The EPEC-O TM Education in Palliative and End-of-life Care - Oncology Project The EPEC-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation. E P E C EPEC – Oncology Education in Palliative and End-of-life Care – Oncology O Module 3d Symptoms – Ascites Malignant ascites . . . Definition: accumulation of fluid in the abdomen . . . Malignant ascites Epidemiology 10% caused by malignancy 80% of malignant ascites is epithelial: Ovaries Endometrium Breast Colon GI tract Pancreas Runyon, et al. Hepatology, 1998. . . . Malignant ascites Impact: dyspnea, early satiety, fatigue, abdominal pain Prognosis: poor Mean survival with malignant ascites < 4 months If chemo-responsive cancer, eg, newly Dx ovarian ca, mean survival = 6 months – 1 year Key points 1. Pathophysiology 2. Assessment 3. Management Pathophysiology . . . Normal physiology: Intravascular pressure = extravascular pressure No extravascular fluid accumulation Ascites: Fluid influx increases Fluid outflow decreases Fluid accumulates . . . Pathophysiology Elevated hydrostatic pressure (eg, congestive heart failure, cirrhosis) Decreased osmotic pressure (eg, nephrotic syndrome, malnutrition) Fluid production > fluid resorption (infections, malignancy) Assessment . . . History & symptoms Ankle swelling Indigestion Weight gain Nausea Girth Vomiting Fullness Reflux Bloating Umbilical changes Discomfort Hemorrhoids Heaviness . . . Assessment Physical examination Bulging flanks Flank dullness Shifting dullness Fluid wave Extra-abdominal signs of ascites Enlarged liver Hernias Scrotal edema Lower extremity edema Abdominal venous engorgement Flattened, protuberant umbilicus Diagnostic imaging If physical exam is equivocal Detects small amounts of fluid, loculation ‘Ground Glass’ X-ray CT scan Diagnostic paracentesis Color Cytology Cell count Total protein concentration Serum-ascites albumin gradient Hoefs J. Lab Clin Med, 1983. Diagnosing ascites Summary Malignant etiology likely when ascitic fluid has: Blood Positive cytology Absolute neutrophil count < 250 cells / ml Total protein concentration > 25 gm / L Serum-ascites albumin gradient < 11 gm / L Management Goal: to relieve the symptoms With little or no discomfort: don’t treat Before intervening, discuss prognosis, benefits, risks When to treat? With these symptoms: Dyspnea Abdominal pain Fatigue Anorexia Early satiety Reduced exercise tolerance Therapeutic options Dietary restriction Chemotherapy Diuretics Therapeutic paracentesis Surgery Dietary management Sodium and severe fluid restriction Difficult for patients Discuss benefits, burdens & other treatment options first Diuretics Effective Well-tolerated Treatment goals: Remove only enough fluid to manage the symptoms Slow & gradual diuresis Pockros J, et al. Gastroenterology, 1992. Selecting a diuretic Spironolactone 25 mg – 50 mg / day Amiloride 5 mg / day Furosemide 20 mg / day Precautions with diuretics Avoid salt substitutes Evaluate benefits & burdens Not appropriate in patients with: Limited mobility UT flow problems Poor appetite, poor oral intake Polypharmacy problems Diuretic adverse effects Problems with Sleep deprivation Self-esteem Skin Safety Fatigue Hypotension Therapeutic paracentesis Indications: Respiratory distress Diuretic failure Rapid symptomatic relief Safe In clinic or home Therapeutic paracentesis technique Patient supine or semirecumbent Select site Cleanse, disinfect skin Insert Attach 3-way connector Evacuate Reposition Surgery Peritoneovenous shunts Drains ascitic fluid into internal jugular vein Rarely done Tenckhoff, other catheters Local anesthesia Large volume ascites Outpatient use Barnett TD, Rubins J. J Vasc Intery Radio, 2002. Burger JA, et al. Ann Oncol, 1997. Summary . . . Ascites causes distress in patients with advanced cancer Rule out nonmalignant causes Treatment is palliative Dietary, pharmacological, and interventional options are available E P E C . . . Summary O Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience