Transcript: Deep Dive Into Ascites

With Dr. Rajeev Suri and Dr. Christopher Beck

Dr. Rajeev Suri tells us about his clinical approach to the high-volume ascites patient, including paracentesis technique and tips, albumin regimen, and discussing the need for TIPS in some patients. You can read the full transcript here or listen to this episode on BackTable.com.

Transcript: Deep Dive Into Ascites

Table of Contents

(1) Referring Patients for Paracentesis

(2) Pre-Procedural Checklist for Paracentesis

(3) Paracentesis Procedure Technique

(4) Post-Paracentesis Treatment

(5) Managing Patients Needing Recurrent Paracentesis

(6) Future Developments in Portal Hypertension Management

Introduction

[Chris Beck]
Welcome to the BackTable Podcast. If you are a new listener, welcome. For all of our regular listeners, welcome back, and thank you for listening. BackTable is a podcast committed to all things IR and endovascular. I'm Chris Beck, and I'll be your host today. I'm a private practice, interventional radiologist based out of New Orleans. Our discussion today will be about paras or paracentesis. Before we get to that, I wanted to plug our new website. For those interested, check out the new website www.backtable.com, very easy to remember. We have recently renovated and are really proud of all the content and new features that we've added. Check it out. It's a work in progress, so if you have any feedback, please let us know.

[Chris Beck]
Also at this time I'd like to thank our sponsor, GI Supply. The RenovaRP Paracentesis Management System by GS Supply offers a new option for your patients with recurrent ascites. This unique approach puts the focus on patient staff satisfaction, providing a closed system alternative to vacuum bottles and wall suction that is fast and gentle. Learn more about Renova by visiting www.rethinkparas.com. For those interested, I will post a link to this in the show notes.

[Chris Beck]
Our guest today is Dr. Rajeev Suri. Our topic will be the procedure paracentesis, as I mentioned. Paras are one of those procedures to me that fall into this interesting category, at least from my practice. For me, I suspect that many interventional radiologists do this procedure all the time, but because the procedure's so technically straightforward, we don't dedicate a lot of bandwidth to this procedure. And so that's why I thought we might benefit from a little bit more of an in-depth discussion of a very common procedure that maybe kind of flies under the radar. With that out of the way, Dr. Suri, welcome to the podcast.

[Rajeev Suri]
Thank you.

[Chris Beck]
So Rajeev, will you go ahead and just introduce yourself to the BackTable audience and tell us a little bit about yourself, your practice, and where you're located?

[Rajeev Suri]
Okay. So first, thank you, Chris, and thank you, Aaron, for inviting me to do this podcast. I'm an interventional radiologist practicing in San Antonio since 2004 after completing my residency and fellowship training in Los Angeles. I'm currently a professor and vice chair of the department of radiology at UT Health San Antonio. San Antonio, or rather South Texas is a major belt for liver disease. Decompensated cirrhosis and portal hypertension are a good part of our practice. We cover the full gamut of interventional treatment for paracentesis, for ascites from paracentesis, TIPS, any tunnel catheters, peritoneovenous shunts. And that's what we are trying to do today--to discuss how we can manage ascites, what we have done in our practice to convert that into a clinic model so that we can evaluate these patients and give them the best option going forward, and sharing our experience with y'all.

(1) Referring Patients for Paracentesis

[Chris Beck]
So let's start with the candidate, so the portal hypertension patient. And I think for the topic of this, we should just go ahead and exclude malignant ascites. So we'll be talking primarily about portal hypertension, but we might get into that a little bit. But just for the beginning, we'll just start with portal hypertension. How do these patients present to you guys and get funneled into either the IR clinic or the IR workflow?

[Rajeev Suri]
So that could be a mix. So these are patients either newly diagnosed with ascites, which could be, as I said, benign or malignant, which we don't know, or they are patients who have known ascites and are presenting with abdominal pain, fever, kind of the suspicion for bacterial peritonitis, and then obviously recurrent patients having ascites causing some sort of a breathing problem, either shortness of breath because of elevation of the diaphragm. So our role gets involved in these, both for the diagnostic and therapeutic portions of things, especially for SBP diagnostic, and then for new patients, both diagnostic and therapeutic. So that's how we get involved in this picture.

[Rajeev Suri]
The referrals come from a full gamut of people, from ED, from hepatology, from the hospitalists, from the surgeons, and then obviously primary care physicians. And they initially come to our procedural service for paracentesis, but then from there, as we evaluate these patients for future treatments, be it TIPS or something else, they would then get transferred to our clinic from that point on if they fit the criteria for a TIPS. Or if they needed recurrent paracentesis, they will continue with the paracentesis model from there.

[Chris Beck]
Sure, sure. So it seems like you guys get a lot of referrals, and I think that this mirrors a lot of interventional radiologist practice. It's inpatient. It's outpatients. It's surgeons. It's hospitalists. It seems like paracentesis, it's a procedure that has a way to flow to interventional radiology. In your hospital system, are there any other physicians or physician extenders which do the same procedure, or is IR the person who bears the main bulk of handling paras?

[Rajeev Suri]
I will say IR does the bulk of the procedures. ED does some, and these patients present to the ED. But these patients who come with large volume ascites are coming in and holding up an ED bed or staying in the ED for a long time. So we set up parameters. These patients, if they come to the ED, they will get an appointment the next day in our ascites clinic, and they can come straight there so that they are not clogging up the ED services. The same time, for other services that do that, there is a procedural team in medicine that does some, obviously maybe less than 5% of paracentesis in the hospital. Now with an IR, we have a nurse practitioner who helps with our inpatient consult service, who also helps with paracentesis and thoracentesis. So apart from IR, I would say less than 5% done by anybody else.

[Chris Beck]
Okay. That's fair. And you kind of already touched on something that I'd like to dig into, but can you talk a little bit about some of those ER parameters that you guys have that, at least just from your brief description of it, sounds like it helps with both ER and IR workflow?

[Rajeev Suri]
Yeah. So two things. One, if the patient has a large volume of ascites and is symptomatic due to respiratory distress and cannot wait until the next day, the ED will deal with those patients. Or any of those patients with ascites, but not presenting with symptoms of bacterial peritonitis, which can be either spontaneous or secondary, those are the ones ED would get involved with. But any patient that can be discharged and can wait till the next day, they automatically have a set-up. We have an outpatient clinic where we have slots available for paracentesis every day. And so these patients will automatically be just scheduled to show up the next day to our paracentesis clinic to do the procedure, because as you all know, we hardly ever require these patients to have any prior blood test. So these patients can just show up directly to our clinic, and we get the procedure done.

(2) Pre-Procedural Checklist for Paracentesis

[Chris Beck]
So that also segues nicely into the next topic, which would be basically your pre-procedural evaluation or your pre-procedural checklist of things that you need or require from your patients prior to doing a paracentesis. So can we talk a little bit about either lab values, or lab tests that you have to have ordered, or any kind of imaging that you need ordered before you do or see a patient in the paracentesis clinic?

[Rajeev Suri]
Imaging wise, no imaging is needed. Obviously, there's some documentation from the ED or the provider who saw the patient that they at least on examinations felt a fluid there or something that was concerning for ascites. As far as blood tests are concerned, we are not requiring any labs, be it platelets or INR, to be checked in these patients. I know the SIR 2019 guidelines that came out differentiated the two, regular versus chronic liver disease patients. And at least for our population, though most of those patients have chronic liver disease, there are still some patients with suspect malignant ascites. So none of these patients currently get any labs. The only time somebody might get an INR would be a patient who's on full dose anticoagulation. They may get an INR just for evaluation purposes, but we generally don't change they're management based on what the INR and platelets are.

[Chris Beck]
Okay. And that was kind of my next question, is that I think there's always situations or there's a patient specific circumstances that do warrant a break from your typical protocol. But I think something that does come up very often are patients who are being anticoagulated. It sounds like sometimes you may draw an INR, sometimes not. Are there any medications that you guys asked to be held as far as anticoagulants prior to doing the procedure?

[Rajeev Suri]
So again, in our practice, non-patients can continue everything. So if they are inpatients, if they're on heparin or Lovenox, no stoppage. If they're on any direct thrombin inhibitors, again, we do not stop them. If they're on a Factor X inhibitor like Xeralto, Eliquis, or any platelet inhibitors like Brilinta or Plavix, no, we do not stop any of those medications. We would proceed with the procedure, because the risk is so low for bleeds in these patients. And at least the way we do our procedures with some guidance, the risk is really minimal. Now, there is some role in literature for patients who have glycoprotein IIb/III3a inhibitors, but that patient volume is so low. And note, some SIR guidelines have talked about waiting four to six hours in those patients. bbt again, we hardly get to see patients with that, so that's never been a major issue for us.

[Chris Beck]
And I don't want to put you too much on the spot here, but occasionally you do run into a patient who's already had labs drawn, and they have a lot of patients with liver failure fall into this portal hypertension category, and they have INRs at three, four, six, seven. Does that then change your management for a patient you might not have drawn labs on, but you already have some pre-existing labs where you have major thrombocytopenia, elevated INR? Or does it give you any pause, or is it just you know it's slightly elevated risk of bleeding and it's business as usual?

[Rajeev Suri]
If we had labs drawn on these patients and the INR was any number, even if it's 10, we would still proceed.

[Chris Beck]
Got you.

[Rajeev Suri]
INR does not affect our pattern. Now, if somebody had platelets drawn and the platelets are below 20,000, we would pause. So it depends, again, at that time, if they are severe ascites and they are in our clinic at that time, we would probably still proceed. If they're an inpatient in that category, I would probably say we consider doing platelet transfuse, but I think we have pushed the limit even beyond what the SIR guidelines are. We really do not check INR and platelets or even modify that in cirrhotic patients. Now, patients who are regular patients who are not cirrhotics, it could be slightly different.

(3) Paracentesis Procedure Technique

[Chris Beck]
Okay. Well, not to dwell on the outlier situation too much. Can we talk a little bit about how you do your paracentesis? And I know it's not an extremely complicated procedure, but we do actually have a fair number of medical students and trainees who listen the podcast. So if you could just go through briefly how you do your para, and then maybe also we can get in a little bit more to the technical components, like, if you've tried different trays or different needles that you find work better or worse.

[Rajeev Suri]
Yeah. So for us, obviously as anything else, we will consent these patients prior to the procedure. All these patients, because in wall fluid removal and at least in our practice, get a preset of vitals before they come in, we will move them onto the procedure suite. Sometimes we will do them in a side room in our holding room area. We will check with the help of ultrasound which site has the biggest pocket. I know there's some literature out there, left is better than right. For us, we probably go over the side with the biggest pocket because we can see. Where we are, we definitely never do midline. Most of our access points will generally be in the left lateral, or almost in the midaxillary line, or anterior axillary line, kind of in that area trying to be lateral to where the rectus muscle would be.

[Rajeev Suri]
We would prep that area mostly with ChloraPrep, use lidocaine without epinephrine, maybe five to 10 CCs, really numb the track all the way down, up to the level of the peritoneum. We use the five French One-Step needle at that point. This is either made by Merit or Cook. Merit has got a thing called a centesis catheter. Cook has got a Yueh Catheter. We generally use the Merit more often than the Cook system. We like to go with at least a 45 degree angle. We also, once we are trying to advance a paracentesis One-Step needle in, we will advance at a 45 degree angle. And then I would probably pull the skin down, laterally, or medially to try to create a Z-pattern so at least I can decrease the risk of leakage. But mostly in our practice, we've seen 45 degree angle--it actually works very well.

[Rajeev Suri]
Get the needle all the way into the ascitic fluid. Advance the catheter, keeping the needle where it is. And at that point of time, in our practice, again, I know you talked with the sponsors earlier. We actually use Renova a lot. 60 to 70% of our practice involves using the Renova system to help drain the fluid out.

[Chris Beck]
So actually there were a couple of things there that I wanted to dig into before we get to what you use for the actual drainage portion. But can you describe for people who may not be familiar with what you meant by the Z pattern, as you're pulling the skin down and advancing the needle? I think some people might gloss over that if they don't know what that is alluding to.

[Rajeev Suri]
Sure. I understand that. So the concept is that, if you went straight into the peritoneal cavity at a 90 degree angle to the skin, perpendicular, as you're pulling the needle out after a paracentesis, the fluid will leak along the track. So the recommended thing is that if you went through the soft tissue or the subcutaneous tissues in a Z pattern, so that means going forward, slightly back, and then going forward against almost like a Z, you are creating trap doors that would prevent fluid from leaking out along the track. So if you access the subcutaneous soft tissues at a 45 degree angle and then you pull the skin down, say quarterly towards the feet, you are creating the backward bend of the Z at that time as you advance the needle into the peritoneal cavity. And then obviously, when you release the skin pressure on the tag, what you'd pull down, the catheter goes into the peritoneal cavity, but it's created a Z along the soft tissue track.

[Chris Beck]
Right. And it's a nice little maneuver to reduce the incidents of ascites leakage after the procedure. Can you also talk about whether or not you use direct sonographic guidance versus, what I think some people would maybe describe as intermittent sonographic guidance? I think there's two camps in that some people will use ultrasound prepped on the field and visualize their numbing needle and also their access needle into the peritoneal cavity. And then some people, and actually I've kind of moved to this practice myself; I usually check, and if the pocket is large enough, I'll usually mark an area with a little pen or the back of a needle just to create a little skin indention. And then I'll go in, I guess you could say going in blind, but I've already marked the area, and then I just access. I aspirate as I'm going in, and then once I pop through, I just thread the catheter off. Do you guys do direct or intermittent ultrasound guidance?

[Rajeev Suri]
I would say 90% of our practice is a direct ultrasound guidance. Less than 10% would be intermittent ultrasound guidance, and that depends when you have a resident or fellow scrubbed then versus a faculty doing the case alone. So at least when I have direct ultrasound guidance, it is resident and fellow-proof, at least make sure they are seeing it all the time; they know where we going in. Anytime there is more than ascites and there's a concern that some bowel loops might float in and out of my field of view, I'll definitely use a continuance ultrasound guidance. But intermittent, if there's large volume ascites, in that case, I would probably, as you said--just mark it with the back of a needle or pen or something and then just aim straight into it. Every time we assess our access track, we will check for the inferior epigastric artery, or sometimes even the circumflex iliac artery in the soft tissue, just to make sure that there's no Doppler signals. So every patient, it's kind of default, will get the Doppler evaluation just to make sure.

[Rajeev Suri]
Now routinely, if you go at the anterior axillary line, the blood vessels should not be there. But sometimes, when patients are very obese, the whole pannus can move to one side of the other, and that can disorient where those vessels are. So we definitely always check for that.

[Chris Beck]
Yeah. And I think that's a good point also to drill down on, is that it's usually not your 70 kilogram man where you have trouble identifying vascular landmarks, but it's a morbidly obese patient where the pannus has kind of shifted everything; they're kind of laying cockeyed in the bed. And I think there is a lot of value in making sure that you identify your vessels, because so often, or at least in my experience, the ultrasound techs want to show you. They're like, "Oh, this is the big, nice pocket that you're looking at." But sometimes you really have to decrease the depth. You're really only interested in the first few centimeters in that soft tissue to see if there's any intervening vessels between you and the peritoneal cavity.

[Rajeev Suri]
Okay, great.

[Chris Beck]
So at this time, I'd like to thank our sponsor GI Supply. GI Supply's Renova Pump is an innovative alternative to traditional methods for paracentesis. The portability allows drains to be performed virtually anywhere while the fully adjustable speed means each patient can have the procedure tailored for their comfort. Learn more about how Renova has benefited providers and patients by downloading the latest case study at www.rethinkparas.com. And like I said earlier, I'll post a link of this too in the show notes. The other thing that I think you had mentioned that we can now kind of get to, going back to the Z stitch and leakage, how often do you guys ever place any glue or stitches after the catheter's out?

[Rajeev Suri]
It's, again, very uncommon. It's only once I do the procedure, because once the catheter's taken out, patients do get a set of vitals, and then they leave. And I'll talk about that separately too if you have a question about that. But again, if we see leakage of fluid, we might do glue at that time. We rarely ever put a stitch. But mostly for us, an OPSITE or even a simple Band-Aid works. But sometimes these patients, especially patients who keep coming back again, again, they can develop that leakage. In that case, we do use glue in those cases.

[Chris Beck]
Sure. I think I agree. That's been my experience. It's the exception rather than the rule, and almost never a stitch. But every now and then I do see somebody and they have a stitch in, and I think, "Well, some people must be doing it." The other thing I was going to ask is, when you're pulling off the fluid, and we can get to what drainage mechanisms you use, but also, is there an MD who stays with the patient the whole time, or are you guys allowed in your practice to put the catheter in, begin drainage, and then either come back for catheter removal or one of the nurses or ultrasound techs allowed to remove the Yueh catheter or whatever catheter you use?

[Rajeev Suri]
So in our practice, the MD is there from the start of the procedure, the numbing until the placement of the centesis catheter and connection to the drainage system. Thereafter, the nurses handle everything. I move on to my next patient. They will complete the drainage, once the drainage is done, they will pull the catheter out at that time.

[Chris Beck]
Similar. And we mentioned earlier what you do after. What do you use to hook up to connect to suction? I know some people use wall suction. Some people use vacuum bottles. Some people use a combination of the two.

[Rajeev Suri]
So in our practice, if there's a small amount of ascites, you can generally look at an ascites and get a feeling that, "Yeah, it's going to be at least two liters, three liters." In those cases where I feel it's a small amount, we generally will use a vacutainer bottle. We used to use wall suction, but the challenge we used to have is that you really have to keep cranking it up and down regularly because it would really start sucking the bowel very close to your catheter, especially in the small to moderate amount of fluid. So for those two to three liter concerns, we probably use the bottles, but again, 80% of practice has moved to using the Renova pump.

[Rajeev Suri]
So for Renova, it's a very simple system. It can easily be managed by a nurse. We connect the catheter from centesis catheter to the pump. And each of the bags that is out there is 1.6 liter capacity. You can adjust how quickly or slowly you want to get the fluid taken out. Each bag, 1.6 liters fills in roughly around three minutes. So patients could have a 15, 18, 20 liter paracentesis in half an hour and go home. Obviously we have a nurse out there, so they will be checking the patient. We don't routinely monitor vitals during the procedure, but if there were any concerns about it, they will check the vitals at that time. But definitely, we can adjust how quickly or slowly you're pulling the fluid out for the Renova system.

[Chris Beck]
For sure. And do you guys have a specific end point in terms of the volume or the amount that you'll remove?

[Rajeev Suri]
Our end point is try-

[Chris Beck]
Dry.

[Rajeev Suri]
... to dry it out completely. We have gone as high as 25 liters. I think I've rarely gone above 25. Mostly it's dry by that time. We obviously do use albumin per protocol, and the nurses are aware of the protocol, so they don't have to keep calling me every time it reaches a particular number. So we take out all the fleet as much as possible.

[Chris Beck]
Okay. And will you tell the albumin protocol without giving away all the trade secrets you teach San Antonio?

[Rajeev Suri]
I don't care. There are no trade secrets.

[Chris Beck]
Right, right, right, right.

[Rajeev Suri]
This is published guidelines. So for us, again, per published guidelines, no albumin is given for the first five liters of fluid taken out. The moment the drain starts going above five liters, our protocol dominantly has been to give the six to eight grams of albumin per liter removed. So we generally use 25% albumin. So to give you an idea, 100ml of a 25% albumin will have 25 grams. So if you took out like four liters, that's roughly 24 grams. So you can give a 100ml for every four liters removed or something like that. So that's our protocol, and the nurses will keep checking that. Now, because we have the Renova system and that does take fluid out very quickly, so nurses will have albumin and ready. So the moment they see the fluid going close to five liters, they will, at that time, go ahead and connect the albumin at the same time, because you could quickly cross over to going to eight liters or nine liters by the time the first fluid is gone in.

[Chris Beck]
Sure. Have you noticed any difference in the rate that you can pull fluid using any of the different catheters or needles?

[Rajeev Suri]
So in our practice, we always just use the five French system. Way back, we had experimented with the eight French catheter system to place it out there. Even if we try to use the Z technique, we just notice more fluid leak cases, especially patients complaining when they would go home, they would have those fluid leakages. So we moved away from the eight French system. And we've not had any challenges as far as flow rates are concerned between the five French, the eight French. Yes, the eight French probably pulls fluid faster, but we only used to compare eight French with the bottles at that time. We never tried eight French with Renova, so I could not especially talk about that. But with the five French, if you could take out 1.6 liters in three minutes most of the time, that's a pretty fast flow for us.

(4) Post-Paracentesis Treatment

[Chris Beck]
Sure, sure. Agreed. And you mentioned it a little bit earlier, but following the paracentesis, so at this point, the patient’s drier, or as dry as they're going to be, the catheter is out. Are there any post-procedural vitals or anything that happens as far as recovery time? Is there anything that happens between the end of the procedure, like sterile bandages getting applied and the patient going home?

[Rajeev Suri]
Just one set of vitals. We just do it while the patient's supine. We do not do any posturals, anything, one set of vitals. If they look okay, the patient goes home, no further recovery needed at that time.

[Chris Beck]
That's great.

[Rajeev Suri]
These patients also are set based on these patients who come to our ascites clinic regularly. Once we have an established pattern, it takes them roughly 10 days to refill their fluid. They will be set up on a recurrent similar 10 day follow up for getting their fluid removed. If they get more symptomatic earlier, they can always call our schedulers and come in earlier, but they are set up on a set schedule. So the moment they leave, they already know when they are coming in next to get the fluid removed.

[Chris Beck]
Got you. Got you. One thing that I meant to ask from a slightly earlier point that you had made, in y'all's practice, is there really any difference? I think sometimes we get referrals for therapeutic and diagnostic paracentesis. From my perspective, what I've just done is I treat all paracentesis consults the same in that I pretty much try and remove all the fluid possible, and I don't really make a big distinction between diagnostic and therapeutic. Is that similar to what you guys do?

[Rajeev Suri]
Yeah, we agree. Even if it's a diagnosed therapeutic, we still take out the maximum fluid we can. Sometimes we might send a 60 CC syringe, but our lab now even accepts the bags that come with the pumps, so we can just send the bag itself for analysis. So you don't have to take a separate syringe and have a concern about splashing, anything of that sort. Just send them the bag, and they can do whatever analysis they want to do from that.

(5) Managing Patients Needing Recurrent Paracentesis

[Chris Beck]
No, that's great. That's great. So now I think it's as good as any to take a left turn away from the actual procedure and talk about the ways that you manage those patients who are coming back every seven to 10 days for recurrent paracentesis. In terms of conversations regarding different procedures that may be a good fit, are you guys involved in medication adjustments, or maybe referral to the hepatologist, or sometimes nephrology services for medication adjustments, in terms of trying to dial in that ascites and that portal hypertension management?

[Rajeev Suri]
So we directly do not get involved with their sodium restriction and diuretic management, but anytime we see these patients, we will, in our follow up note in our plan for the paracentesis, do our recommendation to the hepatologist, make sure they're optimizing the salt restriction. So that's the first thing you got to do, salt restriction to less than 88 millimoles a day, or what, 2,000 grams a day of salt, of sodium restriction. And then the diuretics, obviously, they will start them on spironolactone first and then move on to furosemide later, and they'll maximize that dose. So that is something that generally the hepatologist or the primary physician would take care of that. But obviously if they are continuing to recur off of that, then they fall into our refractory ascites management thing.

[Rajeev Suri]
Now, at that point, once these patients are coming back for recurrent fluid aspiration, we will obviously assess them regularly. Their hepatologists will have sent labs on them on a routine basis. So we do check their MELD score. And we use MELD more often than MELD sodium currently for ascites. And based on published data from our institutional, we use a MELD cutoff of 18. So 18 or less, we will consider proceeding with a TIPS evaluation. That would obviously mean the TIPS evaluation to see, the hepatic vein, the portal venous system, and what everything looks like and proceed the TIPS accordingly after a discussion with the patient in the clinic. If the MELD is more than 18, in our practice, we still continue with the paracentesis regularly on these patients. We only have considered Denver shunts in patients who just cannot keep coming back for fluid aspirations. Denver shunts have not been a big part of our practice, just because the complications that we've seen have been many much, much more in this patient population. So malignant ascites, definitely we've used Denver shunts, but in this patient population, cirrhotics, not much.

[Chris Beck]
Got you. Got you. Going back a little bit to those medication adjustments, in my practice and I think many interventional radiology practices, I think some people feel comfortable making some adjustments to diuretics or recommendations on sodium restriction. But sometimes I even find that, because you're seeing these patients so often, that a specific referral back to their hepatologist or PCP for diuretic management can sometimes prompt that PCP or the hepatologist to kind of adjust that clinic visit for just that thing. And so for me, I don't feel particularly comfortable making those adjustments. And so I've found a referral back to the hepatologist specifically saying, "Hey, can you take a look at the medication adjustment? There might be some room here to move the needle," I think has been very helpful. And it's been well received from our referring docs. I don't know if you guys have had a similar experience.

[Rajeev Suri]
I totally agree with that, because just increasing the dose of a diuretic by ourselves is not the answer, because you also have to assess what the serum sodiums are looking like in these patients. If below 125, how do you manage that? You need to be assessing how much urine sodium is coming out, the difference between the serum sodium and the urine sodium. So there's several factors that, as you adjust these diuretics, who's responsible at that time as the potassium keeps going up? So we definitely do recommend, but our practice has not been involved in any of those diuretic direct maintenance, because it's more different from just changing a dose.

[Chris Beck]
Sure, sure. In regards to conversations you have about TIPS, or DIPS, however you like to think about it, in terms of that, do you guys have a specific contact point where you actually see them in the clinic? Or at least in my practice, I'm seeing these patients so often just while I'm doing the paracentesis procedure; oftentimes I'll test the waters with them. Because some patients don't want it. I've run into that plenty for one reason or another. That just seems like a bridge too far or a procedure too invasive. But oftentimes I'll test the water with small conversations, and then if they sound like it's something they would be amenable to, then actually I will plug them into the IR clinic and we'll go the full gamut. Is that something similar to what you guys are doing?

[Rajeev Suri]
Yes. Actually, that's very true, because when you are with them, or the time you're doing the paracentesis, actually even these patients keep coming back. You develop a wonderful relationship with them. And again, the way our clinics are set up, it might not be the same interventional radiologists interacting with them every time, but you have a relation set up with them. So we've actually had a lot of discussion with these patients about future procedures, TIPS, and everything while we're actually doing the procedure. So that has helped us get them primed for a possible procedure in the future. Obviously, if we decide that TIPS is needed, we will contact the hepatologist. Some of these patients, depending on how they are, our hepatologists work very closely with the transplant service, so they will then get plugged in into a transplant evaluation if they've not already been doing that, get to our clinic for the evaluation and go from there.

(6) Future Developments in Portal Hypertension Management

[Chris Beck]
Sure. So Rajeev, looking forward, do you see anything interesting happening in terms of y'all's practice and things that you guys would like to see as far as your portal hypertension management and maybe also including paracentesis in there, in anything like a y'all's five or 10 year plan, as far as like things that are exciting, which either you're doing with your protocols, which you're maybe doing with your clinics or anything that's coming down the pipe?

[Rajeev Suri]
So some of the changes we already incorporated. Some of the changes that are coming down the pipeline is to have more of these slots available. So we have now a dedicated nurse practitioner for some of these procedures on an outpatient basis. Obviously, we also have our intervention radiologists who do those, but the way we've set it up is that we've set up two days in a week. Currently it's one day a week, but two days in a week. That's the aim, that patients can by default show up there and get the procedure done and go home. Patients love that option. And if they know that they can just come in when they want to, that's really helped.

[Rajeev Suri]
Apart from that, I think just a better way to market this to the hospital system. This is something else we’re working on. And it's easy to tell the hospital, "Yes, you are getting these patients to the ascites clinic, but just imagine the time the patient saved not sitting in the ED, the time the ED physician didn't have to spend on evaluating the patient. All that actually adds revenue to the hospital system." So that's something we are working on and marketing. And try to understand that it might look like you are using up these slots for paracentesis, but in the long run it does help the hospital a lot.

[Chris Beck]
Absolutely. I think now the job is sometimes not only just doing a good job in taking really good care of your patients, but also just showing the hospital systems or whatever healthcare system you belong to, the value added for setting up a streamlined management system where patient care and the business sides of hospitals are aligned. So that's becoming more and more part of the job these days when we're trying to either show your worth or prove how much you're worth. So that's great that you guys are heading that. As a teaching facility, do you have any papers, or management protocols, or anything that's any papers or research projects that you direct some of the residents, fellows, or medical students to, that when you're talking about portal hypertension management, where it's like, "Oh, this is a great paper. Check this out," or, "These are the AASLD guidelines. Go check this website out?"

[Rajeev Suri]
Yeah, definitely. The AASLD 2012 guidelines that came in 2013, I don't think they've got an update on that yet, but those are wonderful. They really cover ascites and ascites management very well. We definitely tell all our trainees to make sure that they are aware of that. That's required reading. SIR, the 2019 coagulation guidelines, not just for ascites, but for everything else, just to know what to stop, what not to stop, when to stop, that helps. There's a great article by Louis Martin from 2012 in Seminars in Interventional for Denver shunts, really goes a lot in details into, not that we do a lot of these, but complications. How do you manage that? How do you clean out a clogged catheter or something? So definitely that is there. So those are some of the articles I recommend reading this.

[Rajeev Suri]
Actually, they are really talking about the fact that in the next decade, they expect ascites to be close to a 2.8 billion market with all these new things coming in the market. I know somebody came and talked to us recently from this company, Sequana Medical, the ALFApump, where you can have the catheter in the peritoneum and the other catheter connected via a pump into the urinary bladder. So those are some things coming down the pipeline. I know some of our oncologists have talked about this medication Removab for malignant ascites. So those are some exciting things coming down the pipeline for this. So look forward to some of those.

[Chris Beck]
Excellent. Excellent. Rajeev, any stone left unturned, anything else that we didn't touch on that you think is worthwhile?

[Rajeev Suri]
I think we covered a lot of the things out there. I guess the only challenge sometimes is that most of the ascites that we see is benign or, what do you call, related to portal hypertension. Malignant ascites is similarly in our practice. We do see less than 10 to 15%, 10% of patients. Our guidelines still remain the same, how much fluid we take out, how do the procedure and everything. So the guidelines still remain almost the same for those too.

[Chris Beck]
Sure.

[Rajeev Suri]
Thanks, Aaron and Chris. What you guys are doing is great. And I think IR really needs something like this. This is wonderful.

[Chris Beck]
Thank you so much for coming on. It was awesome. To our audience, thank you guys for listening. We covered a good topic today. I think it was fun to take a more in-depth look at something that's probably part of our day-to-day practice, but we don't spend too much time thinking about. And I think there's a lot of variations in regional practices. And not to say that one way is better than the other, but I hope that we've given you a broad look at paracentesis, and for those interested, especially trainees, a way to push forward and maybe some things to incorporate into your own practice.

Podcast Participants

Dr. Rajeev Suri

Dr. Rajeev Suri is a practicing Interventional Radiologist and a professor of Radiology at UT Health San Antonio.

Dr. Christopher Beck

Dr. Christopher Beck

Cite This Podcast

BackTable, LLC (Producer). (2020, October 6). Ep. 87 – Deep Dive Into Ascites [Audio podcast]. Retrieved from https://www.backtable.com/podcasts

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