Ascites

KEYPOINTS

  • Ascites is reported in 15-50% of patients with malignancy
  • 10% of all cases of ascites are from malignancy. Non-malignant ascites may also be seen in cancer patients (from other causes), and non-cancer palliative patients may have ascites (cirrhosis, CHF, tuberculosis etc.)
  • Ascites is common in ovarian, breast and GI malignancies (30% of ovarian cancer patients develop ascites)
  • The prognosis is poor so the goal is usually comfort with minimal disturbance (exception is ovarian cancer which may still have a moderate prognosis)
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  • Paracentesis is safe in children
  • Children may fear invasive procedures such as paracentesis. It is important to explain what will happen and gain the child’s consent, depending on his or her ability to understand
  • Consider if patient is well enough to benefit

ASSESSMENT

(see Foreword)

  • Clinical features include abdominal swelling, bloating, weight gain, reflux, and dyspnea
  • Exam may reveal increased abdominal girth, bulging flanks, shifting dullness
  • Investigations to consider are ultrasound, diagnostic paracentesis (cytology, albumin, bacterial culture), serum electrolytes and albumin
  • Malignant ascites may be caused by liver disease/metastases leading to portal hypertension, intra-abdominal metastases/peritoneal seeding, lymphatic obstruction and leakage (chylous ascites), or a combination of these

MANAGEMENT

  • Consider treatment of the primary tumour (particularly with ovarian cancer), but usually the cancer is advanced and the prognosis is poor
  • Diuretics can be helpful in some patients with ascites. Serum electrolytes (Na, K) may need to be followed. Diuretics are unlikely to be helpful in chylous ascites (accumulation of lymph in the peritoneal cavity characterized by increased triglyceride concentrations)
  • Octreotide may also be useful in controlling ascites
  • Paracentesis is best for immediate symptom relief if the ascites does not respond to diuretics and for chylous ascites

Pharmacological Management

  • Spironolactone, starting with 50 mg/day and increasing up to 400 mg/day if required
  • Furosemide, starting at 40 mg/day and increasing up to 160 mg/day if required

Paracentesis

  • This is a simple procedure that can be done at the bedside or with ultrasound guidance (recommended if there is diagnostic uncertainty, possible loculations or uncertainty about catheter placement due to tumor masses)
  • Remove the drain after 6 hours, after 5 litres have drained or when the drainage has stopped
  • A small number of patients (<5%) may deteriorate rapidly after paracentesis. Sepsis and catheter blockage are other complications
  • Intravenous fluids and albumin infusions are not routinely required (unless hypotensive, dehydrated or severe renal impairment)
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  • During paracentesis; check vital signs
  • Remove the quantity of fluid that gives optimum symptomatic relief
  • Not more than 10% of body fluid by volume/24h

PITFALLS/CONCERNS

  • In patients in the final terminal phase – ie. hours to days - it would be normally inappropriate to drain the ascites (treatment should be as least invasive as possible)
  • In patients in the final terminal phase – i.e. hours to days - symptomatic relief through pharmacological and other means would be preferred

PALLIATIVE TIPS

  • Drain for symptomatic relief, not just because the fluid is there
  • If the drain site keeps leaking afterwards, an ostomy bag over the site is helpful in containing the fluid
  • Some patients who rapidly re-accumulate fluid despite high dose diuretics may benefit from an indwelling catheter. If the prognosis is many weeks, consider a tunneled catheter to reduce infection risk
  • Patients with ascites from cirrhosis may benefit from sodium restriction. The benefit of this must be weighed against unnecessary discomfort from dietary restriction

METHOD OF PARACENTESIS

  • If there is substantial ascites (tense abdomen), it is probably safe to proceed without ultrasound
  • With patient semi-recumbent and with an empty bladder, choose a puncture site below the umbilicus in the midline or the lower left quadrant at the anterior axillary line below the level of percussible dullness
  • Using sterile technique, prep the skin with antiseptic and infiltrate local anaesthetic
  • Retract the skin inferiorly; insert a 14-16 g needle or catheter that is attached to a drainage tube (IV extension tube)
  • Gravity drain to dryness or a total of 5-6 litres into a container
  • Withdraw the needle allowing the skin to return to the original position (creates a Z-track and lowers the post procedure leakage)

SOURCES/REFERENCES

  1. Aslam N, Marino CR. Malignant Ascites. Arch Int Med 2001;161(22):2733-2737. http://www.ncbi.nlm.nih.gov/pubmed/11732940
  2. Kramer RE, Sokol RJ, Yerushalmi B, Liu E, MacKenzie T, Hoffenberg EJ et al. Large-volume paracentesis in the management of ascites in children. J Pediatr Gastroenterol Nutr 2001;33(3):245-249. http://www.ncbi.nlm.nih.gov/pubmed/11593116
  3. Lee A, Lau TN, Leong KY. Indwelling catheters for the management of malignant ascites. Support Care Cancer 2000;8(6):493-499. http://www.ncbi.nlm.nih.gov/pubmed/11094995
  4. Stephenson J, Gilbert J. The development of clinical guidelines on paracentesis for ascites related to malignancy. Palliat Med 2002;16(3):213-218. http://www.ncbi.nlm.nih.gov/pubmed/12046997
  5. Waller A, Caroline N. Handbook of palliative care in cancer. 2nd ed. Butterworth-Heinemann; 2000.

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