Malignant Ascites - Yorkshire and the Humber Deanery
Download
Report
Transcript Malignant Ascites - Yorkshire and the Humber Deanery
Lucy Adkinson
Case
history
Reminder of different causes
Update on recent NICE guidance
Joe
Locally
advanced pancreatic cancer
Admission February for pain control
Whilst inpatient accumulating ascites
Trial diuretics with no improvement
Paracentesis performed
Discharged home on increased diuretics
2
weeks later readmitted with tense ascites
again
BRI for PleurX ascitic drain insertion
Ascites
75% cirrhosis
10% malignancy
3 % heart failure
2% TB
Estimated
problems associated with ascites
present in 3.6 – 6% of hospice inpatients
Two
principal mechanisms in malignant ascites
divided into transudates and exudates
Transudates
Low protein
Exudates
High protein
Multiple hepatic mets or single large
tumour causing Budd-chiari syndrome
? Increased vascular permeability
Increased hepatic venous pressure
Fluid leakage into Increase in plasma
renin conc and
peritoneum from
thus salt and water
sinusoids
retention
Indicative of portal hypertension
Similar to cirrhosis
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
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
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
In
malignancy role is controversial and slim
evidence base
BSG Guidelines on management of ascites in
cirrhosis
9
observational studies
6 were case series 10+ patients
1 qualitative case series
3 case reports
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
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
50
patients
8 complications
100% patency at death
Per pt PleurX
IP paracentesis
OP 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
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)