1. Current practice in the management of
malignant ascites
Nancy Preston
INTRODUCTION from the peritoneal cavity is dynamic and able to
adjust to this increased production of fluid.
Malignant ascites is the build up of protein- Bronskill et al (1977) demonstrated that in
rich fluid in the peritoneal cavity, accompanied patients with malignant ascites there was a marked
by debilitating symptoms of breathlessness, decrease in flow from the peritoneal cavity due to
indigestion, alteration in bowel habit, fatigue, blockage of the diaphragmatic lymphatics. These
reduced mobility, loss of appetite, nausea, causes account for the majority of patients with
abdominal swelling, pain and changes in body malignant ascites. A separate cause is compression
image (Preston 1995, Parsons et al 1996). Research of the hepatic portal vein by a tumour, leading to
into the management and effect of ascites on well- fluid being forced into the peritoneal cavity. Fluid
being has been limited. Currently, there is no produced as a result of mechanical obstruction
nursing research related to the management or is called a transudate and is low in protein
experience of malignant ascites and little reference concentration (see Table 1).
is made to its management in textbooks. Medical
research concentrates on evaluating different
management methods but this research is usually TREATMENT
limited in its potential application as there are no
published randomized trials to evaluate the different Studies on treatments are either retrospective or
therapies. Research is underway to evaluate new only evaluate a single option of treatment. This
methods of control and the effect of ascites on well- limited information makes decisions difficult. A
being (Preston 1995). Audits of current practice are rationale for the various approaches will be
either underway or now published (Parsons et al discussed, along with the known side-effects and
1996). There is no current 'Gold Standard' in sequelae, with the purpose of informing healthcare
treatment but the mainstay of treatment still appears workers when choosing their own management
to be frequent drainage. The purpose of these approaches for patients.
practice notes are to describe the aetiology of
malignant ascites and also to summarize current
approaches to management which healthcare PARACENTESIS/ABDOMINAL
workers can consider when trying to relieve this DRAINAGE
symptom in individual patients under their care.
In cases of suspected malignant ascites, a sample of
fluid needs to be taken at least once for diagnostic
AETIOLOGY purposes. Only about 50% of patients have their
fluid analysed for malignant cells (Parsons et al
Fluid is produced from the capillaries lining the
peritoneal cavity and is drained by lymphatic vessels
under the diaphragm. This fluid is collected by the
right lymphatic duct which drains into the vena cava.
However, in patients with malignant ascites, this
balance of production and drainage is disrupted. Exudate Transudate
Nancy Preston BSc
0-1ons), RGN, North
Hirabayashi and Graham (1970) demonstrated
• Fluid leaked from blood • Fluid leaked from blood
Thames Research that there was increased production of fluid in the vessels as a result of vessels as a result of
Practitioner, Centre for
Cancer & Palliative Care
peritoneal cavity in the presence of a turnout due to increased permeability, mechanical obstruction,
Studies, Institute of Cancer increased permeability. Fluid accumulation due to i.e. due to malignant i.e. t u m o u r compression
Research/Royal blarsden cells on peritoneal lining
NHSTrust, Fulham Rd,
increased permeability is called exudate and is
• High protein content • Low protein content
London SW3 6Jj, UK protein-rich (see Table 1). The drainage system
journal af CancerNursing I (3), 144-146© PearsonProfessionalLtd 1997

2. Current practice in management of malignant ascites 145
• nurse in supine position for 12-24 hours • 4 hourly abdominalgirth
• I/4 hourly observation (including CVP) for first • 4 hourly positive pressure breathing exercises,
hour, then 4 hourly i.e. blowing againstthe thumb for I S
• monitor urine output (should be > 100 minutes
ml per hour) • 4 hourly abdominalgirth
• 4 hourly bloods for haematocrit and electrolytes • Subsequent daily weight and girth
• regular analgesia • After 24 hours, apply an abdominal binder
• observe for signs of fluid overload
(breathlessness,engorgement of neck veins).
If present, sit upright
1996). Other causes of ascites, such as cirrhosis of and frusemide 40 mg but much higher doses may be
the liver or heart failure, need to be excluded. required to reduce ascites. Success may be achieved
Protein concentration may also be used to by dehydration. Rarely would regular electrolyte
differentiate between transudates and exudates and monitoring be viable or desirable in a palliative care
microbiology is useful in ruling out infection. setting, leaving doubt as to the advisability of using
Drainage usually gives relief from the common diuretics in malignant ascites.
symptoms associated with ascites. However, some
patients literally feel 'drained' for a number of days
and bowel motions may be temporarily disrupted. PERITONEOVENOUS SHUNTS
There is a risk of perforating the bowel but this can
be reduced through ultrasound guidance. Protein Peritoneal shunts offer the best approach
depletion usually accompanies drainage, with serum physiologically. The shunt lies in the peritoneal
albumin dropping substantially (Parsons et al 1996). cavity (tunnelled under the skin) and drains into the
Speed of drainage has not been evaluated in superior vena cava or the right atrium. Fluid moves
malignant ascites. Instead, drainage regimes in along the shunt as a result of changes in pressure
cirrhosis of the liver have been implemented. Patients from the thoracic cavity and the abdominal cavity.
with a malignancy are weaker than patients with The fluid is prevented from returning to the
cirrhosis of the liver and, while rapid drainage of peritoneal cavity by a one-way valve. Recent
ascites has been shown to be safe in cirrhosis of the studies have identified high mortality and morbidity
liver, there are no studies to support this assumption rates associated with shunts (Schumacher et al
in malignant ascites. The administration of albumin 1994). Patients require careful monitoring to be sure
following drainage has not been addressed in they are not becoming overloaded by the increase in
malignant ascites. Administration of albumin may, in circulating fluid (see Table 2). Many clinicians feel
fact, only prove to be an expensive and futile gesture that only fit patients with a reasonable prognosis
in malignant ascites. Slower drainage regimes range (months rather than weeks) benefit from this
from 1 litre per hour to 1 litre per 24 hours. approach.
DIURETIC THERAPY INTRAPERITONEAL TH ERAPY
Anecdotally, the use of diuretics in the management A great deal of attention has been paid to
of malignant ascites is widespread. Research intraperitoneal administration of either chemo-
evidence is confounding. Some studies recommend therapeutic or biological agents. Research has con-
diuretics and other studies reject them. A detailed centrated on patients with small volume disease
study to evaluate the effect of diuretics on malignant which may be very different to the usual clinical
ascites was carried out by Pockros et al (1992), picture. Any agent administered intraperitoneally is
targeting patients with three different types of at risk of causing or exacerbating bowel obstruction.
malignant ascites: exudative, chylous and transuda- In addition, treatment can be unpleasant, require
five. The volume of ascites hardly changed in frequent admission and expensive. If intraperitoneal
patients with exudative or chylous ascites and they therapy is likely to work, it should have a similar
concluded that in these patients there was no effect given intravenously.
mobilization of the ascites. This was in contrast to
the patients with transudative ascites where ascites
may be mobilized with diuretics. Establishing the SUMMARY
cause of ascites is crucial before using diuretics
because cases of renal impairment in the exudative It can be seen that there is little consensus on the
and chylous groups were noted (Pockros et al 1992). management of malignant ascites. Any nurse
The diuretics of choice are spironolactone 100 mg moving from one cancer unit to another will see
journalofCancerNursing 1(3), 144 146

3. 146 Journalof CancerNursing
Advantages Disadvantages
Repeated Rapid relief of symptoms • Admission (although can be done at home)
paracentesis • Feeling 'drained'
• Altered bowel habit
• Riskof perforation, protein depletion
• Temporary relief
Diuretics Non-invasive • Electrolyte imbalance
• Nausea and vomiting at high doses
• Slow/partial relief of symptoms
• Not all will respond
Peritoneovenous Physiologically-based • Shunt malfunction, i.e. blockage
shunts solution with permanent • Tumour implantation at exit site
results • Riskof fluid overload, disseminated
intravascular coagulation (DIC), infection
• Effect of general anaesthetic, though can be done
under local anaesthetic
variations in practice. I am conducting a national REFERENCES
survey to describe these differences in practice but
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patients. For some patients, minimal ascites can
a 2-year review from a teaching hospital. European
cause great distress through the effect on their body Journal of Surgical Oncology 22:237-239
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and support from nursing staff to establish when an is dependent on ascitic fluid characteristics.
Gastroenterology 103:1302-1306
i n t e r v e n t i o n is necessary. A coherent protocol
Preston N (1995) New strategies for the management of
agreed amongst all clinicians in an area would be a malignant ascites. European Journal of Cancer Care 4:
step forward, rather than management changing 178-183
constantly with the introduction of new teams of Schumaeher D L, Saclarides T J, Staren E D (1994)
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malignant ascites. Annals of Surgical Oncology 1:
maintaining such a protocol. The side-effects of all
378-381
treatments are summarized (see Table 3) and,
currently, relief through drainage appears to offer
the safest method of control.
journal oF CancerNu~ing 1(3), 144-146