MALIGNANT ASCITES

Lucy Adkinson

Case history Reminder of different causes Update on recent NICE guidance

CASE Joe Locally advanced pancreatic cancer Admission February for pain control Whilst inpatient accumulating ascites

Trial diuretics with no improvementParacentesis performed Discharged home on increased diuretics

2 weeks later readmitted with tense ascites again BRI for PleurX ascitic drain insertion

REVISION... Ascites

75% cirrhosis10% malignancy3 % heart failure2% TB

Estimated problems associated with ascites present in 3.6 – 6% of hospice inpatients

PATHOPHYSIOLOGY OF MALIGNANT ASCITES Two principal mechanisms in malignant

ascites divided into transudates and exudatesTransudates

Low proteinExudates

High protein

Multiple hepatic mets or single large tumour causing Budd-chiari

syndrome

Increased hepatic venous pressure

? Increased vascular permeability

Peritoneal tumour deposits and tumour neovasculature = leaky

Extravasation of fluid

BUT Ascitic fluid can also arise from unaffected peritoneum:

Observed marked neovascularisation of peritoneum in malignant ascites and ovarian ascites - ? Cytokine and VEGF in ovarian cancer related leaky

capillaries

Fluid leakage into peritoneum from sinusoids

Increase in plasma renin conc and thus salt and water

retention Indicative of portal hypertension Similar to cirrhosis

CHYLOUS ASCITES Complication of retroperitoneal tumour

spread or its treatment Either due to damage of lymphatic

vessels or obstruction of lymphatic flow through lymph nodes or pancreas

ALBUMIN GRADIENT Serum-ascites albumin gradient= serum

albumin (same day) – ascites albumin High gradient “transudate” > 11g/l

Indicative of portal hypertension Important because can help assess the

likelihood response to diuretic therapy with aldosterone antagonist

DIURETICS In malignancy role is controversial and

slim evidence base BSG Guidelines on management of

ascites in cirrhosis

NICE GUIDANCE

THE RECOMMENDATION

THE BENEFITS

CLINICAL EVIDENCE 9 observational studies

6 were case series 10+ patients1 qualitative case series3 case reports

ROSENBERG ET AL 2004 N = 40 (pleurX) assessing treatment

complication rates compared with large volume paracentesis

Complications same for both types Infection n=1 Leakage n=1 Loculations n=1 N=27 working at death but 11 lost to

follow up

COURTNEY ET AL 2008 34 patients over 12 weeks (or death) 100% technical success 2 catheters needed to be removed Infection n=2, loculations n=14, leakage

n=7, dizziness n=5, SOB n=1 Mean number of drainage sessions 23.3 28% performed by patient, 58% by carer Improved QoL at 12 weeks 28%

respondents

MULLAN ET AL 2011 50 patients 8 complications 100% patency at death

COSTPer pt PleurX IP

paracentesisOP paracentesis

£2466 £3146 £1457

• Saving of £679 per patient in comparison with inpatient paracentesis•7.4 hospital days saved per patient•23.5 more community nurse visits

SUMMARY Different causes of ascites in

malignancy If diuretics don’t work +/- ascites

reaccumulates after paracentesis consider referral for pleurX ascitic drain (via oncology in BRI for costing)