FAST FACT AND CONCEPT #177: Palliative Treatment of Malignant Ascites

Authors: Karen LeBlanc and Robert Arnold MD

The natural history, presenting signs/symptoms, and diagnostic approach to the patient with malignant ascites are discussed in Fast Fact #176; readers are encouraged to read this Fast Fact to review the important role of determining the Serum-Ascites Albumin Gradient as a diagnostic and treatment aid. This Fast Fact will review treatment approaches.

• Diuretics : Malignant ascites (SAAG < 1.1) generally does not respond to diuretic treatment although no randomized trials have been completed. Patients with evidence of portal hypertension (SAAG > 1.1) are more likely to respond to diuretics.

• Paracentesis: Paracentesis can provide immediate relief of symptoms in up to 90% of patients. Drainage of uncomplicated large-volume ascites (4-6 L/session) can be done safely and quickly in the outpatient setting—including the home—or at the hospital bedside; ultrasound guidance is necessary only when there is loculated fluid.

• Drainage catheters: For patients who require frequent paracentesis, external drainage catheters placed through the abdominal wall allow frequent or continuous drainage of ascites fluid without repetitive needle insertions. Patients or caretakers may perform the drainage, reducing visits to medical clinics. Several types of catheters are available:
  
• Pigtail Catheter: A simple, temporary all-purpose catheter; prone to complications when used over an extended duration (peritonitis, accidental removal, leakage, occlusion).
  
• Tunneled Catheter: A catheter that prevents infection by promoting scarring around an antibiotic-impregnated Dacron cuff in subcutaneous tissue. Used conventionally for peritoneal dialysis, it is placed with ultrasound or fluoroscopic guidance and has lower risks of infection and leakage than the pigtail catheter. Complications are reduced by daily drainage for the first two weeks of cuff healing. The Pleurx catheter is FDA approved for malignant ascites and features a one-way rubber valve to prevent leaks between draining sessions. Tunneled catheters are used in patients with life expectancy of at least one month.

• Vascular Shunts:
  
• Peritovenous shunt (PVS ) systems are designed to channel peritoneal fluid and proteins in benign ascites back into the circulation via the superior vena cava. PVS has not been shown to have clinically significant risk of disseminating tumor cells in malignant ascites. A PVS is placed by interventional radiology under conscious sedation, and patients typically require 24 hours of monitoring with a central venous line after the procedure. The best response to PVS (only about 50%) is in ovarian and breast cancers. PVS is recommended only in patients with a life expectancy of one to three months.
  
• Transjugular Intrahepatic Portosystemic Shunt (TIPS) is a shunt between the portal vein and hepatic vein, designed to reduce portal hypertension and improve sodium balance. Most patients with malignant ascites do not have portal hypertension although TIPS might be helpful in the occasional cancer with evidence of increased portal pressures (SAAG > 1.1).

References

1. Thomas J, von Gunten CF. Diagnosis and Management of Ascites. In: Principles and Practice of Palliative Care and Supportive Oncology. Eds: AM Berger, J Von Roenn, J Schuster. Lippincott, Williams & Wilkins, 3 rd edition, Philadelphia.
2. Adam RA, Adam YG. Malignant ascites: past, present, and future. Journal of the American College of Surgeons. 2004;198:999-1011.
3. Spratt JS, Edwards M, Kubota T, et al. Peritoneal carcinomatosis: anatomy, physiology, diagnosis, management. Current Problems in Cancer. 1986;10:553-584.
4. Becker G, Galandi D, Blum HE. Malignant ascites: systematic review and guideline for treatment. European Journal of Cancer. 2006;42:589-97.
5. Aslam N, Marino CR. Malignant ascites: new concepts in pathophysiology, diagnosis, and management. Archives of Internal Medicine. 2001;161:2733-7.
6. Smith EM, Jayson GC. The current and future management of malignant ascites. Clinical Oncology. 2003;15:59-72.
7. Pockros PJ, Esrason KT, Nguyen C, Duque J, Woods S. Mobilization of malignant ascites with diuretics is dependent on ascitic fluid characteristics. Gastroenterology. 1992;103:1302-1306.
8. Abeloff M, Armitage J, Niederhuber J, Kastan M, McKenna WG, eds. Clinical Oncology, 3rd ed. Publisher: Churchill Livingstone; 2004, pp. 1199-1205.
9. Covey AM. Management of malignant pleural effusions and ascites. The Journal of Supportive Oncology. 2005;3:169-73.

Fast Facts are edited by Drew A. Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For comments/questions write to: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. LeBlanc K and Arnold RA. Fast Fact and Concept #177. Palliative Treatment of Malignant Ascites. March 2007. End-of-Life/Palliative Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Purpose: Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Medical Knowledge

Keyword(s): gastrointestinal diseases & nutrition; cancer

Specific Disease and Organ System Category(s): Gastrointestinal Diseases & Nutrition; Cancer