Malignancy accounts for 10% of cases (liver cyrrhosis 80%)

Malignant Ascites

Malignancy accounts for 10% of cases (liver cyrrhosis 80%)

· 15-50% of the cancer population will develop ascites

· 80% due to ovarian, breast, colon, gastric and pancreatic

Cause of malignant ascites:

Metastatic spread to peritoneum –50%

Lymphatic invasion –20%

Portal venous compression and liver invasion –15%

Combined metastatic spread and liver invasion –15%

· Poor prognostic sign, average life expectancy of 1-4 months (except ovarian ~ 10 months)

Pathophysiology

Not completely understood

Mechanical: obstruction of lymphatic drainage due to tumor growth

Cytokines: protein production causing increased vascular permeability leading to excess fluid accumulation (i.e. VEGF)

Hormonal: decreased removal of fluids due to lymphatic obstruction –reduced circulating blood volume –activation of renin-angiotensin system –sodium & fluid retention

Albumines supstitution

Diagnosis

Examination

Ultrasound or CT likely required to demonstrate small volumes of free peritoneal fluid

Diagnostic paracentesis to determine type of ascites with newly diagnosed cases

Identifying etiology is essential to determining interventions required

Treat reversible causes where possible and desirable according to goals of care

Pharmacological Treatment

Chemotherapy: systemic and/or intraperitoneal, if tumor chemosensitive, balance between toxicities and QOL

Diuretics: rarely effective in reducing volume of fluid, most benefit if portal hypertension

Spironolactone 100-400mg/day

Furosemide 40-120mg/day

Observation if asymptomatic

Salt Restriction found to have limited effect

Paracentesis (cornerstone of management)

5L can be removed with little risk of hypotension/hypovolemic shock

Require repeated procedures –can cause anxiety and discomfort

Risk for bleeding, infection, leakage

Peritoneal Port

Catheters

Дата добавления: 2015-11-04