Loading
When cancer causes fluid to build up in the abdomen, draining it through a thin tube (paracentesis) quickly relieves bloating and breathlessness, often as a day case. Treating the cancer can slow it down. If the fluid keeps coming back, a soft tube can be left in place so it can be drained at home in small amounts. The evidence for the details of drainage is weak, so practice varies.
The evidence for draining malignant ascites is weak: a 2006 systematic review found no randomised trials of paracentesis, diuretics or shunts, and the 2019 Cochrane update found one high-risk-of-bias trial (catumaxomab) and concluded there is insufficient evidence to recommend how drainage should be managed in gynaecological cancer. Paracentesis gives good, temporary relief and is the first-line treatment (Japanese guideline 2021). Practice carried over from cirrhosis (intermittent clamping, routine intravenous fluids or albumin, admission for several days) is not supported in malignant ascites: a UK hospice guideline (2002) drained up to 5 litres without clamping, removed drains within 6 hours and gave fluids only when indicated, and a UK series (2012) drained 21 people without clamping (4 had an asymptomatic fall in systolic pressure below 95 mm Hg, none felt unwell) and then drained to dryness as a day case, without intravenous fluids, in 18 of 19 procedures. Diuretics should be considered and judged individually (Becker 2006). Systemic treatment is strongly recommended for ovarian cancer with massive ascites (strong, evidence A) and weakly for gastric cancer. For treatment-resistant, recurrent ascites NICE recommends an indwelling peritoneal catheter (PeritX) drained into 1-litre vacuum bottles at home, which saves an estimated £1,095 a person against inpatient large-volume paracentesis. The Japanese guideline recommends against peritoneovenous (Denver) shunts because of frequent, sometimes fatal complications, and supports cell-free and concentrated ascites reinfusion (CART) with a weak grade.
Why: Draining the fluid relieves bloating and breathlessness quickly, and it can be done almost anywhere.
“However, since it can be easily performed at any facility, it can be considered as the first-line treatment for massive ascites.”
Japanese Society for Peritoneal Dissemination guideline committee (International Journal of Clinical Oncology) 2021 · Not graded (general statement in the guideline)
Why: Shrinking the cancer can stop the fluid coming back, and people with ovarian cancer can live a long time even with a lot of fluid.
“Ovarian cancer is extremely sensitive to chemotherapy. Although most patients with advanced PD have a large amount of ascites, long-term survival can be expected even from this condition. Chemotherapy is strongly recommended.”
Japanese Society for Peritoneal Dissemination guideline committee (International Journal of Clinical Oncology) 2021 · Strength of recommendation: Strong; strength of evidence: A (ovarian). Gastric cancer: weak, C. Other cancers: not recommended, D.
Why: Clamping comes from liver disease, where large drainage can drop blood pressure; in cancer, free drainage has been safe in the studies done so far.
“Free drainage of malignant ascites is safe.”
British Journal of Cancer 2012 · Observational study (no grade)
Why: Routine drips keep people in hospital and have not been shown to help in malignant ascites.
“giving intravenous fluids only when specifically indicated”
Palliative Medicine 2002 · Local guideline based on limited evidence (no grade)
Why: Most people can be drained completely in a working day and go home, which is what most patients prefer.
“Daycase paracentesis is feasible, cost-effective and reduces hospital admissions, and potentially represents the standard of care for patients with malignant ascites.”
British Journal of Cancer 2012 · Observational study (no grade)
Why: Some people's ascites responds to diuretics and many do not; the trials have not been done.
“The use of diuretics therefore should be considered in all patients, but has to be evaluated individually.”
European Journal of Cancer 2006 · Systematic review; evidence weak (no randomised trials)
Why: Draining small amounts often at home avoids repeated hospital visits and long drainage stays.
“The PeritX system is recommended as an option for drainage of treatment-resistant, recurrent malignant peritoneal ascites.”
NICE 2012 · Not graded (NICE HealthTech guidance 1.1, 'recommended as an option')
Why: Frequent small drainages keep symptoms down instead of waiting for the abdomen to fill.
“Better symptom control by frequent drainage of smaller quantities of ascitic fluid.”
NICE 2012 · Not graded (NICE committee's statement of expected benefit)
Why: Infection, leakage and blockage are the common catheter problems, and most can be treated.
“adverse events (catheter site infections, peritonitis, catheter occlusion, and haemorrhage or bowel perforation when the device is inserted)”
NICE 2012 · Not graded (outcomes the NICE evidence review collected)
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
There is no high-grade guideline for draining malignant ascites, and the sources agree that the evidence is weak. The best supported approach now combines: paracentesis as first-line relief (Japanese guideline 2021); free drainage as a day case without routine clamping or intravenous fluids (UK hospice guideline 2002 and UK series 2012, both small and non-randomised); treatment of the cancer where it responds (strong for ovarian cancer); and, for treatment-resistant recurrent ascites, an indwelling peritoneal catheter drained at home (NICE HealthTech guidance 282). The Japanese guideline and NICE differ in emphasis: Japan grades CART as an option and recommends against Denver shunts; NICE assessed only the PeritX catheter.
Japanese Society for Peritoneal Dissemination guideline committee (International Journal of Clinical Oncology) 2021 · British Journal of Cancer 2012 · Palliative Medicine 2002 · NICE 2012 · Cochrane 2019 · European Journal of Cancer 2006
Where it differs: Clamps the drain after set volumes, or drains small amounts (1 to 3 litres) at a time.
Evidence: Derived from cirrhosis practice (Harding 2012). The Japanese Society of Palliative Medicine guidance cited in the 2021 guideline drains 1 to 3 litres, while noting small drainages relieve symptoms poorly and refill quickly; free drainage was safe in the UK series.
British Journal of Cancer 2012 · Japanese Society for Peritoneal Dissemination guideline committee (International Journal of Clinical Oncology) 2021
Where it differs: Ultrasound only when the diagnosis is uncertain, up to 5 litres without clamping, drain left no more than 6 hours.
Evidence: Exeter hospice guideline (2002); after its introduction, ultrasound use, drain time and length of stay fell, with no symptomatic hypotension. Before-and-after case note review, abstract read.
Where it differs: Filters and concentrates the drained fluid and returns its protein to the person intravenously; widely used in Japan.
Evidence: Japanese guideline 2021: weak recommendation, evidence C (the statement's wording says 'strongly recommended', the printed grade says weak).
Where it differs: A permanent shunt returns ascites to the bloodstream.
Evidence: Japanese guideline 2021 recommends against it because complications are frequent and can be fatal (weak against, evidence C). Becker 2006: can control ascites but must be balanced against the risks.
Japanese Society for Peritoneal Dissemination guideline committee (International Journal of Clinical Oncology) 2021 · European Journal of Cancer 2006
Where it differs: Gives the antibody catumaxomab into the abdomen after drainage.
Evidence: One randomised trial (245 participants) in the Cochrane review: longer time to deterioration in quality of life, very low certainty, high risk of bias.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Chemotherapy for gastric cancer with massive ascites “Chemotherapy is recommended after careful evaluation of general condition of patients.” | Strength of recommendation: Weak; strength of evidence: C | Japanese Society for Peritoneal Dissemination guideline committee (International Journal of Clinical Oncology) 2021 |
| CART for massive malignant ascites “It is strongly recommended to perform CART for patients with massive cancerous ascites.” | Strength of recommendation: Weak; strength of evidence: C; consensus 100% | Japanese Society for Peritoneal Dissemination guideline committee (International Journal of Clinical Oncology) 2021 |
| No peritoneovenous shunt “However, the complications are frequent and can be fatal and thus abdominal-venous shunting is strongly recommended not to be performed.” | Strength of recommendation: Weak; strength of evidence: C; consensus 70% | Japanese Society for Peritoneal Dissemination guideline committee (International Journal of Clinical Oncology) 2021 |
| Intraperitoneal triamcinolone “It is a treatment option that is easy to operate and accessible to patients, but no clear recommendations can be made.” | Not recommended; strength of evidence: D | Japanese Society for Peritoneal Dissemination guideline committee (International Journal of Clinical Oncology) 2021 |
| Evidence on drainage management in gynaecological cancer “Currently, there is insufficient evidence to recommend the most appropriate management of drainage for malignant ascites among women with gynaecological cancer, as there was only very low-certainty evidence from one small RCT at overall high risk of bias.” | Very low certainty (Cochrane) | Cochrane 2019 |
| Speed of drainage and intravenous hydration “Fluid withdrawal speed and concurrent intravenous hydration is not sufficiently studied.” | Not sufficiently studied (systematic review) | European Journal of Cancer 2006 |
| Cost of the indwelling catheter against inpatient paracentesis “The PeritX system can lead to an estimated cost saving of £1,095 per person compared with inpatient large-volume paracentesis.” | NICE cost model | NICE 2012 |
Shares Pleural and peritoneal shunts (Denver shunts, ACES), Indwelling peritoneal catheters for malignant ascites (PeritX, Rocket, Aspira, Passio), Malignant pleural effusion and ascites.
Shares Peritoneal metastases from bowel cancer, Peritoneal metastasis, Peritoneal mesothelioma.
Shares Peritoneal metastases from bowel cancer, Peritoneal metastasis, Peritoneal mesothelioma.
Shares Peritoneal metastases from bowel cancer, Peritoneal metastasis, Peritoneal mesothelioma, Gastric & gastro-oesophageal junction cancer.
Shares Pleural and peritoneal shunts (Denver shunts, ACES), Malignant pleural effusion and ascites.
Shares Indwelling peritoneal catheters for malignant ascites (PeritX, Rocket, Aspira, Passio), Peritoneal metastasis, Pancreatic ductal adenocarcinoma.
Shares Malignant pleural effusion and ascites, Gastric & gastro-oesophageal junction cancer, Ovarian cancer, Pancreatic ductal adenocarcinoma.