Refractory ascites in end stage liver disease focussing on the use of long term drains in a palliative setting

  • Lucia Macken

    Student thesis: Doctoral Thesis


    Background: The burden of end stage liver disease (ESLD) in England is high. Ascites is the commonest complication of ESLD, refractory ascites (RA) carries a limited prognosis, and the majority of patients are ineligible for liver transplantation. Standard management is large volume paracentesis (LVP), providing intermittent symptom relief, and is usually a palliative intervention. Long term abdominal drains (LTAD) are used in malignant ascites but evidence in ESLD is limited.

    Aims: To characterise and describe local RA management with LVP, and current evidence on LTADs. To establish the feasibility of undertaking a research study in this patient group and report the methods and results of the REDUCe study.

    Methods: REDUCe was a mixed methods feasibility RCT comparing LVP with LTAD, in those with ESLD and RA, running between September 2015-September 2018. Eligibility for liver transplantation was an exclusion. Clinical, health related quality of life assessments and qualitative interviews were undertaken.

    Results: Nearly 40% undergoing an LVP developed RA, ≤15% were accepted for liver transplant and ≤45% highlighted as having palliative disease. Current data on LTAD in ESLD and RA are lacking. REDUCe study success criteria were achieved, 36 patients were randomised, attrition was 42%, uptake of questionnaires/interviews was ≥80% and those in the LTAD group spent ≤50% ascites related study time in hospital compared with the LVP group. No complications mandated LTAD removal and no LTAD related safety concerns were seen.

    Conclusion: We demonstrated that research can be successfully undertaken in a palliative ESLD cohort. Initial results suggest LTAD are an alternative for managing RA and are an acceptable strategy for patients and healthcare staff. Definitive answers on safety and efficacy need to be established in a full scale trial.
    Date of AwardJan 2023
    Original languageEnglish
    Awarding Institution
    • Brighton and Sussex Medical School
    SupervisorSumita Verma (Supervisor)

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