Ascites
An approach to symptom management to guide decision-making in the management of patients with life-threatening illness
Definition
Ascites is an abnormal accumulation of fluid in the abdomen. Malignant ascites accounts for 10% of all causes of ascites. It is associated with cancer of the ovary, breast, stomach, pancreas, colon & lymphoma. Cardiac failure, liver failure & renal failure are common causes of non-malignant ascites.
Appropriate assessment to identify cause and severity of symptoms
Symptoms
- Abdominal distension, discomfort & pain
- Dyspnoea
- Nausea & vomiting mainly due to squashed stomach syndrome
- Oesophageal reflux
- Leg oedema
Causes
- Peritoneal metastasis
- Sub-phrenic lymphatics blocked by tumour infiltration
- Increased peritoneal permeability
- Liver metastasis leading to hypo-albuminaemia & sometimes portal hypertension
Management
- Chemotherapy
- Diuretics
- Paracentesis
Spironolactone is the drug of choice. Doses from 100-300mg orally. For rapid results 40mg of lasix (frusemide) which is a loop diuretic, can be added. Serum electrolytes should be monitored
Paracentesis is appropriate for patients with a tense distended abdomen & for whom there is no relief from diuretics. Paracentesis can be repeated if diuretics do not prevent re-accumulation of fluids & can be carried out in any setting including the patient’s home. Patients with advanced disease, who accumulate fluid very quickly, could have a catheter type shunt put in which they can drain themselves.
Review and re-assess frequently (at least every 3rd day) to identify whether ascites re-accumulates. consider referral to palliative care service.