Palliative long-term abdominal drains in refractory ascites due to end-stage liver disease: A case series

• Published in: Palliative medicine 2017-07, Vol.31 (7), p.671-675
• Main Authors: Macken, Lucia, Joshi, Deepak, Messenger, Jenny, Austin, Mark, Tibble, Jeremy, Mason, Louise, Verma, Sumita
• Format: Article
• Language: English
• Subjects: Abdomen; Adult; Aged; Aged, 80 and over; Ascites - etiology; Ascites - therapy; Case management; Case reports; End of life decisions; Female; Hemorrhage; Humans; Life threatening; Liver cirrhosis; Liver Cirrhosis - complications; Liver Cirrhosis - therapy; Liver diseases; Male; Malignant; Middle Aged; Palliative care; Palliative Care - methods; Paracentesis - methods; Prospective Studies; Retrospective Studies; Teaching; Terminal Care - methods; Transplants
• ISSN: 0269-2163; 1477-030X
• DOI: 10.1177/0269216316671281

Background: Ascites, the commonest complication of cirrhosis, leads to frequent hospitalisations. Refractory ascites confers a median survival of 6 months without liver transplantation. In many, the management remains palliative (large-volume paracentesis). Despite calls for improvement, palliative and end-of-life care is not yet integrated into end-stage liver disease. Long-term abdominal drains are a palliative strategy in malignant ascites, but not end-stage liver disease. Case presentation: A retrospective, single centre, case series review was performed of patients undergoing long-term abdominal drain placement for refractory ascites secondary to end-stage liver disease at a large teaching hospital between August 2011 and March 2013. Case management: Patients with end-stage liver disease and refractory ascites, where liver transplantation was not an option, were considered for long-term abdominal drains. Seven patients underwent successful long-term abdominal drain insertion after multi-professional assessment. Case outcome: Following long-term abdominal drain insertion, mean hospital attendances reduced to 1 (0–4) from 9 (4–21), with none for ascites management. Median survival after long-term abdominal drain insertion was 29 days (8–219). The complication rate was low and none life threatening. Conclusion: Palliative and end-of-life care needs in end-stage liver disease remain under-addressed. Our data suggest that long-term abdominal drains may be a safe and effective palliative intervention in end-stage liver disease. Prospective randomised controlled trials comparing large-volume paracentesis versus long-term abdominal drains in refractory ascites secondary to end-stage liver disease are warranted.