Patient with known malignant ascites

Female with malignant ascites probably/possibly due to ovarian cancer

Asymptomatic

Symptomatic

Treat as ovarian cancer with surgical debulking and chemotherapy. Use alternative methods if ascites uncontrolled.

Systemic therapy as appropriate

Hospice

End

Minimize intravenous hydration as much as possible (e.g., with chemotherapy)

Limited/no systemic options, progressive disease

Salt/free water restriction if possible
Diuresis with spironolactone ± furosemide as needed

Systemic therapy as indicated
Close monitoring with weights, physical examination

Percutaneous tunneled drainage catheter

Expected survival >3 mos
No loculation
Fluid nonviscous/bloody
No cardiac or renal dysfunction

Shunt

Systemic therapy as needed, repeat therapeutic paracentesis as needed

Consider intraperitoneal therapy if available or on clinical trial

Rapid recurrence of ascites with expected survival >4 weeks

Progression of ascites or refractory to diuretics

Therapeutic paracentesis

Consider intraperitoneal therapy if available or on clinical trial

Trial of salt/free water restriction if possible
Diuresis with spironolactone ± furosemide as needed
Low threshold for declaring ineffective

Transudative OR clearly due to increased portal pressure from extensive hepatic metastases or cirrhosis