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Malignant Ascites

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  1. Malignant Ascites Lucy Adkinson

  2. Case history • Reminder of different causes • Update on recent NICE guidance

  3. Case • 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 PleurXascitic drain insertion

  4. Revision... • Ascites • 75% cirrhosis • 10% malignancy • 3 % heart failure • 2% TB • Estimated problems associated with ascites present in 3.6 – 6% of hospice inpatients

  5. Pathophysiology of malignant ascites • Two principal mechanisms in malignant ascites divided into transudates and exudates Increase in plasma reninconc and thus salt and water retention Fluid leakage into peritoneum from sinusoids Indicative of portal hypertension Similar to cirrhosis

  6. Chylousascites • 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

  7. 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

  8. diuretics • In malignancy role is controversial and slim evidence base • BSG Guidelines on management of ascites in cirrhosis

  9. Nice Guidance

  10. The recommendation

  11. The benefits

  12. Clinical evidence • 9 observational studies • 6 were case series 10+ patients • 1 qualitative case series • 3 case reports

  13. 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

  14. 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

  15. Mullan et al 2011 • 50 patients • 8 complications • 100% patency at death

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

  17. summary • Different causes of ascites in malignancy • If diuretics don’t work +/- ascitesreaccumulates after paracentesis consider referral for pleurXascitic drain (via oncology in BRI for costing)