Checked: 04-04-2018 by
vicky.ryan Next Review: 20-09-2019
EOL Gastrointestinal symptoms NS MOM
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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties
The gastrointestinal tract extends from the lips to the anus and includes the liver, biliary system and pancreas.
Information for this care map has been adapted from the Adult Palliative Care Guidelines (April 2014) available here - this has been updated (2016)
· csci = continuous subcutaneous infusion (via a syringe driver)
1.1 Who is eligible for care by St Peter’s Hospice?
Anyone over the age of 18 with an active and advanced life limiting disease such as cancer, heart and/or lung disease and neurological diseases;
Patients referred to St Peter’s Hospice may be close to the end of active treatment when a doctor has advised either that no further treatment will be of benefit or that further treatment is purely for the relief of difficult symptoms;
The patient may be near the end of their life and may have chosen to die in a hospice. The patient (or their chosen representative i.e. next of kin) must agree to the referral;
St Peter’s Hospice provides care to the people of Bristol, South Gloucestershire, North Somerset and part of B&NES.
1.2 Who can make a referral to St Peter’s Hospice?
Anyone can make a referral but usually patients are referred by a health or social care professional such as their GP, District Nurse or Hospital Palliative Care Team. The patient’s GP must be in agreement with the referral.
Once a patient has been accepted by St Peter’s Hospice they will be contacted by a triage nurse to let them know what will happen next. For the majority of patients the first contact they will receive will be a telephone call from the triage nurse to introduce the service and assess any urgent issues. This will often be followed by a visit from a Community Nurse Specialist or perhaps an invitation to an outpatient appointment.
Hard copies of the Drug chart and patient information leaflet are available in GP Practices and with Community Nursing teams. The version attached below is provided as a last resort as these are not designed to be printed locally.
Narrow spectrum antiemetic according to cause (metoclopramide / cyclizine / haloperidol)
Combination e.g. cyclizine plus haloperidol
OR broad-spec e.g. levomepromazine
OR 2nd line narrow spec e.g. ondansetron
+/- administer by CSCI
+/- antiperastaltic drugs e.g. hyoscine
Metoclopramide orally for nausea and vomiting associated with gastritis, gastric stasis and functional bowel obstruction- see BNF for dose ranges per route.
Haloperidol orally for most metabolic causes of vomiting (e.g. hypercalcaemia, renal failure) see BNF for dose ranges per route.
Cyclizine orally. Used for nausea and vomitting due to mechanical bowel obstruction, raised intracranial pressure and motion sickness- see BNF for dose changes per route.
Levomepromazine is used as an antiemetic, given by mouth or subcutaeneous injection.
NB. Levomepromazine has 20-40% bioavailability so it may be necessary to reduce dose when converting oral to subcutaneous administration route. See BNF for dose ranges for each route
Dexamethasone 8-16mg daily by mouth can be used as an adjunct. See BNF for dose ranges for each route.
NICE NG31: For people in the last days of life with obstructive bowel disorders who have nausea or vomiting, consider:
Hyoscine butylbromide as the first-line pharmacological treatment
Octreotide if the symptoms do not improve within the 24hrs of starting treatment with hyoscine butylbromide
Intestinal obstruction most commonly occurs with carcinoma of the ovary or bowel. It is associated with a poor prognosis of a few months.
The obstruction may be mechanical: intraluminal, intramural or extrinsic (from surrounding peritoneal disease or adhesions) or functional: peristaltic failure, or a combination of these. It is often at multiple sites.
In many patients, particularly in ‘functional’ obstruction, symptoms spontaneously resolve and worsen again over time.
A plain abdominal X-ray can be helpful in excluding constipation.
Severe constipation with faecal impaction may mimic obstruction
In a patient with advanced peritoneal cancer the most likely cause of obstruction is malignant tumour. If the obstruction is localised, there is not diffuse intra-abdominal disease and the patient is fit enough, a surgical opinion should be sought and the advantages and disadvantages of laparotomy assessed. The potential mortality and morbidity associated with surgery should be weighed against quality of life in a patient with a likely short prognosis.
If surgery is inappropriate, palliative symptomatic measures are the mainstay of treatment - the traditional ‘drip and suck’ approach is ineffective in 80% of cases and may be distressing, whereas medical management can relieve distressing symptoms.
Do not forget measures such as frequent mouth care and advice about small amounts of food (low fibre and fat) and drink as tolerated. It is usually possible to control fluid balance with symptomatic measures well enough for ongoing parenteral fluids to be unnecessary, but initial IV or SC fluids may be important: dehydration can itself cause symptoms.
Oral medications will not always be absorbed and parenteral drugs should be used. In palliative care these will usually be administered via a syringe driver.
Symptomatic treatment of nausea, vomiting, colic, pain, diarrhoea and constipation should be started alongside targeted specific treatments such as stenting, bowel wall oedema reduction and anti-secretory measures. Gut motility stimulation precludes the use of some antiemetics and anti-secretory drugs because of mutual antagonism
•expensive, but faster action and higher efficacy than anticholinergics (evidence level ii) 
11.H2 Antagonists and PPIs
•Not currently widely used in palliative care for bowel obstruction
12. Nasogastric tube drainage
•this should only be considered if vomiting is not subsiding with above measures, or if very distressing and/or faecal. Full discussion with patient and carers is mandatory. Traditional "drip and suck" approach is ineffective in the majority of cases
•occasionally, in clinically stable patients with a prognosis of at least weeks who are distressed by vomiting, it may be an option to discuss a venting gastrostomy and hydration with SC fluids.
Good mouth care is essential to the well being of debilitated patients. Although mouth problems are very common (up to 90% of patients in some surveys), it is often a neglected area of care.
Assess oral cavity daily using a pen torch and spatula. Note the state of the lips, teeth/dentures (remove the dentures for examination), mucousmembranes and tongue, and also the type/volume of saliva.
Assess nutritional status - quality of diet and adequacy of fluid intake.
Assess mental state - will determine the patient’s ability and willingness toparticipate in his or her care.
Dry mouth (xerostomia) especially from drugs (opioids, tricyclic antidepressants, antimuscarinics), dehydration (reduced intake or diuretics) and local radiotherapy
Angular cheilitis (cracked corners of the mouth)
Dysgeusia is the most common problem in advanced cancer and is often related to cancer treatment though it can also be a non specific effect of the disease. Referral to a dietician is recommended along with good oral care and management of concomitant xerostomia.
Sore mouth may be due to oral infection, ulceration, mucositis or simply poorly fitting dentures. Treat with local anaesthetic agents such as choline salicylate gel (Bonjela®), benzydamine hydrochloride (Difflam® mouthwash or spray) or benzocaine lozenges. Ulceration can also be treated with Gelclair® a bioadherent oral gel. (Adcortyl in Orabase® was discontinued in 2009).
Swilling with soluble aspirin can also help reduce the pain of mouth ulcers. Opioids may be needed for severe radiation-induced stomatitis.
The mouth may become infected and malodorous particularly if there is an oral cancer infected with anaerobic organisms. Poor dental hygiene may also encourage infection. Oral metronidazole is useful for controlling anaerobic infection and the associated odour.
Review of medications. In practice it may not be feasible to stop drugs which are essential for good symptom control
Saliva substitutes such as water and artificial salivas (e.g. Biotene oralbalance gel, salivia orthana spray, glandosane spray)
Saliva stimulants such as sugar free gum, vitamin C and pilocarpine tablets
There have been few studies of these treatments. In general patients prefer saliva stimulants over saliva substitutes. Of the different saliva substitutes available, mucin based products (Saliva Orthana®) seem to be more effective and better tolerated than cellulose based products (Glandosane®) which should not be used in dentate patients. Also note the mucin is pork based and is therefore not suitable for patients of either Jewish or Islamic faith. (Level of evidence II)
Particular attention is needed for patients in the terminal phase who are semi-comatose or mouth breathing. Sponge sticks moistened in mouthwash preparations may be used by healthcare staff and family members, for whom it may provide a role in comforting a dying relative.
NB. Do not leave sponge sticks to soak in water as adhesive will fail and sponge fall off.
· Increase the flow of saliva as described above
· Nystatin oral suspension 1ml qds for at least 7 days (TLS Green) for localised/mild oral candidal infection.
· Fluconazole 50mg daily by mouth for 7 days (TLS Blue). Less effective in xerostomia. Note that there is increasing resistance to triazole antifungals. BNSSG Antimicrobial Guidelines advise that in immunocompromised patients, consider a further 7 days of treatment if infection not fully resolved.
· Ensure that dentures are thoroughly cleaned and disinfected
· Treat the infections as appropriate - metronidazole for fungating tumours in the mouth, herpesorogingivitis is extremely painful (may need aciclovir)
· For symptomatic relief use Difflam (TLS Green) or soluble aspirin gargle, flurbiprofenlozenges or systemic NSAIDs by other routes
· aphthous ulcers may be treated by hydrocortisone pellets (TLS Green)
- chemotherapy induced ulcers may be treated by chlorhexidine gluconate mouthwash (TLS Green), Gelclair gel (TLS Blue); sucralfate suspension (TLS Blue).
Anorexia is the absence or loss of appetite for food and occurs in up to half of all patients with advanced cancer, chronic kidney disease, cardiac failure, Acquired Immune Deficiency Syndrome (AIDS) and chronic obstructive pulmonary disease.
Cachexia is characterised by: weight loss (usually 5-10% of pre-morbid weight over 6 months) and skeletal muscle loss. Fat loss and anorexia are often but not always associated. The prevalence in cancer varies according to primary type: it occurs in up to 70% of upper gastrointestinal and lung cancer patients, while being much less prevalent in others such as breast cancer. Cachexia is also well recognised in the non-malignant diseases mentioned above but prevalence data are lacking.
“Cancer cachexia” is a multifactorial syndrome defined by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to functional impairment. Its pathophysiology is characterized by negative protein and negative energy balance driven by a variable combination of reduced food intake and abnormal metabolism.
Asthenia often accompanies cachexia. The features are: fatigue or easy tiring, reduced sustainability of performance, generalised weakness resulting in a reduced ability to initiate movement, mental fatigue with poor concentration, impaired memory, and emotional lability
Anorexia without accompanying cachexia is more likely to have reversible causes and to respond to treatment. Cachexia involves a chronic inflammatory state with aberrant neuronal signalling in the hypothalamus and the gut. A hypermetabolic state is induced with a particular emphasis on skeletal muscle breakdown. A number of culprit molecules have been identified whose modulation could be potential therapeutic targets.
1. Dysphagia - due to oral thrush, mucositis, mouth dryness, ulceration or upper gastrointestinal masses which might respond to radiotherapy, chemotherapy or a bypass procedure.
2. Nausea and vomiting - for any reason including drugs
3. Other catabolic states e.g. hyperthyroidism, diabetes
4. Uncontrolled symptoms - constipation, pain, anxiety and depression
5. Co-existing cognitive impairment should be looked for and treated where possible
Caloric intake should be optimised and dietitian advice about use of supplements may be sought where appropriate. Preliminary studies suggest a role for branch chain amino acid supplementation.  Pre-prandial alcohol may help stimulate appetite. There is evidence for exercise in cancer-related fatigue  and this may help to slow down skeletal muscle loss.
Cachexia as a visual marker of advanced disease can present many challenges to both patients and families. Sensitivity to the patient’s experience relating to body image and eating is required. Further specialised emotional support may be beneficial for patients with refractory cachexia. The emphasis in nutritional support in such patients is on being able to maintain some enjoyment of food and eating within the limits of their condition / capability. Families frequently require explanations and support around caring whilst not pressurising the patient into eating.
Gastro-prokinetic drugs such as metoclopramide may be of use for patients with gastric stasis and early satiety.
These may increase appetite and general well being in up to 80% of patients. However, the effect may only last for a few weeks and there is no measurable increase in nutritional status or survival. Corticosteroids have many side effects and these should always be considered especially if prolonged courses are given.
Palliative Care Guidelines advise: to try:- dexamethasone 2- 4mg o.d. If there is a GOOD RESPONSE after a few days, continue but consider reducing the dose to the minimum effective dose to avoid side effects.
If there is NO RESPONSE after 7-10 days, STOP.
There is grade 1 evidence for effectiveness in terms of appetite and weight gain BUT not skeletal muscle mass or survival gains. Most of the weight gained with these drugs is fat and fluid.
Onset of action may take up to 2 weeks but response may last longer than with corticosteroids. They are however considerably more expensive, and side effects include oedema, thromboembolism, hypertension and insomnia.
Try:-megestrol acetate 160mg-320 mg (note doses up to 800 mg have been used) o.d. OR medroxyprogesterone acetate 400mg o.d. See Palliative Care Guidelines for more information.
Role of Clinically Assisted Nutrition and Hydration (CANH)
For some patients who cannot swallow (for example patients with motor neurone disease), enteral feeding (usually via a feeding gastrostomy) may well be appropriate. Patients undergoing radiotherapy to the head and neck may develop mucositis as a side effect of treatment and eneteral feeding may also be required in this situation.
Giving clinically assisted hydration may relieve distressing symptoms or signs relating to dehydration but it may also cause pain, discomfort or swelling at the infusion site. (NICE NG31)
Total Parenteral Nutrition (TPN)
In the palliative care setting the efficacy of TPN has not been clearly proven and its routine use is not recommended. It may occasionally be considered in particular situations such as when patients are preparing for, or, recovering from surgery or awaiting chemotherapy.
Hydration in the dying patient
There is often an overwhelming need for relatives and staff to give dying patients food and water but this must not be allowed to override the patient’s need for comfort. Benefits and burdens of artificial hydration for patients at the end of life should be weighed up for individual patients and reviewed on a regular basis. For most patients who are dying the burdens tend to outweigh the benefits. Avoiding overhydration in a dying patient may improve comfort, by reducing urinary output (and therefore the need for catheterisation) and reducing the volume of distressing bronchial secretions or (in bowel obstruction) intestinal secretions. A dry mouth can be treated with local measures.
An understanding of the patient’s normal and acceptable bowel habit and an accurate history are essential for effective management of constipation. Obtaining a thorough history of the patient’s bowel pattern, diet changes and medications, along with a physical examination can identify possible causes of constipation. This evaluation should also include assessment of associated symptoms.
The following questions may provide a useful constipation assessment guide.
1.What is normal for the patient? e.g. frequency, amount, and timing
2.When was the last bowel movement?
3.What was the amount, consistency and colour of the last bowel movement and was blood passed with it?
4.Has the patient been experiencing any abdominal discomfort, cramping, nausea or vomiting, excessive gas or rectal fullness?
5.Does the patient regularly use laxatives - if so which one?
6.What does the patient normally do to relieve constipation?
7.What medication is the patient taking?
8.Is this symptom a recent change?
9.What type of diet does the patient take?
Physical examination should include general observation, abdominal palpation and rectal examination. Routine bloods would also be useful e.g. U&E, calcium, thyroid function tests.
decreased food intake
low residue diet
poor fluid intake
increased fluid loss i.e. vomiting, polyuria, fever
inability to raise intra-abdominal pressure
e.g. general debility
inability to reach toilet when urge to defaecate occurs
Whilst these guidelines are predominantly focused on the use of laxative therapy, it must be remembered that the management of constipation extends beyond the use of laxatives. Attention must be paid to other problems such as pain, diet, fluid intake, immobility and toileting.
The aim of laxative therapy is to promote comfortable defaecation not any particular frequency of bowel action.
The dose should be titrated against the response.
In opioid induced constipation, laxative therapy should be regular not intermittent.
A combination of stimulant and softener is usually required.
Drug treatments: use softeners if stool is hard, stimulants if soft stool is not expelled. Patients taking regular opioids will usually and routinely need both, although macrogols alone are often sufficient:
Senna 2 - 4 tablets nocte (onset of action 8-12 hours). See BNF
bisacodyl tablets 5 - 20mg nocte (onset of action 10 -12 hours). See BNF
docusate sodium capsules. Up to 500mg daily in divided doses (onset of action 6-24 hours). See BNF
macrogol, eg Cosmocol Orange, 1-3 sachets daily in divided doses for up to 2 weeks, then 1-2 sachets per day thereafter (onset of action 24-72 hours). See BNF
lactulose 10 - 15ml bd (not advised, excess wind) (onset of action 48 hours). See BNF.
codanthramer liquid or capsules (two strengths). See BNF
Note, these combined preparations should only be initiated for constipation in terminally ill patients.
Often, patients need suppositories or enemas for established constipation. If rectal faeces, glycerol or bisacodyl suppositories usually given. If the rectum is empty but colon loaded with hard stool, use arachis oil retention enemaovernight (check no peanut allergy) followed by phosphates enema. If opioid related constipation consider methylnaltrexone sc (dose according to weight).
Manual evacuation should be a last resort, and consent obtained after full explanation. Sedation may be required.
Diarrhoea occurs in up to 10% of patients with cancer on admission to hospice.
Diarrhoea is the passage of frequent loose stools. It has been defined as the passage of more than three unformed stools within a 24-hour period.
As with constipation patients can understand “diarrhoea” in different ways and clarification of the term is always required.
Diagnostic Diarrhoea Patterns
Defaecation described as “diarrhoea” happening only two or three times a day without warning suggests anal incontinence
Profuse watery stools are characteristic of colonic diarrhoea
Sudden onset of diarrhoea after a period of constipation raises suspicion of faecal impaction:- “overflow”
Alternating diarrhoea and constipation suggests poorly regulated laxative therapy or impending bowel obstruction
Pale, fatty, offensive stools (steatorrhoea) indicate malabsorption due to either pancreatic or ileal disease
Faecal impaction needs to be excluded by a rectal and abdominal examination. Persistent watery diarrhoea with systemic upset which might indicate an infective cause, may require investigation.
Common causes of diarrhoea in the palliative setting
1. Imbalance of laxative therapy. (Especially when laxatives have been increased to clear severe constipation.)
Should settle within 24 hours if laxatives stopped and reintroduced at a lower dose
2. Drugs such as antibiotics and antacids, NSAIDs or iron preparations.
3. Malignant partial intestinal obstruction and faecal impaction is associated with fluid stool which leaks around the mass.
4. Radiotherapy involving the abdomen or pelvis is likely to cause diarrhoea especially in the second or third week of therapy.
5. Malabsorption associated with:
Carcinoma of head of pancreas with lowered pancreatic secretions thus less fat absorption and resultant steatorrhoea.
Gastrectomy poor mixing of food with secretions, hence steatorrhoea, and associated vagotomy can cause increased water secretion into the colon.
Ileal resection reduces ability to resorb bile acids producing again increased fluid in the colon and explosive diarrhoea.
A resection of over 100cm of terminal ileum will outstretch the liver’s capacity to compensate for the bile salt loss and fat malabsorption will compound the diarrhoea.
Colectomy. A total or almost total colectomy results in a high volume of fluid effluent which rapidly diminishes over a week post-operatively but will still remain at between 400 and 1000 ml/day as the small intestine cannot compensate for the loss of the water absorbing capacity of the colon. Such patients often require an ileostomy and need an extra litre of fluid and 7g of extra salt a day with vitamin and iron supplements.
6. Colonic or rectal tumour can result in diarrhoea by causing partial obstruction and overflow or through increased mucous secretion.
7. Rare endocrine tumours which secrete hormones causing diarrhoea. e.g. carcinoid.
A cause for the diarrhoea should be looked for prior to giving antidiarrhoeal agents. The presence of blood in the stool or fever should prompt the seeking of specialist gastroenterology or microbiology advice to ensure the most appropriate treatment. This may include source isolation. Continuous Subcutaneous Infusion (CSCI) should be considered if diarrhoea is limiting absorption of analgesics
Increase fluid intake, constant sipping.
Reassurance that most diarrhoea is self limiting.
Loperamide alone does not cross the blood brain barrier and is the antidiarrhoeal opioid of choice. See BNF for dosage for relevant indication.
Follow BNSSG pathway for treating non-severe CDI and severe CDI.
BNSSG Formulary stipulates that treatment should be for 10-14 days , with advice sought from microbiology if no improvement after 5 days of treatment
For symptoms/signs of severe CDI or if patient is acutely unwell- discuss treatment options with medical microbiologist urgently/consider hospital admission for assessment.
Assess fistula size, site and type, and patient's overall condition
Prevent excoriation with a barrier product
Collect effluent in a closed stoma bag. A good seal is needed to minimise leakage and odour. If necessary seek advice from stoma care nurses
Octreotide (TLS Blue) reduces secretions in the small bowel and reduces intestinal motility. It is useful in drying up high-output fistulae. It is indicated on BNSSG Formulary for high volume vomiting/fistula on advice of palliative care team.
Ascites is the abnormal accumulation of fluid in the peritoneal cavity. The healthy adult has approximately 50ml of transudate in the peritoneal cavity. This has a protein level of about 25% of that found in plasma. Peritoneal fluid turnover is 4-5mL/hour in health. In advanced disease this can increase twenty fold.
Symptoms caused by tense ascites
abdominal distension, discomfort and pain
nausea & vomiting due to 'squashed stomach syndrome'
Malignant ascites accounts for 10% of all cases of ascites. It is associated with a variety of primary neoplasms including ovary, breast, stomach, pancreas, colon and lymphoma. Up to 20% of cases of malignant ascites have unknown primary tumour sites.
The pathophysiology of malignant ascites is not completely understood. Several mechanisms have been suggested including: obstruction of lymphatic drainage by tumour cells, alterations in vascular permeability, peritoneal carcinomatosis and hepatic congestion. Cytokines and hormonal effects have also been implicated. The renin-angiotensin-aldosterone system is additionally activated leading to sodium retention.
Malignant ascites is associated with troublesome symptoms including pain, dyspnoea, anorexia, nausea and vomiting and reduced mobility. It is usually a poor prognostic sign with many patients surviving 1-4 months. Patients with ovarian primary however may survive significantly longer.
Cardiac failure, liver failure and renal failure are common causes of non-malignant ascites and account for 90% of patients with ascites. Palliative management options are similar for both malignant and non-malignant disease with treatment of the underlying primary cause as appropriate.
The symptomatic treatment of ascites falls into 3 categories:
Beware of using diuretics for ascites without monitoring the albumin level.
The evidence for all of these treatments is weak with no randomized controlled trials in malignant ascites. Treatment should be guided by the patient’s symptoms and underlying prognosis. Analgesics and good symptom control may be all that is necessary.
Phase II data suggest that oral diuretics are effective in a third of patients; their effectiveness may depend on the plasma renin / aldosterone concentration. Diuretics are also more likely to be useful if liver metastases causing hepatic dysfunction are present. Choice of diuretic and doses are not well evaluated. In practice aldosterone antagonists such as spironolactone (usual dose 25-150mg but up to 400mg reported) are usually used either alone or in combination with a loop diuretic. Serum electrolytes should be monitored.
Paracentesis is indicated for patients with symptoms of increasing intra-abdominal pressure. Available evidence suggests immediate good albeit temporary relief of symptoms. When removing up to 5L of fluid, intravenous fluids seem not to be routinely required in normotensive patients. In a frail hypotensive patient fluid may be removed more slowly, i.e. 2-3 litres per 24hrs.There is no evidence to support concurrent albumin infusions in patients with malignant ascites. (Grade of evidence V). Indwelling catheters are also now available and my be more comfortable for the patient than frequent drainage.
To avoid repeated paracenteses a permanent drain or peritoneo-venous shunt may be considered. The latter can be inserted under general anaesthesia or local anaesthesia. They comprise a multi-perforated catheter in the peritoneal cavity which joins to a one-way valve positioned subcutaneously just above the costal margin. From here ascitic fluid is drained into the superior vena cava via a tunneled catheter which enters the external or internal jugular vein. Fluid flows through the shunt on inspiration. The two commonest shunts in use (Denver and LeVeen) have similar performance profiles. Shunts are prone to blockage. Patients with ovarian and breast cancer who undergo peritoneo-venous shunting have the best response rate (>50%) in contrast to gastrointestinal cancers (10-15%). Major complications occur in 5% of patients so a shunt should only be considered where diuretics and paracentesis have failed and life expectancy is over a month. (Grade of evidence V)
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.
Spironolactone can be used for ascites. However it takes about 7 days to improve symptoms, and up to 28 days for full effect.
1.BNF advises to start start initially with 100-200mg daily, increased if necessary to 400mg with the maintenance dose adjusted according to response.
Dose increments should be every 5-7 days as per SPC
2.If desired weight loss is not achieved after two weeks, add furosemide 40mg o.d. increased if necessary to 80mg o.d.
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.