men (71%), had alcohol-related cirrhosis as primary etiology (53.6%), an average age of 60 years, and an average Model for End-Stage Liver Disease-sodium (MELDNa) score at baseline of 16. Within six months from index paracentesis, 44 patients (64.7%) underwent repeat IR outpatient paracentesis (total 187 paracenteses, 4.25 paracenteses/patient), 43 patients (62.3%) had ER visits (total 118 ER visits, 2.8/patient), 41 patients (59.4%) had hospital admissions (total 88 admissions, 2.2/patient), and 11 patients required ICU admission. Complications of cirrhosis noted during follow-up included hepatic encephalopathy (40.5%), acute kidney injury (38.2%), upper gastrointestinal (UGI) bleeding (16%), and spontaneous bacterial peritonitis (SBP) in 15%. The mortality rate at six months was 20%. On multivariate analysis, the predictive factors for mortality were older age (p = 0.03) and MELDNa score (p = 0.02). Baseline MELDNa was predictive of acute kidney injury (p = 0.02), UGI bleed (p < 0.01), and ICU admission (p < 0.01), but not of SBP, encephalopathy, ED visit, or hospital admissions. Among patients with more than one paracentesis (64%),six patients underwent transjugular portosystemic shunt (TIPS), but there was no documentation of TIPS consideration in 31 patients (70.4%). A total of 20 patients (29%) were waitlisted for liver transplantation.
In this contemporary cohort of patients with cirrhosis undergoing outpatient IR paracentesis, we found a high rate of short-term cirrhosis complications and hospital utilization, while TIPS consideration was very low. Further data are needed to identify specific gaps in care, but IR paracentesis should be integrated within a multidisciplinary management model, with emphasis on early TIPS in eligible patients, as recommended by the current practice guidelines.
目前腹腔穿刺术由介入放射科医生（IR）而非胃肠病学家/肝病学家或内科医生进行。在这种护理模式下，腹腔穿刺术时通常不评估患者的肾功能或调整其用药。本研究的目的是分析IR门诊首次腹腔穿刺术后六个月内的医院利用情况和肝硬化并发症，并确定护理中潜在的改进领域。
这是一项对2015年10月15日至2018年10月15日在一家三级学术医疗中心接受IR门诊腹腔穿刺术的肝硬化腹水患者的回顾性研究。我们收集了人口统计学资料、肝硬化病因/并发症数据、实验室检查、医疗记录、门诊腹腔穿刺日期、急诊科就诊、住院情况以及首次腹腔穿刺术后六个月内的重症监护病房（ICU）入住情况。使用卡方检验分析分类预测因素与临床结局之间的关联。使用Wilcoxon秩和检验分析定量预测因素与临床结局之间的关联。
我们的研究纳入了69例在研究期间至少有一次接受IR门诊腹腔穿刺术的患者。大多数患者为男性（71%），以酒精性肝硬化作为主要病因（53.6%），平均年龄60岁，基线时终末期肝病钠模型（MELDNa）评分平均为16分。在首次腹腔穿刺术后六个月内，44例患者（64.7%）接受了重复IR门诊腹腔穿刺术（共187次腹腔穿刺，平均每位患者4.25次），43例患者（62.3%）到急诊科就诊（共118次就诊，平均每位患者2.8次），41例患者（59.4%）住院（共88次住院，平均每位患者2.2次），11例患者需要入住ICU。随访期间发现的肝硬化并发症包括肝性脑病（40.5%）、急性肾损伤（38.2%）、上消化道（UGI）出血（16%）以及自发性细菌性腹膜炎（SBP）（15%）。六个月时的死亡率为20%。多因素分析显示，死亡的预测因素为年龄较大（p = 0.03）和MELDNa评分（p = 0.02）。基线MELDNa可预测急性肾损伤（p = 0.02）、UGI出血（p < 0.01）和ICU入住（p < 0.01），但不能预测SBP、肝性脑病、急诊科就诊或住院情况。在接受不止一次腹腔穿刺术的患者中（64%），6例患者接受了经颈静脉肝内门体分流术（TIPS），但31例患者（70.4%）没有TIPS评估的记录。共有20例患者（29%）被列入肝移植等待名单。
在这个接受门诊IR腹腔穿刺术的当代肝硬化患者队列中，我们发现短期肝硬化并发症和医院利用发生率很高，而TIPS评估率很低。需要进一步的数据来确定护理中的具体差距，但IR腹腔穿刺术应纳入多学科管理模式，按照当前实践指南的建议，重点对符合条件的患者尽早进行TIPS。
