Management of Malignancy-related Ascites

Anne Marie C. Flaherty, MSN, RN, APNc, AOCNS®

Disclosures

Oncol Nurs Forum. 2015;42(1):96-99. 

In This Article

Management

Paracentesis is performed initially not only to relieve symptoms but to obtain analysis of the ascites. Glucose, protein, cell count, culture, SAAG, and cytology are obtained to identify the cause and characteristics of the ascites. The volume of fluid that can safely be removed is determined by the type of ascites. When ascites are caused by peritoneal carcinomatosis, amounts greater than 5 L can be drained versus when portal hypertension and cirrhosis are the cause. The latter present a less hemodynamically stable condition if large amounts of ascites are drained. The use of colloid- or albumin-based infusions with paracenteses is controversial and no evidence supports their routine use unless the patient is hemodynamically unstable after the procedure.

Complications of performing a paracentesis are low but include infection or peritonitis, intestinal perforation, hypoproteinemia, hypotension, and pulmonary embolus (Chung & Kazuch, 2008). The ascites reaccumulate in an average of 7–10 days, requiring repeated paracenteses which exposes the patient to repeated risk of complications and numerous trips to the hospital for the procedure (Becker, Galandi, & Blum, 2006). Diuretics and a low-sodium diet can help re-accumulation, but have been found to be effective only in those patients who have ascites from portal hypertension and liver metastases, which is about one-third of all cases (Cavazzoni, Bugiantella, Graziosi, Franceschini, & Donini, 2013). Portal hypertension results in elevated levels of plasma renin and aldosterone, which can respond to spironolactone and furosemide. The recommended dosages to begin are 100 mg spironolactone and 40 mg furosemide and may be increased while keeping the proportion the same (Cavazzoni et al., 2013). Clinicians often institute diuretics in all patients since some may have a component of portal hypertension with peritoneal carcinomatosis.

Because of a lack of large, randomized clinical trials, no evidenced-based guideline or standard exists for the management of malignancy-related ascites. Alternatives to repeated paracenteses have been explored and one alternative is peritoneovenous shunts such as Denver® or LeVeen®. These have been deemed high risk, expensive, and they often malfunction (Schumacher, Saclarides, & Staren, 1994). Complications include pulmonary embolism, disseminated intravascular coagulation, pulmonary edema, and occlusion. They are not recommended for patients with malignant ascites (Runyon, 2014). Experience with intraperitoneal dialysis led to the use of Tenckhoff catheter for ascites management. The concept of a tunneled, cuffed catheter for home drainage of ascites would increase the convenience and improve the comfort and quality of life for patients with refractory ascites. Experience revealed a relatively low infection and complication rate (O'Neill, Weissleder, Gervais, Hahn, & Mueller, 2001). However, problems arose with leakage, ease of drainage, and access to appropriate equipment (since it was not approved by the U.S. Food and Drug Administration [FDA]). Those were the issue facing the staff and patient in the case study.

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