Transcript Module 11 - IPCRC.NET

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
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. . . Summary
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Use comprehensive
assessment and
pathophysiology-based therapy
to treat the cause and improve
the cancer experience