Safety of Ascitic Paracentesis in Patients with Budd-Chiari Syndrome on Oral Anticoagulation and Elevated International Normalized Ratio

Background/Aims: Anticoagulation is the standard of care in patients with Budd-Chiari Syndrome (BCS). Ascites is a common symptom in patients with BCS. Often such patients require paracentesis while taking oral anticoagulation concurrently. It is unclear whether paracentesis leads to increased bleeding in such patients or whether anticoagulation has to be temporarily suspended. We describe our experience with paracentesis in patients with BCS taking oral anticoagulation. Methods: Our study subjects included consecutive patients with BCS with ascites on oral anticoagulation admitted between 2007 and 2011. The dose of oral anticoagulation was titrated to achieve international normalized ratio (INR) between 2 and 3. Routine hematological tests included Factor VIII (FVIII) levels. Paracentesis was undertaken without the prior administration of fresh frozen plasma and without the aid of ultrasonography. We looked for occurrences of bleeding at the puncture site or hemoperitoneum during and after the procedure. Results: Thirty-two of the 60 patients with BCS patients taking oral anticoagulation concurrently developed ascites. Thirty among 32 patients required paracentesis on one or more occasions. A total of 51 paracentesis procedures were performed (Median 1.6, Range 1-7). The mean INR was 3.1 (Range 1.4-7.9). No patient developed bleeding or hemoperitoneum. The mean FVIII measured was 138.8% of laboratory control and mean platelet level was 2.2x10(5)/ ml. Conclusions: Ascitic paracentesis in patients with BCS on anticoagulation is safe without an increased risk of abdominal wall bleeding or hemoperitoneum. Normal or high FVIII and platelet levels likely mitigate against bleeding risks.