Symptoms caused by tense ascites

• abdominal distension, discomfort and pain
• dyspnoea
• nausea & vomiting due to 'squashed stomach syndrome'
• dyspnoea
• oesophageal reflux

Treatment options

• chemotherapy - intraperitoneal or systemic
• paracentesis
• diuretics
• peritoneovenous shunt

Management

1. Chemotherapy can be considered if the prognosis warrants, but for most patients, therapy aimed at symptomatic control is appropriate.
2. Paracentesis is the treatment of choice for rapid symptom control.
3. Repeated paracentesis as needed is appropriate for most patients with a poor prognosis of <4-6 weeks e.g. gross hepatomegaly or jaundice.
4. Commence diuretics if prognosis > 4 weeks, paracentesis not accepted or unsuccessful. Leg oedema is an additional indication for using diuretics. See diuretic regime below.
5. If diuretics unsuccessful, or for persistently recurring ascites, consider a peritoneovenous shunt - can be effective, but shunt obstruction, sepsis and other complications are frequent.[1-3]

Diuretic regime

Spironolactone is the drug of choice for ascites, as increased plasma rennin activity and sodium retention occur in malignant ascites. Doses between 100-400mg o.d. are used. However it takes about 7 days to improve symptoms, and up to 28 days for full effect.[4-7] The addition of furosemide will help achieve a more rapid response until spironolactone works,[7] or may help in cases resistant to spironolactone alone.

1. Start spironolactone 100mg o.d.
2. Add furosemide 40mg o.d. if rapid initial result desired, as long as the patient is not dehydrated/hypovolaemic:
   • aim to withdraw furosemide after a week or so
3. Increase spironolactone by 100mg increments once or twice weekly to maximum 200mg b.d.
4. If ascites is resistant to 400mg spironolactone, add furosemide 40mg o.d. increased if necessary to 80mg o.d.
5. If little or no response to furosemide, change to bumetanide 2mg o.d. or furosemide 100mg/24h by CSCI.[8]

Monitoring

Patients on diuretics should be monitored closely for dehydration (indicated by U&Es, thirst, postural hypotension or confusion). Girth measurements can be used once to twice weekly to monitor the effect of diuretics.