Guidelines for the Management of Malignant Ascites

St Peters Hospice, Bristol

Introduction
Ascites is an accumulation of fluid within the peritoneal cavity of the
abdomen and can occur in association with many conditions such as
cirrhosis of the liver, congestive cardiac failure, protein depletion and
malignancy. 1
Symptoms of ascites can be distressing and include abdominal distension,
abdominal pain, nausea, vomiting, lower body oedema and breathlessness.2
The commonest causes of malignant ascites are primary tumours of breast,
colon, ovary, stomach, pancreas and bronchus.
Two main mechanisms underly the development of malignant ascites:
peritoneal cancer and portal hypertension. With peritoneal cancer the
peritoneum becomes leaky and the ascites is an exudate with a relatively
high albumin concentration and a low serum/albumin ascites gradient
(SAAG). Gradients of <11g/L indicate an exudate and diuretics are less
likely to be helpful in these patients. Portal hypertension is most commonly
associated with massive hepatic metastases or cirrhosis. With portal
hypertension, the ascites is a transudate and there is a high SAAG. Gradients
of >11g/L indicate a transudate and it is often worth trying diuretics in these
patients post drainage to slow the rate of reaccumulation.3
Malignancy-related ascites (other than ovarian carcinoma responsive to
chemotherapy) usually carries a poor prognosis.4 Therefore, the guiding
principle for management of malignant ascites should be aimed at relieving
symptoms, should not add to the patients’ burden and should be minimally
invasive.

Treatment
For most patients, paracentesis is the treatment of choice and relieves
symptoms in up to 90% patients. For some patients diuretics have a place in
controlling rate of reaccumulation of ascites.
If the prognosis is short and the patient is rapidly deteriorating, there is no
indication to treat the ascites. If the prognosis is short but patient has
troublesome symptoms, consider a brief paracentesis of 1-2 litres to reduce
discomfort.
If the patient is known to have ascites before it is significantly symptomatic,
diuretics should be considered. If the patient presents with a tense abdomen,
the drainage should be performed, including taking a sample of ascitic fluid
to measure albumin content. The patient should be considered for a trial of
diuretics after the procedure. The patients most likely to respond to diuretic
therapy are those with liver metastases and resulting portal hypertension.
They will have a serum-ascites albumen gradient of >11g/dL and this can be
used as a guide to the likelihood of response to diuretics.5

Paracentesis
Paracentesis is the technique used to drain a collection of ascitic fluid by
inserting a fenestrated catheter into the peritoneal cavity.6
Procedure
1. The patient should be admitted as an inpatient for the first procedure.
Uncomplicated follow up procedures can be arranged as day case and
 in some situations, eg. for symptom relief in terminal care,
paracentesis can be carried out in the home setting.
2. The procedure and potential complications should be explained to the
patient and carer and written consent should be obtained. It should be
noted that with appropriate caution, paracentesis is a very safe
procedure, but there are potential complications such as hypovolaemia
and shock, increased abdominal pain following the procedure, and
rarely, perforation of bowel or blood vessel by the drain leading to
peritonitis or haemorrhage.
3. Platelet count and clotting studies should be checked before the
procedure is undertaken. Stop routine anticoagulation 48 hours before
the procedure. INR should be 1.5 or less to safely proceed. Baseline
observations of BP and pulse should be recorded.
4. The patient should have an abdominal examination immediately prior
to the procedure with confirmation of clinical diagnosis of ascites:
abdominal distension, flank dullness, shifting dullness, fluid thrill.
Exclude other causes of abdominal distension such as hepatomegaly,
abdominal tumour, bowel obstruction, gaseous distension. If any
doubt exists, or the patient has previously been noted to have
loculated ascites, arrange ultrasound scan with marking of
maximum collection of ascites.
The preferred method of drainage is to perform paracentesis using a
Bonano suprapubic catheter. Other methods include a trochar, large
bore venflon or peritoneal dialysis catheter.
Puncture sites should be away from scars, tumour masses, distended
bowel, bladder, liver or the inferior epigastric artery that runs 5cm
either side of the midline. The best site is in either iliac fossa (but left
ideally) at least 10cm from midline.
• The patient should empty their bladder and then lie as flat as
possible for the procedure.
• The puncture site should be infiltrated with 2% lignocaine and a
green needle can be used to withdraw a small amount of fluid to
check that ascites is present and to send a sample for a
serum/ascites albumin gradient. (See introduction)
• The Bonano catheter is inserted using aseptic technique and is
connected to a catheter bag for drainage.
• If the patient is normotensive prior to procedure, ascites should
be allowed to drain freely. In malignant ascites it is safe and
effective to drain up to 5 litres over the first 4 hours without
intravenous fluid replacement.7 If significant ascites is still
present after 4 hours, clamp the tube and allow 1L per hour
maximum to drain until drainage slows to a minimum. Most
patients will have their tube removed within 24 hours.
• There is no evidence to support intravenous albumin
replacement in malignant ascites.
• If the patient is dehydrated and/or hypotensive (systolic <100
mmHg) prior to procedure, support with 0.9% N saline IV
during drainage. Hourly T/P/BP obs to be carried out for the
first 4 hours. If patient becomes hypotensive during procedure
also consider use of 0.9% N saline IV. After 4 hours, obs
measurements to be recorded as clinically indicated.
 • When the drain is removed a dressing pad or stoma bag can be
applied to the drainage site. Any residual leakage usually settles
within 2-3 days.
• The patient can be discharged a few hours after drain removal
or the following morning depending on their general condition.
6. When symptoms return, repeat paracentesis can be arranged if
appropriate. Remember that repeat drainage will result in steady loss
of albumin and, therefore, lower serum albumin with resulting
peripheral oedema.

Diuretics
Spironolactone should be considered if the patient is likely to live for several
months and the serum/albumin gradient is >11g/L. Elimination of the ascites
takes up to 4 weeks 8 during which time patient should be closely monitored.
1. Measure baseline urea and electrolytes
2. Measure abdominal girth and weight prior to starting diuretics
3. Start with spironolactone 100-200mg mane
4. Increase dose by 100mg every 5-7 days to achieve a weight loss of
0.5-1kg/24hours
5. Typical maintenance dose is 300mg mane
6. Consider adding furosemide 40mg mane if desired weight loss not
achieved after 2 weeks
7. Monitor U&Es carefully as electrolyte disturbance and hypotension
may occur. If renal impairment occurs or patient not tolerating
diuretics, stop
8. If diuretics do not achieve satisfactory reduction in ascites, stop
Other treatments
Indwelling catheters and peritonovenous shunts have been used in patients
with a prognosis of >3 months. There is no evidence to date to show added
benefit over repeated paracentesis. Systemic and intraperitoneal
chemotherapy has been used but, other than in chemosensitive ovarian
carcinoma and lymphoma, no benefit has been shown.

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Runyon B, Hoefs J. Ascitic fluid analysis in malignancy-related ascites. Hepatology 1988; 8: 1104-1109.
6
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