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.

Education in Palliative and End-of-life Care - Oncology

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ProjectEPEC-O

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EEPPEECC

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EEPPEECC

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Module 3dModule 3dSymptoms – AscitesSymptoms – Ascites

Module 3dModule 3dSymptoms – AscitesSymptoms – Ascites

EPEC – Oncology Education in Palliative and End-of-life Care – Oncology

EPEC – Oncology Education in Palliative and End-of-life Care – Oncology

Malignant ascites . . .Malignant ascites . . .

Definition: accumulation of fluid in Definition: accumulation of fluid in the abdomenthe abdomen

Definition: accumulation of fluid in Definition: accumulation of fluid in the abdomenthe abdomen

. . . Malignant ascites. . . Malignant ascitesEpidemiologyEpidemiology 10% caused by malignancy10% caused by malignancy 80% of malignant ascites is epithelial:80% of malignant ascites is epithelial:

OvariesOvariesEndometriumEndometriumBreastBreastColonColonGI tractGI tractPancreasPancreas

EpidemiologyEpidemiology 10% caused by malignancy10% caused by malignancy 80% of malignant ascites is epithelial:80% of malignant ascites is epithelial:

OvariesOvariesEndometriumEndometriumBreastBreastColonColonGI tractGI tractPancreasPancreas

Runyon, et al. Hepatology, 1998.

. . . Malignant ascites. . . Malignant ascites

Impact: dyspnea, early satiety, fatigue, Impact: dyspnea, early satiety, fatigue, abdominal pain abdominal pain

Prognosis: poorPrognosis: poor

Mean survival with malignant ascitesMean survival with malignant ascites< 4 months< 4 months

If chemo-responsive cancer, If chemo-responsive cancer, eg, newly Dx ovarian ca, eg, newly Dx ovarian ca, mean survival = 6 months – 1 yearmean survival = 6 months – 1 year

Impact: dyspnea, early satiety, fatigue, Impact: dyspnea, early satiety, fatigue, abdominal pain abdominal pain

Prognosis: poorPrognosis: poor

Mean survival with malignant ascitesMean survival with malignant ascites< 4 months< 4 months

If chemo-responsive cancer, If chemo-responsive cancer, eg, newly Dx ovarian ca, eg, newly Dx ovarian ca, mean survival = 6 months – 1 yearmean survival = 6 months – 1 year

Key pointsKey points

1.1. PathophysiologyPathophysiology

2.2. AssessmentAssessment

3.3. ManagementManagement

1.1. PathophysiologyPathophysiology

2.2. AssessmentAssessment

3.3. ManagementManagement

Pathophysiology . . .Pathophysiology . . .

Normal physiology:Normal physiology:

Intravascular pressure = extravascular Intravascular pressure = extravascular pressurepressure

No extravascular fluid accumulationNo extravascular fluid accumulation

Ascites:Ascites:

Fluid influx increasesFluid influx increases

Fluid outflow decreasesFluid outflow decreases

Fluid accumulatesFluid accumulates

Normal physiology:Normal physiology:

Intravascular pressure = extravascular Intravascular pressure = extravascular pressurepressure

No extravascular fluid accumulationNo extravascular fluid accumulation

Ascites:Ascites:

Fluid influx increasesFluid influx increases

Fluid outflow decreasesFluid outflow decreases

Fluid accumulatesFluid accumulates

. . . Pathophysiology. . . Pathophysiology

Elevated hydrostatic pressure Elevated hydrostatic pressure (eg, congestive heart failure, cirrhosis)(eg, congestive heart failure, cirrhosis)

Decreased osmotic pressureDecreased osmotic pressure(eg, nephrotic syndrome, malnutrition) (eg, nephrotic syndrome, malnutrition)

Fluid production > fluid resorption Fluid production > fluid resorption (infections, malignancy) (infections, malignancy)

Elevated hydrostatic pressure Elevated hydrostatic pressure (eg, congestive heart failure, cirrhosis)(eg, congestive heart failure, cirrhosis)

Decreased osmotic pressureDecreased osmotic pressure(eg, nephrotic syndrome, malnutrition) (eg, nephrotic syndrome, malnutrition)

Fluid production > fluid resorption Fluid production > fluid resorption (infections, malignancy) (infections, malignancy)

Assessment . . . History & symptomsAssessment . . . History & symptoms Ankle swellingAnkle swelling

Weight gainWeight gain

GirthGirth

FullnessFullness

BloatingBloating

DiscomfortDiscomfort

HeavinessHeaviness

Ankle swellingAnkle swelling

Weight gainWeight gain

GirthGirth

FullnessFullness

BloatingBloating

DiscomfortDiscomfort

HeavinessHeaviness

IndigestionIndigestion

NauseaNausea

VomitingVomiting

RefluxReflux

Umbilical changesUmbilical changes

HemorrhoidsHemorrhoids

IndigestionIndigestion

NauseaNausea

VomitingVomiting

RefluxReflux

Umbilical changesUmbilical changes

HemorrhoidsHemorrhoids

. . . AssessmentPhysical examination. . . AssessmentPhysical examination

Bulging flanksBulging flanks

Flank dullnessFlank dullness

Shifting dullnessShifting dullness

Fluid waveFluid wave

Bulging flanksBulging flanks

Flank dullnessFlank dullness

Shifting dullnessShifting dullness

Fluid waveFluid wave

Extra-abdominal signs of ascitesExtra-abdominal signs of ascites Enlarged liverEnlarged liver

HerniasHernias

Scrotal edema Scrotal edema

Lower extremity edemaLower extremity edema

Abdominal venous engorgementAbdominal venous engorgement

Flattened, protuberant umbilicusFlattened, protuberant umbilicus

Enlarged liverEnlarged liver

HerniasHernias

Scrotal edema Scrotal edema

Lower extremity edemaLower extremity edema

Abdominal venous engorgementAbdominal venous engorgement

Flattened, protuberant umbilicusFlattened, protuberant umbilicus

Diagnostic imagingDiagnostic imaging

If physical exam is equivocalIf physical exam is equivocal

Detects small amounts of fluid, Detects small amounts of fluid, loculationloculation

‘‘Ground Glass’ X-rayGround Glass’ X-ray

CT scan CT scan

If physical exam is equivocalIf physical exam is equivocal

Detects small amounts of fluid, Detects small amounts of fluid, loculationloculation

‘‘Ground Glass’ X-rayGround Glass’ X-ray

CT scan CT scan

Diagnostic paracentesisDiagnostic paracentesis

ColorColor

CytologyCytology

Cell countCell count

Total protein concentrationTotal protein concentration

Serum-ascites albumin gradient Serum-ascites albumin gradient

ColorColor

CytologyCytology

Cell countCell count

Total protein concentrationTotal protein concentration

Serum-ascites albumin gradient Serum-ascites albumin gradient

Hoefs J. Lab Clin Med, 1983.

Diagnosing ascites - SummaryDiagnosing ascites - Summary

Malignant etiology likely when ascitic Malignant etiology likely when ascitic fluid has:fluid has:

BloodBlood

Positive cytologyPositive cytology

Absolute neutrophil count < 250 cells / mlAbsolute neutrophil count < 250 cells / ml

Total protein concentration > 25 gm / LTotal protein concentration > 25 gm / L

Serum-ascites albumin gradient < 11 gm / LSerum-ascites albumin gradient < 11 gm / L

Malignant etiology likely when ascitic Malignant etiology likely when ascitic fluid has:fluid has:

BloodBlood

Positive cytologyPositive cytology

Absolute neutrophil count < 250 cells / mlAbsolute neutrophil count < 250 cells / ml

Total protein concentration > 25 gm / LTotal protein concentration > 25 gm / L

Serum-ascites albumin gradient < 11 gm / LSerum-ascites albumin gradient < 11 gm / L

ManagementManagement

Goal: to relieve the symptomsGoal: to relieve the symptoms

With little or no discomfort: don’t With little or no discomfort: don’t treattreat

Before intervening, discuss Before intervening, discuss prognosis, benefits, risksprognosis, benefits, risks

Goal: to relieve the symptomsGoal: to relieve the symptoms

With little or no discomfort: don’t With little or no discomfort: don’t treattreat

Before intervening, discuss Before intervening, discuss prognosis, benefits, risksprognosis, benefits, risks

When to treat?When to treat?

With these symptoms:With these symptoms:

DyspneaDyspnea

Abdominal painAbdominal pain

FatigueFatigue

AnorexiaAnorexia

Early satietyEarly satiety

Reduced exercise toleranceReduced exercise tolerance

With these symptoms:With these symptoms:

DyspneaDyspnea

Abdominal painAbdominal pain

FatigueFatigue

AnorexiaAnorexia

Early satietyEarly satiety

Reduced exercise toleranceReduced exercise tolerance

Therapeutic optionsTherapeutic options

Dietary restrictionDietary restriction

ChemotherapyChemotherapy

DiureticsDiuretics

Therapeutic paracentesisTherapeutic paracentesis

SurgerySurgery

Dietary restrictionDietary restriction

ChemotherapyChemotherapy

DiureticsDiuretics

Therapeutic paracentesisTherapeutic paracentesis

SurgerySurgery

Dietary managementDietary management

Sodium and severe fluid restrictionSodium and severe fluid restriction

Difficult for patientsDifficult for patients

Discuss benefits, burdens & other Discuss benefits, burdens & other treatment options firsttreatment options first

Sodium and severe fluid restrictionSodium and severe fluid restriction

Difficult for patientsDifficult for patients

Discuss benefits, burdens & other Discuss benefits, burdens & other treatment options firsttreatment options first

DiureticsDiuretics

EffectiveEffective

Well-toleratedWell-tolerated

Treatment goals:Treatment goals:

Remove only enough fluid to manage Remove only enough fluid to manage the symptomsthe symptoms

Slow & gradual diuresisSlow & gradual diuresis

EffectiveEffective

Well-toleratedWell-tolerated

Treatment goals:Treatment goals:

Remove only enough fluid to manage Remove only enough fluid to manage the symptomsthe symptoms

Slow & gradual diuresisSlow & gradual diuresis

Pockros J, et al. Gastroenterology, 1992.

Selecting a diureticSelecting a diuretic

Spironolactone 25 mg – 50 mg / day Spironolactone 25 mg – 50 mg / day

Amiloride 5 mg / dayAmiloride 5 mg / day

Furosemide 20 mg / dayFurosemide 20 mg / day

Spironolactone 25 mg – 50 mg / day Spironolactone 25 mg – 50 mg / day

Amiloride 5 mg / dayAmiloride 5 mg / day

Furosemide 20 mg / dayFurosemide 20 mg / day

Precautions with diureticsPrecautions with diuretics

Avoid salt substitutesAvoid salt substitutes

Evaluate benefits & burdensEvaluate benefits & burdens

Not appropriate in patients with:Not appropriate in patients with:

Limited mobilityLimited mobility

UT flow problemsUT flow problems

Poor appetite, poor oral intakePoor appetite, poor oral intake

Polypharmacy problemsPolypharmacy problems

Avoid salt substitutesAvoid salt substitutes

Evaluate benefits & burdensEvaluate benefits & burdens

Not appropriate in patients with:Not appropriate in patients with:

Limited mobilityLimited mobility

UT flow problemsUT flow problems

Poor appetite, poor oral intakePoor appetite, poor oral intake

Polypharmacy problemsPolypharmacy problems

Diuretic adverse effectsDiuretic adverse effects

Problems withProblems with

Sleep deprivationSleep deprivation

Self-esteemSelf-esteem

SkinSkin

SafetySafety

FatigueFatigue

HypotensionHypotension

Problems withProblems with

Sleep deprivationSleep deprivation

Self-esteemSelf-esteem

SkinSkin

SafetySafety

FatigueFatigue

HypotensionHypotension

Therapeutic paracentesisTherapeutic paracentesis

Indications:Indications:

Respiratory distressRespiratory distress

Diuretic failureDiuretic failure

Rapid symptomatic reliefRapid symptomatic relief

SafeSafe

In clinic or home In clinic or home

Indications:Indications:

Respiratory distressRespiratory distress

Diuretic failureDiuretic failure

Rapid symptomatic reliefRapid symptomatic relief

SafeSafe

In clinic or home In clinic or home

Therapeutic paracentesis techniqueTherapeutic paracentesis technique

Patient supine Patient supine or or semirecumbentsemirecumbent

Select siteSelect site

Cleanse, Cleanse, disinfect skindisinfect skin

Patient supine Patient supine or or semirecumbentsemirecumbent

Select siteSelect site

Cleanse, Cleanse, disinfect skindisinfect skin

InsertInsert

Attach 3-way Attach 3-way connector connector

EvacuateEvacuate

RepositionReposition

InsertInsert

Attach 3-way Attach 3-way connector connector

EvacuateEvacuate

RepositionReposition

SurgerySurgery Peritoneovenous shuntsPeritoneovenous shunts

Drains ascitic fluid into internal jugular Drains ascitic fluid into internal jugular veinvein

Rarely doneRarely done

Tenckhoff, other cathetersTenckhoff, other catheters

Local anesthesiaLocal anesthesia

Large volume ascitesLarge volume ascites

Outpatient useOutpatient use

Peritoneovenous shuntsPeritoneovenous shunts

Drains ascitic fluid into internal jugular Drains ascitic fluid into internal jugular veinvein

Rarely doneRarely done

Tenckhoff, other cathetersTenckhoff, other catheters

Local anesthesiaLocal anesthesia

Large volume ascitesLarge volume ascites

Outpatient useOutpatient use

Barnett TD, Rubins J. J Vasc Intery Radio, 2002.Burger JA, et al. Ann Oncol, 1997.

Summary . . .Summary . . .

Ascites causes distress in patients Ascites causes distress in patients with advanced cancerwith advanced cancer

Rule out nonmalignant causesRule out nonmalignant causes

Treatment is palliativeTreatment is palliative

Dietary, pharmacological, and Dietary, pharmacological, and interventional options are availableinterventional options are available

Ascites causes distress in patients Ascites causes distress in patients with advanced cancerwith advanced cancer

Rule out nonmalignant causesRule out nonmalignant causes

Treatment is palliativeTreatment is palliative

Dietary, pharmacological, and Dietary, pharmacological, and interventional options are availableinterventional options are available

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. . . Summary. . . Summary

Use comprehensive Use comprehensive assessment and assessment and

pathophysiology-based therapy pathophysiology-based therapy

to treat the cause and improve to treat the cause and improve the cancer experiencethe cancer experience

Use comprehensive Use comprehensive assessment and assessment and

pathophysiology-based therapy pathophysiology-based therapy

to treat the cause and improve to treat the cause and improve the cancer experiencethe cancer experience