血性腹水之安寧療護經驗：個案報告

Experience of Managing Hemorrhagic Ascites in Palliative/Hospice Care: A Case Report

張喬雅(Chiao-Ya Chang) ； 蘇芳玉(Fang-Yu Su) ； 陳虹錚(Hung-Cheng Chen) ； 吳建誼(Chien-Yi Wu) ； 曾子桂(Tzyy-Guey Tseng)

《安寧療護雜誌》 25卷1期 (2020/12) Pp. 53-65

https://doi.org/10.6537/TJHPC.202012_25(1).05

摘要

癌症病人常為腹水所苦，惡性腹水暗示著不好的預後，常造成病人及家屬身心的不適及疲憊。目前並無針對惡性腹水的治療指引，最常使用的第一線治療為利尿劑與止痛藥物，若效果不彰或症狀嚴重，可施行腹水穿刺術，大部分病人症狀可在腹水引流後改善。若腹水生成速度快，病人須頻繁接受腹水穿刺術，造成生活品質上極大的影響，可考慮放置腹水引流管等治療方式。然而，對於出血性腹水的處理，比一般惡性腹水更困難，對於現行的各種治療有許多極限性。本文個案，在疾病末期為癌症血性腹水所苦，對於利尿劑的治療反應效果差，使用嗎啡、類固醇後雖有改善，但仍感腹脹不適；安寧醫療團隊嘗試腹水穿刺術，腹水引流後，病人雖覺改善，卻有頭暈、虛弱的不適，治療上極其困難。本文就此個案照護經驗，回顧近年對於惡性腹水治療的文獻，再針對血性腹水的治療加以討論。

關鍵字

惡性腹水 ； 血性腹水 ； 安寧照護 ； 癌症末期

並列摘要

Ascites is a common symptom of cancer patients, and the presence of malignant ascites implies a poor prognosis. Besides, the patients and their families may also suffer from somatic and psychological distress. Currently, there is no consensus guideline on the management of malignant ascites. The first-line treatment is diuretics and analgesics. Paracentesis can be performed if there is a poor response to the medications. Most patients' symptoms will be improved after paracentesis; however, some patients require frequent paracentesis due to ascites re-accumulation. This can significantly reduce their quality of life. Intraperitoneal indwelling catheters implantation could be considered as an alternative. Here, we presented a case that had suffered from malignancy-related hemorrhagic ascites in her end-of-life period. She had a poor response to diuretics and continued to experience abdominal discomfort even after the administration of morphine and steroids. Paracentesis was therefore performed. Although her abdominal distention and fullness improved, she suffered from dizziness and weakness after the paracentesis. Controlling malignant hemorrhagic ascites is challenging. In this article, we reviewed the recent literature regarding malignant ascites and discussed its management options.

並列關鍵字

malignant ascites ； hemorrhagic ascites ； hospice care ； terminal cancer

參考文獻

Cavazzoni E, Bugiantella W, Graziosi L, Franceschini MS, Donini A. Malignant ascites: pathophysiology and treatment. Int J Clin Oncol 2013; 18: 1-9.

Hodge C, Badgwell BD. Palliation of malignant ascites. J Surg Oncol 2019; 120: 67-73.

Orgiano L, Pani F, Astara G, et al. The role of “closed abdomen” hyperthermic intraperitoneal chemotherapy (HIPEC) in the palliative treatment of neoplastic ascites from peritoneal carcinomatosis: report of a single-center experience. Support Care Cancer 2016; 24: 4293-9.

Jehn CF, Küpferling S, Oskay-Özcelik G, Lüftner D. A survey of treatment approaches of malignant ascites in Germany and Austria. Support Care Cancer 2015; 23: 2073-8.

Yarmohammadi H, Getrajdman GI. Symptomatic Fluid Drainage: Peritoneovenous Shunt Placement. Semin Intervent Radiol 2017; 34: 343-8.