I

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7
Healthr,lr:rejl
Qassim Cluster

Poliry Title MANAGEMENT OF ASCITES IN PATTIATIVE CARE

lssuing Body Policy Number Replaces No. Policy Level

Model of Care QHC-MOC-PP-056-E-V1 New Cluster
ApprovalDate Effective Date Revision Date No. of Pages Applicable To
KFSH& Ash Shifa
2210812022 2slo8l2022 2210812024 5
Hospital

1. STATEMENT OF PURPOSE
1.1 To provide a guideline for the identification, diagnosis and management of ascites in adu lt patients who
are aged 14 years and older and have advanced life threatening illness.

2. DEFINITIONS
2.1 Ascites: ls the accumulation of fluid within the peritonealcavity.
2.2 Diuretic:lsanysubstancethatpromotestheproductionof urine.Thisincludesforceddiuresis.Thereare
several categories of diuretics. All diuretics increase the excretion of waterfrom bodies, although each class
does so in a distinct way.
2.3 Octreotide: ls an octapeptide that mimics natural somatostatin pharmacologically, though it is a more
potentinhibitorofgrowthhormone,glucagon,andinsulinthanthenaturalhormone.
2.4 Paracentesis: ls a form of bodyfluid sampling procedure in which the peritoneal cavity is punctured by a
needle to sample peritoneal fluid.

3. GENERAL GUIDLINES
3.1 All admitted palliative patients aged 14 years and olderexperiencing the symptom of ascites shall be
assessed, diagnosed and managed by a Physician.
3.2 Physicia ns sha ll identify the u nderlying cause(s) of ascites a nd treat them a ppropriately.
3.3 Physicians shall note the following in relation to ascites:
3.3.1Ascites may develop in15%to50% of patientswith malignancies.
3.3.2 Ascites due to cirrhosis is usuallya sign of advanced liver disease and generally has a fair
prognosis with a 3-year survival rate of aboutTS%.
3.3.3 Ascites due to heart failure has a fair prognosis as patients may live years with appropriate
treatments.
3.4 Physicia ns sha ll consider the fact that in most cases of ma ligna nt ascites the prognosis is poor. Resea rch
shows that, dependent upon the type of malignancy, a mean survival time of between 20 to 58 weeks can
be expected.

4. ASSESSMENT AND MANAGEMENT

4. 1 Util ize the fol lowing forms of assessment for a patient with ascites.
4.1..1 lnterview the patient using acronym O, P, Q, R, S, T, U and V (see Appendix One: Ascites
Assessment usingAcronym O, P, q R, S, T, U and V).
4.1.2 Conduct physical assessment.
4.1.3 Review medication.

Page 1 of 5
 p*Eiill glr+i
,7 Healthun.r.trjl
Qassim Cluster

Policy Title MANAGEMENT OF ASCITES IN PATLIATIVE CARE

lssuing Body Policy Number Replaces No. Policy Level

Model of Care QHC-MOC-PP-056-E-V1 New Cluster
ApprovalDate Effective Date Revision Date No. of Pages Applicable To
KFSH& Ash Shifa
221O812022 2slo8l2022 221O812024 5
Hospital

4.1.4 Conduct medical and surgical review.

4. 1.5 Cond uct psychosocia I a nd physica I envi ronment review.
4.2 Obtain or request appropriate diagnostics:
4.2.1 Abdominalradiography-ascites may demonstrate a 'ground glass appearance'.
4.2.2 Ultrasound orCT scan - it may be requiredto demonstratesmallvolumesof free peritoneal
fluid.
4.2.3 Diagnostic pa racentesis - it may be req u ired to elucidate the type of ascites a nd sh ou ld be done
on newly diagnosed cases of ascites.
4.3 ldentify the causes of ascites such as:
4.3.1 Cirrhosis - is the predominant cause in80% of cases. lt presents as transudative ascites (ascitic
fl u id protei n concentration of I ess tha n 2.59/d I ).
4.3.2 Malignancy- causes Llo/o of cases. They are mostly (80%) epithelial related ovarian, uterus,
breast, colon, gastric and pancreatic however the remaining20% have tumours of primary unknown
origin. The fluid produced in malignancy is exudative (asciticfluid protein concentration of greater
than 2.59/dl).
4.3.3 Heartfailure- is responsiblefor 3% of cases. The fluid produced istransudative.
4.3.4 Renalrelated -3%o,tuberculosis,2o/o,pdnctedtitis,2o/oandL% miscellaneous.
4.4 ldentifytypes of ascites as follows:
4.4.1 Raised hydrostatic pressure - caused by cirrhosis, congestive heart failure, inferior vena cava
obstruction and hepatic vein occlusion.
4.4.2 Deueased osmotic pressure - caused by protein depletion (nephroticsyndrome, proteinlosing
enteropathy), reduced protein intake (malnutrition)or reduced protein production (cirrhosis).
4.4.3 Fluid production exceeding resorptive capacity -caused by infection or neoplasms.
4.4.4 Chylous - due to obstruction and leakage of the lymphatics drainingthe gut.
4.5 Discuss with the patient and family treatment methods for ascites and the value of paracentesis when
the patient becomes symptomatic.
4.6 Ma nage patient with ascites non -pha rmacologica I ly as fol lows:
4.6.1 Observe appropriately if the condition is asymptomatic including measuringthe abdominalgirth
at a marked site each week as well as appropriatelyscheduled weight measurement.
4.6.2 Perform pa racentesis by d ra in ing ascitic fluid via a catheter inserted th rough th e a bdominal
wall.
4.6.2.L Note: This may be achieved under ultrasound guidance or in an outpatientsettingfor
quick relief of symptoms. Generally, upwards of 5 litres of fluid may be removed with little
risk of hypotension or hypovolemic shock when patient screening is applied. lntravenous
hydration should be considered if the patient is hypotensive, dehydrated or known to have

Page 2 of 5
I

p*Efll go+\i
Healthllrrall
Qassim Cluster

Poliry Title MANAGEMENT OF ASCITES IN PATLIATIVE CARE

lssuing Body Policy Number Replaces No. Policy Level

Model of Care QHC-MOC-PP-056-E-Vl New Cluster
Approva! Date Effective Date Revision Date No. of Pages Applicable To
KFSH& Ash Shifa
221O812022 2s1o812022 2210812024 5
Hospital

severe renal impairment and paracentesis is still indicated. lf there is leakage over the
paracentesis site an ostomy bag can be applied. Single or repeated paracentesis in patients
with adva nced ca ncer does not sign ifica ntly lower seru m protein.
4.5.3 Use peritonea I catheters (sma ller bore catheter) when ascites is ra pid ly accu mu lating a nd
req u iring freq uent pa racentesis for symptom control.
4.6.3.L Note this significantly exposes the patient to the risk of peritonitis and is usually
reserved for patients in theterminal phase of their illness, with a prognosis of weeks.
4.6.4 Use radiation therapy and chemotherapy in cases where a meaningful response to tumour
growth may be expected, such as lymphoma.
4.6.5 Ensure salt restriction where fluid is transudative, but may also provide relief in patients with
cancer and hepatic metastases.
4.6.6 Advise a low fat diet and increase in medium-chain triglyceride intake as it may be useful in
patients with chylous ascites.
4.7 Manage patient with ascites pha rmacologically using d iu retics treatment as follows:
4.7.1 Use of diuretics in all patients has to be evaluated individually. Patients with malignant ascites
due to massive hepatic metastases seem to respond betterto diuretics than those with malignant
ascites due to peritoneal carcinomatosis or chylous ascites.
4.7.2 Consider d iu retics for patients with portal hypertension (hepatic m etastaset hea rt fa ilu re a nd
cirrhosis)and should betried in most patients, aftertheirfirst abdominalparacentesis, as
approximately one-third of patients are shown to benefit.
4.7.3 Evaluate goal of diuretictherapywhich is achieved when patient's weight loss is 0.5 to 1 kg
per day.
4.7 .4 Prescribe Spironolactone 100 mg daily titrated slowly to 400 mg daily.
4.7 .4.L Note: titrate to remove enough fluid for comfort.
4.7.5 Prescribe Furosemide 40 to 120 mg daily addingto Spironolactone to improve the effect and
prevent hypokalemia.
4.7 .5.L Note Furosemide given by continuous infusion is reported to produce significant
diuresis and marked relief of ascites.
4.7.6 Monitorelectrolytes, renalfunction,druginteractionsand blood pressurewhen utilizing
diuretics
4.8 Manage patient with ascites pharmacologically using Octreotide treatment as follows:
4.8.1 Prescribe Octreotide 200 to 500 micrograms subcutaneously daily divided intotwo-three
doses as this has found beneficial in cases of ascites refractory to paracentesis.

Page 3 of 5
t
7

iL

F.+rrill Fo.;\i
7? Healthtlr:.all
Qassim Cluster

Poliry Title MANAGEMENT OF ASCITES IN PALLIATIVE CARE

lssuing Body Policy Number Replaces No. Policy Level

Model of Care QHC-MOC-PP-0s6-E-Vl New Cluster
ApprovalDate Effective Date Revision Date No. of Pages Applicable To
KFSH& Ash Shifa
221O812022 251O812022 221O812024 5
Hospital

5. APPENDIX
5.1 Appendix One: Ascites Assessment usingAcronym O, P, Q, R, S, T, U and V.

One: Ascites Assessment usi o P S T UandV

Onset When did it begin?
How often does it occur?
Provoking / Palliating What brings it on?
What makes it better?
What makes it worse?
Quality What does it feel like?
Can you describe it?
Have you noticed weight gain?
Region / Radiation Where is the pressure?
ls it spreading?
Severity What is the intensity of this symptom (On a scale of 0 to
10 with 0 being none and 10 being worst possible)? Right
Now? At Best? At Worst? On Average? How bothered
are you by this symptom? Are there any other
symptom(s) that accompany this symptom?
Nausea/vomiting, loss of appetite, pain?
Treatment What medications and treatments are you currently
using?
How effective are these? Do you have any side effects
from the medications and treatments?
What medications and treatments have you used in the
past?
Understanding / lmpact on What do you believe is causing this symptom? How is
You this symptom affectingyou and/or your family?
Values What is your goalfor this symptom? What is your
comfort goalor acceptable level forthis symptom (On a
scale of 0 to 10 with 0 being none and 10 being worst
possible)? Are there any other views orfeelings about
this symptom that are important to you or your family?

Page 4 of 5
 *

p#dlIl ge+fi
HealthUtr.trJl
Qassim fluster

Policy Title MANAGEMENT OF ASCITES IN PALLIATIVE CARE

lssuing Body Policy Number Replaces No. Policy Level

Model of Care QHC-MOC-PP-056-E-V1 New Cluster
ApprovalDate Effective Date Revision Date No. of Pages Applicable To
KFSH& Ash Shifa
221O812022 2s10812022 221O812024 5
Hospital l,l

1. APPROVATPROCEDURES

Prepared by:

Name Title Signature Date

Project Manger 'zJ
Ms. RABAIH ALFRHIDIY -3-a<
DT. MUSAAD AUALOUD Project Manger
e?' L5 /g

Reviewed by:

Name Title Signature Date

Consultant of Family
Dr. Ahmad Saeed Almutairi
Medicine, MoC Lead
lLg
D
Dr. Luay Alhamad Service Line Lead

Director of Therapeutic
Dr. Sultan Alanazi
Services Department :F
Dr. Abdullelah Alhudaithi VP Of Health Care Delivery

Chairman, Standa rdization

4 r*)
\ Mr. Ayed Awadh AlReshidi
Steering Committee
C-^.,

Approved by:

Name Title Signature Date

Dr. Sultan Saud Alshaya

President, Qassim Health
Cluster
C
7
Page 5 of 5