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
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

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


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
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
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
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)